/pdf/equity-and-the-economic-evaluation-of-healthcare-2kma89dfil.pdf

Equity and the economic evaluation of healthcare.

Background:

Although pathological analysis provides the definitive diagnosis for most resection specimens, recent evidence suggests that such analysis may be omitted for certain routine samples. This was a retrospective analysis of the value of routine histopathological examination performed in daily general surgical practice.



Methods:

All specimens from routine appendicectomies, cholecystectomies, haemorrhoidectomies and inguinal hernia repairs performed between 1993 and 2002 were included. The analysis included a comparison of histological and macroscopic diagnoses, review of preoperative and peroperative findings, and an evaluation of the consequences of routine histopathological assessment on patient management and costs.



Results:

With the exception of hernia specimens, the rate of submission for routine pathological evaluation was 100 per cent. No hernia sac specimen from more than 2000 interventions revealed aberrant histological findings. Of 311 haemorrhoidectomy specimens three showed malignancy, all of which had a suspicious macroscopic appearance. Of 1465 appendices, only one (0·1 per cent) had a potentially relevant histological diagnosis that was not suspected macroscopically. Among 1523 cholecystectomy specimens, all adenomas (0·6 per cent) and carcinomas (0·4 per cent) were suspected macroscopically or developed in association with a known disease.



Conclusion:

The rarity of incidental histological findings relevant to patient management, especially in the absence of macroscopic abnormalities, suggests that routine histological examination of certain specimens may be omitted. A more elementary role for macroscopic examination of the specimen by the surgeon and the pathologist is proposed. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Routine surgical pathology in general surgery

Background: The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. The purpose of this investigation was to evaluate the cost and effectiveness of routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement for the treatment of osteoarthritis.

Methods: Effectiveness was assessed by comparing clinical and pathological diagnoses associated with 1234 consecutive primary total joint replacements (471 hip and 763 knee replacements) performed between 1992 and 1995 in one hospital in patients with the clinical diagnosis of osteoarthritis. Clinical and pathological diagnoses were considered concordant if they agreed, discrepant if they differed without a resultant change in patient management, and discordant if they differed with a resultant change in patient management. Cost identification was performed by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement. The cost per health-effect was determined by calculating the cost per discrepant and discordant diagnosis.

Results: The prevalence of concordant diagnoses was 97.6 percent (1205 of 1234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1234) (95 percent confidence interval, 0.1 to 0.3 percent). The cost per discrepant diagnosis was $4383, and the cost per discordant diagnosis was $122,728.

Conclusions: Routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement because of the clinical diagnosis of osteoarthritis had limited cost-effectiveness at our hospital due to the low prevalence of findings that altered patient management.

Cost and Effectiveness of Routine Pathological Examination of Operative Specimens Obtained During Primary Total Hip and Knee Replacement in Patients with Osteoarthritis

The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger.

OBJECTIVES: Recent literature has suggested that histopathologic analysis of routine tonsillectomy and adenoidectomy (T&A) specimens may be unnecessary. This study investigates T&A specimen handling practices in the United States between 1989 and 1999.METHODS: Surveys were sent to 4715 members of the American Academy of Otolaryngology. Surveys assessed practice type, pathologic processing practices (full, gross, no pathology), and reasons for change. The authors also performed a retrospective analysis of 1583 pediatric T&A specimens for evidence of occult malignancy.RESULTS: Practice types were 80% private, 12% academic, 6% salaried, and 2% military. Chi squared analysis revealed a significant increase (P < 0.001) in respondents ordering “gross only” and “no pathology.” The retrospective analysis found no occult malignancies.CONCLUSIONS: There is a statistically significant increase in the number of otolaryngologists sending routine T&A specimens for “gross only” and “no pathology.” There was no correlati...

Pathologic analysis of routine tonsillectomy and adenoidectomy specimens.

To study the cost-effectiveness of the histologic examination of tonsil and adenoid specimens, the histologic diagnoses for all routine (2,700) and nonroutine (71) tonsil and adenoid specimens during a 10-year period were reviewed. There were 27 routine cases (1%) and 56 nonroutine cases (79%) with a diagnosis other than normal, tonsillitis, or hyperplasia. Twelve of the 27 routine cases did not have a significant clinical history, and a potentially significant pathologic diagnosis was made in only 6 cases; in none of these cases did the pathologic diagnosis affect patient care. In all nonroutine cases, the pathologic diagnosis affected patient care. The average charge per case to detect potentially significant disease in routine and nonroutine cases was $64,718 and $525, respectively. We conclude that histologic examination of nonroutine cases is cost-effective, whereas in most routine cases with adequate clinical history, histologic examination is not cost-effective.

/pdf/value-based-pathology-a-cost-benefit-analysis-of-the-10g5bos8ka.pdf

Julie C. Netser

Papers

Value-based pathology: a cost-benefit analysis of the examination of routine and nonroutine tonsil and adenoid specimens.