Liow Ming Han Lincoln, Agrawal Kshitijkumar, Anderson David W, Freiberg Andrew A, Rubash Harry E, Kwon Young-Min
Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
J Arthroplasty. 2017 Mar;32(3):735-742. doi: 10.1016/j.arth.2016.08.017. Epub 2016 Aug 24.
Routine femoral head histopathology during primary total hip arthroplasty (THA) has been recently reported as a potentially useful screening tool for bone- and bone marrow-associated malignancies. However, cost-effectiveness of routine histopathology during THA remains unclear due to low prevalence of significant medical findings which alter patient management. The aim of this study was to evaluate the cost-effectiveness of routine histopathology in diagnosing unsuspected malignancy in patients undergoing primary THA.
From 1993 to 2011, we retrospectively analyzed routine histopathologic findings of 3200 femoral head specimens from 2725 patients that underwent primary THA. Preoperative and postoperative diagnoses were classified into concordant (clinical diagnosis concurred with pathologic diagnosis), discrepant (differing diagnosis with no resultant impact on patient management), and discordant (differing diagnosis with subsequent change in patient management). Cost-effectiveness analysis was performed using the incremental cost-utility ratio.
A total of 3055 of 3200 pathologic samples were concordant with the preoperative diagnosis (95.4%), 140 of 3200 were discrepant (4.4%), and 5 of 3200 were discordant (0.2%). Routine histopathology revealed 1 unsuspected malignancy out of 640 (5 of 3200) femoral heads. The total cost of histopathologic screening was $614,664.80. The average cost to identify a discrepant case was $4390.46, and the cost to identify a discordant case was $122,932.96. The incremental cost-utility ratio was $49,569.74 per quality-adjusted life year (QALY) gained.
Our study indicates routine femoral head histopathology may be cost-effective in diagnosing unsuspected malignancy at $49,569.74/QALY gained (less than World Health Organization recommended threshold $159,000/QALY gained), providing useful clinical information for surgeons considering the value of routine femoral head histopathology in patients undergoing THA.
近期有报道称，初次全髋关节置换术（THA）期间的常规股骨头组织病理学检查可能是一种用于筛查骨及骨髓相关恶性肿瘤的有用工具。然而，由于能改变患者治疗方案的重大医学发现的发生率较低，THA期间常规组织病理学检查的成本效益仍不明确。本研究的目的是评估常规组织病理学检查在诊断初次接受THA患者的未被怀疑的恶性肿瘤方面的成本效益。
从1993年至2011年，我们回顾性分析了2725例行初次THA患者的3200份股骨头标本的常规组织病理学检查结果。术前和术后诊断分为一致（临床诊断与病理诊断一致）、不符（诊断不同但对患者治疗无影响）和不一致（诊断不同且随后改变了患者治疗方案）。使用增量成本效用比进行成本效益分析。
3200份病理样本中共有3055份与术前诊断一致（95.4%），3200份中有140份不符（4.4%），3200份中有5份不一致（0.2%）。常规组织病理学检查在640个（3200个中的5个）股骨头中发现了1例未被怀疑的恶性肿瘤。组织病理学筛查的总成本为614,664.80美元。识别1例不符病例的平均成本为4,390.46美元，识别1例不一致病例的成本为122,932.96美元。每获得1个质量调整生命年（QALY）的增量成本效用比为49,569.74美元。
我们的研究表明，常规股骨头组织病理学检查在诊断未被怀疑的恶性肿瘤方面可能具有成本效益，每获得1个QALY的成本为49,569.74美元（低于世界卫生组织建议的阈值159,000美元/QALY），为考虑常规股骨头组织病理学检查对接受THA患者价值的外科医生提供了有用的临床信息。
