Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
Clin Orthop Relat Res. 2023 Oct 1;481(10):1993-2002. doi: 10.1097/CORR.0000000000002630. Epub 2023 Mar 27.
Patients with incidentally found musculoskeletal lesions are regularly referred to orthopaedic oncology. Most orthopaedic oncologists understand that many incidental findings are nonaggressive and can be managed nonoperatively. However, the prevalence of clinically important lesions (defined as those indicated for biopsy or treatment, and those found to be malignant) remains unknown. Missing clinically important lesions can result in harm to patients, but needless surveillance may exacerbate patient anxiety about their diagnosis and accrue low-value costs to the payor.
QUESTIONS/PURPOSES: (1) What percentage of patients with incidentally discovered osseous lesions referred to orthopaedic oncology had lesions that were clinically important, defined as those receiving biopsy or treatment or those found to be malignant? (2) Using standardized Medicare reimbursements as a surrogate for payor expense, what is the value of reimbursements accruing to the hospital system for the imaging of incidentally found osseous lesions performed during the initial workup period and during the surveillance period, if indicated?
This was a retrospective study of patients referred to orthopaedic oncology for incidentally found osseous lesions at two large academic hospital systems. Medical records were queried for the word "incidental," and matches were confirmed by manual review. Patients evaluated at Indiana University Health between January 1, 2014, and December 31, 2020, and those evaluated at University Hospitals between January 1, 2017, and December 31, 2020, were included. All patients were evaluated and treated by the two senior authors of this study and no others were included. Our search identified 625 patients. Sixteen percent (97 of 625) of patients were excluded because their lesions were not incidentally found, and 12% (78 of 625) were excluded because the incidental findings were not bone lesions. Another 4% (24 of 625) were excluded because they had received workup or treatment by an outside orthopaedic oncologist, and 2% (10 of 625) were excluded for missing information. A total of 416 patients were available for preliminary analysis. Among these patients, 33% (136 of 416) were indicated for surveillance. The primary indication for surveillance included lesions with a benign appearance on imaging and low clinical suspicion of malignancy or fracture. A total of 33% (45 of 136) of these patients had less than 12 months of follow-up and were excluded from further analysis. No minimum follow-up criteria were applied to patients not indicated for surveillance because this would artificially inflate our estimated rate of clinically important findings. A total of 371 patients were included in the final study group. Notes from all clinical encounters with orthopaedic and nonorthopaedic providers were screened for our endpoints (biopsy, treatment, or malignancy). Indications for biopsy included lesions with aggressive features, lesions with nonspecific imaging characteristics and a clinical picture concerning for malignancy, and lesion changes seen on imaging during the surveillance period. Indications for treatment included lesions with increased risk of fracture or deformity, certain malignancies, and pathologic fracture. Diagnoses were determined using biopsy results if available or the documented opinion of the consulting orthopaedic oncologist. Imaging reimbursements were obtained from the Medicare Physician Fee Schedule for 2022. Because imaging charges vary across institutions and reimbursements vary across payors, this method was chosen to enhance the comparability of our findings across multiple health systems and studies.
Seven percent (26 of 371) of incidental findings were determined to be clinically important, as previously defined. Five percent (20 of 371) of lesions underwent tissue biopsy, and 2% (eight of 371) received surgical intervention. Fewer than 2% (six of 371) of lesions were malignant. Serial imaging changed the treatment of 1% (two of 136) of the patients, corresponding to a rate of one in 47 person-years. Median reimbursements to work up the incidental findings analyzed was USD 219 (interquartile range USD 0 to 404), with a range of USD 0 to 890. Among patients indicated for surveillance, the median annual reimbursement was USD 78 (IQR USD 0 to 389), with a range of USD 0 to 2706.
The prevalence of clinically important findings among patients referred to orthopaedic oncology for incidentally found osseous lesions is modest. The likelihood of surveillance resulting in a change of management was low, but the median reimbursements associated with following these lesions was also low. We conclude that after appropriate risk stratification by orthopaedic oncology, incidental lesions are rarely clinically important, and judicious follow-up with serial imaging can be performed without incurring high costs.
Level III, therapeutic study.
偶然发现肌肉骨骼病变的患者通常会被转诊至矫形骨肿瘤科。大多数矫形骨肿瘤科医生都明白，许多偶然发现的病变并无侵袭性，可通过非手术方式进行治疗。然而，临床上重要病变（即需要活检或治疗的病变，以及被诊断为恶性的病变）的患病率尚不清楚。漏诊临床上重要的病变可能会对患者造成伤害，但不必要的监测可能会增加患者对诊断的焦虑，并给支付方带来低价值的费用。
问题/目的：（1）偶然发现的骨病变被转诊至矫形骨肿瘤科的患者中，有多少患者的病变是临床上重要的，定义为接受活检或治疗或被诊断为恶性的病变？（2）使用 Medicare 报销作为支付方费用的替代指标，在初始检查期间和如果需要进行监测期间，对偶然发现的骨病变进行成像的医院系统会产生多少报销费用？
这是一项回顾性研究，研究对象为在两个大型学术医院系统中因偶然发现的骨病变而被转诊至矫形骨肿瘤科的患者。通过查询“偶然”一词来检索病历，并通过人工复查来确认匹配结果。纳入 2014 年 1 月 1 日至 2020 年 12 月 31 日期间在印第安纳大学健康中心评估的患者，以及 2017 年 1 月 1 日至 2020 年 12 月 31 日期间在大学医院评估的患者。所有患者均由本研究的两位资深作者进行评估和治疗，没有其他医生参与。我们的搜索共确定了 625 名患者。625 名患者中有 16%（97 名）因病变并非偶然发现而被排除，12%（78 名）因偶然发现的病变并非骨病变而被排除。另有 4%（24 名）因病变已由外部矫形骨肿瘤科医生进行了检查和治疗而被排除，2%（10 名）因信息缺失而被排除。共有 416 名患者可进行初步分析。在这些患者中，33%（136 名）需要进行监测。监测的主要指征包括影像学表现为良性且临床怀疑恶性或骨折的可能性较低的病变。这些需要监测的患者中，有 33%（45 名）的随访时间不足 12 个月，因此被排除在进一步分析之外。由于这会人为地增加我们估计的临床上重要发现的比率，因此没有对未被监测的患者应用最低随访标准。共有 371 名患者被纳入最终的研究组。所有与矫形和非矫形提供者的临床接触记录都被筛选以确定我们的研究终点（活检、治疗或恶性肿瘤）。活检指征包括具有侵袭性特征的病变、影像学特征不明确且临床怀疑恶性的病变、以及在监测期间影像学上出现病变变化的病变。治疗指征包括有增加骨折或畸形风险、某些恶性肿瘤和病理性骨折的病变。如果有活检结果，则根据活检结果确定诊断，否则根据咨询矫形骨肿瘤科医生的意见确定诊断。2022 年从 Medicare 医师费用表中获取了影像学报销费用。由于影像学费用因机构而异，支付方的报销费用也因机构而异，因此选择这种方法可以增强我们在多个医疗系统和研究中的发现的可比性。
7%（26 名）的偶然发现被确定为临床上重要，如前所述。5%（20 名）的病变接受了组织活检，2%（8 名）接受了手术干预。不到 2%（6 名）的病变为恶性。连续影像学检查改变了 1%（2 名）患者的治疗方案，对应的年发生率为每 47 人年 1 例。分析偶然发现的初始检查的中位数报销费用为 219 美元（四分位距 USD 0 至 404），范围为 USD 0 至 890。在需要监测的患者中，中位数年度报销费用为 78 美元（IQR USD 0 至 389），范围为 USD 0 至 2706。
偶然发现的骨病变被转诊至矫形骨肿瘤科的患者中，临床上重要的病变的患病率较低。监测导致治疗方案改变的可能性较低，但随访这些病变的中位报销费用也较低。我们的结论是，在经过矫形骨肿瘤科的适当风险分层后，偶然发现的病变很少具有临床上重要性，通过连续影像学检查进行谨慎的随访可以在不产生高成本的情况下进行。
III 级，治疗性研究。
