Reimbursement for medical procedures began to diminish in the 1980s with the introduction of a prospective-payment system that was based on diagnosis-related groups. The problem has escalated with increasing administrative costs and the advent of managed care. An important, and much discussed, result has been the curtailment of funding for education and research. In an environment in which cost-cutting has become a paramount goal, it was also inevitable that many laboratory and clinical procedures that we have taken for granted during most of our professional lives would be called into question.
The study by Raab et al.4, "The Utility of Histological Examination of Tissue Removed during Elective Joint Replacement. A Preliminary Assessment," which appears in this issue of The Journal, is based on a relatively small sample of 168 specimens. As Raab et al. did not find any unexpected diagnoses that necessitated a change in treatment, they concluded that the utility of histological examination of such tissue has yet to be determined.
These authors have performed previous studies2,3 in which they applied the standard of utility to routine histological examination of other types of specimens, and they came to similar negative conclusions. Although the widely accepted definitions of utility include relative worth, merit, and usefulness to the possessor, Raab et al. used the term utility only to indicate whether or not the diagnosis rendered after the histological examination of a joint specimen produced a change in the management of the patient. Yet, we do not advocate discontinuing the use of ophthalmoscopy, auscultation of the chest, or testing for an Achilles tendon reflex just because there is a low statistical yield of positive findings when they are used in routine physical examination. Similarly, we must avoid regarding histological specimens that rarely reveal unanticipated findings as so-called never-yields. Indeed, the experience of other surgical pathologists, both published and unpublished, indicates a different perception regarding routine histological examinations. In a study of 1794 femoral heads obtained during 19921, there was an overall disagreement of 5.4 per cent between the clinical and histological diagnoses. Only ninety-four (67 per cent) of the 140 cases of avascular necrosis, sixty-nine (88 per cent) of the seventy-eight cases of inflammatory arthritis, and 107 (93 per cent) of the 115 non-tumorous fractures were correctly diagnosed clinically. In addition, important morbid conditions (enchondroma in two specimens and myeloma, ochronosis, Gaucher disease, and Paget disease in one specimen each) were not included in the clinical diagnosis but were found histologically.
At a time when the Office for Quality Assurance and Quality Control has become a major cost-control center in many hospitals, we believe that many individuals forget that the examination of tissue by a trained independent physician remains the gold standard of quality assurance. More importantly, most of what we know about the pathogenesis and etiology of degenerative joint disease, subchondral osteonecrosis, and rheumatoid arthritis has come from routine, thorough, thoughtful examination of histological specimens obtained during total joint replacements in the last three decades. It would be a great impediment to the further acquisition of knowledge about these still poorly understood pathological processes if specimens obtained during joint replacement procedures were to be discarded in a cursory manner. As all of these conditions are treated in the same way, some might say: who cares? Our reply would be: only those who care about the continuation of scientific medicine.
Peter G. Bullough, M.D.
Howard D. Dorfman, M.D.