INTERVENTIONAL PULMONOLOGY IN OTHER JOURNALS: Commentary on Selected Publications
Immediate on-site interpretation of fine-needle aspiration smears: a cost and compensation analysis.
Cancer 2001;93:319–22. Layfield LJ, Bentz JS, Gopez EV. Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A.
This study evaluated the cost-effectiveness of on-site interpretation of endoscopic fine-needle aspirations (FNA) in the diagnostic workup of patients with potential neoplastic disease. This study also assessed whether compensation from Medicare is adequate to support the pathologist in this endeavor compared with other potentially more remunerative activities, including routine surgical pathology sign-out, nongynecologic cytopathology sign-out, and frozen section consultation. The study included a series of 142 FNAs with immediate on-site evaluations performed in a variety of clinical settings. The FNAs were obtained from bronchoscopic, endoscopic, ultrasound-guided, and CT-guided biopsies along with palpation-directed biopsies performed by either cytopathologists or clinicians. For these aspirates, total pathologist attendance time was calculated and correlated with guidance technique, target organ, location where aspirate was performed, and nature of the aspirator. Fifty frozen section evaluations were timed similarly. For comparison purposes, cytopathologists' costs were calculated using the 80th percentile pay level of an associate professor with full-time clinical duties. Medicare rate schedules were used to calculate compensation. Including salary and benefits, the pathologist cost was approximately $88.83 per hour. The results showed that, on average, an intraprocedural FNA evaluation for a CT-guided biopsy required 48.7 minutes, an ultrasound-guided biopsy required 44.4 minutes of a pathologist's time, an endoscopic procedure required 56.2 minutes, a bronchoscopic procedure required 55.3 minutes, a clinic aspirate performed by a pathologist required 42.5 minutes, and a clinical FNA performed by a clinician required 34.7 minutes. The average frozen section required 15.7 minutes of a pathologist's time for performance and interpretation. With the exception of FNAs performed in the clinic by the cytopathologist, time costs exceeded compensation by $40 to $50 per procedure. Clinic aspirates performed by a clinician and evaluated immediately by a pathologist resulted in a deficit of approximately $18 over actual time cost. Based on these findings, the authors conclude that intraprocedural consultations by cytopathologists for CT-guided, ultrasound-guided, bronchoscopic, or endoscopic procedures are compensated insufficiently by current Medicare compensation schedules using the current procedural terminology code 88172 for on-site evaluation. Furthermore, the authors indicate that only when the cytopathologist performs the aspirate personally and interprets it immediately (current procedural terminology codes 88172 and 88170) does the Medicare payment compensate adequately for professional services. For those who practice in countries that pay compensation based on rules akin to those enforced by Medicare and other third-party payers in the United States, this study shows that on-site interpretation as described by Layfield et al. is not cost-effective. The findings from this study contradict several authorities who have stated that immediate, on-site smear evaluation by cytopathologists optimizes diagnostic accuracy and minimizes the technique's insufficiency rate.