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Are Histological Examinations of Arthroplasty Specimens Performed Consistently Across the Country? A Large Database Study

Suchman, Kelly I. BS; Poeran, Jashvant MD, PhD; Huang, Hsin-Hui MD, PhD; Mazumdar, Madhu PhD; Bronson, Michael MD; Galatz, Leesa M. MD; Moucha, Calin S. MD

Clinical Orthopaedics and Related Research®: August 2019 - Volume 477 - Issue 8 - p 1815–1824
doi: 10.1097/CORR.0000000000000635

Background It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers.

Questions/purposes Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?

Methods From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures.

Results In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001).

Conclusions Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties.

Level of Evidence Level III, therapeutic study.

K. I. Suchman, Icahn School of Medicine at Mount Sinai, New York, NY, USA

J. Poeran, H.-H. Huang, M. Mazumdar, Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA

M. Bronson, Mount Sinai West, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

J. Poeran, H.-H. Huang, L. M. Galatz, C. S. Moucha, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

J. Poeran, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Box 1077, Room L2-70, Icahn Building, New York, NY 10029, USA, email:

One author certifies that he (CSM) is an unpaid consultant for a 3M speaker panel and a biocomposites speaker panel. One author certifies that she (LMG) is an unpaid consultant for Medacta and a board member at large of the American Shoulder and Elbow Surgeons. One author certifies that he (MB) is a board member of the Arthritis Foundation.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

Received July 03, 2018

Accepted December 14, 2018

Online date: February 06, 2019

© 2019 Lippincott Williams & Wilkins LWW
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