Clinical Faceoff: Should Routine Histopathological Analysis be Performed on Specimens Obtained During Primary Arthroplasty Surgery?

The United States Institute of Medicine (IOM) has described six domains of healthcare quality [7]: Safety, effectiveness, efficiency, patient-centeredness, equity, and timeliness. But even within the same healthcare process—such as histopathological analysis of surgical specimens—different experts and experts from different backgrounds may value each of those domains somewhat differently.

As a healthcare process, histopathological analysis of specimens obtained during routine arthroplasty varies widely from institution to institution. While some variation among physicians in the care of patients is inevitable (and beneficial), unexplained systemwide variation should attract our attention as a potential opportunity to improve quality. In this Clinical Faceoff on whether histopathological analysis should be performed on surgical specimens as a matter of routine after arthroplasty surgery, I am joined by two international experts with very different backgrounds: Thomas W. Bauer MD, PhD, and Ola Rolfson MD, PhD.

Dr. Bauer is the Pathologist-in-Chief in the Department of Pathology and Laboratory Medicine at the Hospital for Special Surgery in New York, NY, USA. Dr. Bauer is an expert in the best use of laboratory testing to diagnose periprosthetic infections and other periprosthetic conditions, and is recognized as an innovator in the application of digital imaging to surgical pathology diagnosis. Considering the IOM’s key domains of quality, I think it is fair to say that Dr. Bauer places a heavy emphasis on process safety and patient-centeredness.

Dr. Rolfson is the Director of the Swedish Hip Arthroplasty Register, which has tracked results of patients after THA on a nationwide scale for more than 40 years. He also is an associate professor in the Department of Orthopaedics at the Institute of Clinical Sciences of the Sahlgrenska Academy, at the University of Gothenburg. My impression is that Dr. Rolfson comes at the problem of when and whether to use histopathological analysis more through the IOM’s lens of efficiency.

Quality improvement begins when the gap between the ideal state and the current state is recongized. Balancing safety with efficiency—both of which are recognized by the IOM as key quality values—will require systems-based thinking and collaboration between surgeons and pathologists. I see this Clinical Faceoff as a start to that process.