The clinical application and cost analysis of fine-needle aspiration biopsy in the diagnosis of mass lesions in sarcoidosis.

BACKGROUND: Sarcoidosis is a prevalent disease of unknown cause characterized by granulomatous inflammation that often creates deep and/or superficial mass lesions. Tissue samples are considered the "gold standard" in diagnosis; however, it is a medically treated disease. We analyzed the utility and relative cost-effectiveness of fine-needle aspiration biopsy (FNAB) in the clinical investigation of patients with both suspected and unsuspected sarcoidosis. METHODS: All FNAB cases with sarcoidosis either as the cytologic diagnosis or mentioned as part of the differential diagnosis were retrospectively reviewed for clinical history, follow-up, cytologic features, and surgical pathology findings. Comparative analysis of cost of FNAB and excisional biopsy were also made. RESULTS: Thirty-two FNABs in 28 patients included 17 women and 11 men. Anatomic sites included lymph node (n = 17), lung (n = 5), salivary gland (n = 8), and liver (n = 2). Sarcoidosis had already been diagnosed or was a clinical consideration prior to FNAB in 14 cases. Chest radiograph showed abnormal findings in 19 cases. Angiotensin-converting enzyme (ACE) was measured in seven patients and was elevated in four. All aspirates showed granulomatous inflammation; in 22 patients, special stains or cultures for microorganisms were negative. Simultaneous or subsequent excisional biopsies confirmed the FNAB findings in 17 patients. Institutional ratios of excisional biopsy to FNAB in the diagnosis of sarcoidosis ranged from 4 to 19:1. The cost of FNAB was only 12.5 to 50% that of tissue biopsy. CONCLUSIONS: FNAB appears to be underutilized in the diagnosis of sarcoidosis. When used in conjunction with radiologic and laboratory data, FNAB may be a reliable and cost-effective method of diagnosis, especially in patients with an established diagnosis of sarcoidosis.

The cost-effectiveness of the cytology laboratory and new cytology technologies in cervical cancer prevention.

The effect of changes in cytology laboratory costs, including the costs of new technologies, on the cost-effectiveness of cervical cancer prevention has not been studied. Using University of Iowa laboratory detection rates and costs, a decision model determined the cost-effectiveness of the laboratory with and without new technologies. Compared with not performing a cervicovaginal smear, the cost to increase the discounted life expectancy per patient by 1 year was $2,805 for the laboratory component alone and $19,655 for the entire cervical cancer prevention strategy. In moderate- to high-risk women, cervical cancer screening was cost-effective even at high cytology laboratory costs (eg, $75 per smear). New technologies were cost-effective only if they resulted in a substantial increase in the detection of high-grade squamous intraepithelial lesions (eg, an additional 236 high-grade squamous intraepithelial lesions per 10,000 women). New technologies have not demonstrated these increased detection rates.

Sensitivity and cost-effectiveness of fine-needle aspiration with immunocytochemistry in the evaluation of patients with a pulmonary malignancy and a history of cancer.

OBJECTIVE: To determine the sensitivity and cost-effectiveness of transthoracic fine-needle aspiration in the separation of primary from metastatic malignancy. MATERIALS AND METHODS: Eighty-nine malignant pulmonary fine-needle aspirations in patients with a history of cancer were classified retrospectively by light microscopy, comparison with previous material, and immunocytochemistry. Decision analysis compared the cost-effectiveness of fine-needle aspiration, bronchoscopy, and thoracoscopy. RESULTS: Fine-needle aspiration classified 87% of the malignancies as primary (n = 7) or metastatic (n = 70) and 13% as indeterminate. By immunocytochemistry alone, 14 of 18 malignancies were subclassified. Decision analysis showed that pulmonary fine-needle aspiration with select use of thoracoscopy was more cost-effective than either bronchoscopy or thoracoscopy alone in many common clinical scenarios. CONCLUSIONS: Pulmonary fine-needle aspiration with immunocytochemistry is sensitive and cost-effective in subclassifying malignancies in patients with a history of cancer.

Clinician-directed hospital cost management for total hip arthroplasty patients.

Can patients treated with total hip arthroplasty (THA) receive high-quality inpatient care at less cost? In 1984, a group of orthopedic surgeons and nurses examined the use of resources for THA patients and changed certain clinical practices to promote more cost-effective hospital care. At the end of the two-year project, orders for complete blood counts fell 72% and mean operating room time dropped 47 minutes for the participating orthopedists. For all orthopedists in the division, average length of stay (ALOS) decreased from 13 to 11 days. By the end of the following year, when clinicians received quarterly length-of-stay (LOS) data, ALOS dropped further to 9.8 days. This significant ALOS reduction was not accompanied by an increase in hospital readmissions or nursing home placements. The ALOS reduction was also not seen in elective coronary artery bypass graft patients whose ALOS did not substantially change over the same period. Two years after the project, ALOS for THA patients remained at ten days or below. This reduction in LOS and in the use of other hospital services translated into a mean total hospital charge decrease of $2045 per THA patient.

Morphometric and morphologic evaluations in stage III non-small cell lung cancers. Prognostic significance of quantitative assessment of infiltrating lymphoid cells.

This study evaluated data from 30 non-small cell lung cancer (NSCLC) patients to determine whether demographic, clinical, and morphologic and morphometric data that were obtained prior to treatment, could be used to predict survival. All patients had Stage III disease, and all subsequently were treated identically with concurrent radiotherapy, cisplatin, and 5-fluorouracil. The series consisted of 18 squamous carcinomas, eight adenocarcinomas, and four large cell carcinomas. Morphometric measurements of randomized selected cancer cells per case included diameter of cytoplasm, nuclei, and nucleoli. Morphologic parameters evaluated were mitotic index, histologic differentiation, and pattern of nuclear chromatin of cancer cells, and the degree of necrosis and fibrosis of tumor tissue. The lymphoid and neutrophil index defined as the ratio of lymphoid cells and neutrophils to cancer cells from randomized microscopic fields (median = 25) at 400 x magnification were also determined. Our study indicated that the peritumor lymphoid index was the only factor significantly associated with the length of survival. The correlation coefficient (Pearson r) of these two factors was 0.5 (P less than 0.005). The median survival time of patients with peritumor lymphoid index less than 3 and greater than or equal to 3 was 95 days and 376 days, respectively (Kaplan-Meier estimation). The peritumor lymphoid index was an independent prognosticator of clinical outcome of Stage III NSCLC patients, and did not correlate with any of the other parameters analyzed.

Physician-generated cost containment in transurethral prostatectomy.

Cost containment need not be imposed on physicians by government, insurance companies and hospital administrators. Decreases in hospital cost can be achieved voluntarily by physicians without sacrificing quality of care, especially for common procedures with relatively homogeneous patient populations, such as transurethral prostatectomy. Variations in existing practice were identified and shared, and optimal scientific practice was discussed at 5 meetings of the division of urology during a 16-month period. Strict guidelines were not developed; surgeons were encouraged to apply cost-related knowledge individually. Resource use was measured before, during and after the intervention. A total of 356 transurethral prostatectomies was studied. There were significant decreases in preoperative and postoperative length of stay, specific ordering practices and total hospital charges. University faculty differed from community urologists and individual surgeons varied considerably. Suggestions for scientific cost management in prostatectomy are presented.

The triage role of fine needle aspiration biopsy of palpable breast masses. Diagnostic accuracy and cost-effectiveness.

A total of 219 fine needle aspiration (FNA) biopsies of the breast were performed during the period 1983 to 1985 at a tertiary medical center. The series consisted of 215 women (98.2%) and 4 men (1.8%), with an are range of 14 to 90 years (mean of 46.5 years). Histologic confirmation (93 cases) or clinical follow-up for up to two years was obtained. The sensitivity of the FNA procedure was 82.2%, its specificity was 98.8%, and the overall efficiency of the test was 95.4%. The false-negative rate was 4.4%, with no false-positive diagnoses for the primary diagnosis of breast carcinoma. We have found that one of the major advantages of FNA biopsy is that it lowers costs by allowing the surgeon to triage which patients should have an outpatient excisional biopsy under local anesthesia and which patients should have a one-stage inpatient procedure with frozen section confirmation. For this triage role, suspicious diagnoses (3.2%) were included in the positive group and atypical (1.8%) and insufficient diagnoses (6.8%) in the negative group. Taking into account the FNA biopsy cost of $75, the procedure resulted in a savings per case of $262 over the cost that would have occurred if all cases had had routine inpatient biopsy and $154 per case over the cost that would have occurred with routine outpatient biopsy of all cases. Our results indicate that FNA breast biopsy is a diagnostically accurate and economical triage procedure, even when followed by an excisional or frozen-section biopsy for confirmation. The use of FNA biopsy could be expanded to a greater number of medical centers and decrease the potential for false-positive diagnoses by combining FNA biopsy with frozen-section confirmation.

Intensive care for the elderly: outcome of elective and nonelective admissions.

Survival, quality of life, and need for continuing medical care were evaluated for 134 elderly patients admitted to the intensive care units (ICU) at Stanford University Hospital and for a control group. Of the patient group, 57.5% were admitted to the ICU following elective surgery; 42.5% were emergency surgical and medical patients. Hospital mortality was 3.9% for elective and 22.8% for nonelective patients; 18-month mortality was 13.0% and 47.4%, respectively. Fifty-nine patients (60.8% of survivors) completed follow-up questionnaires. Subjective and objective quality of life was good. Quality of life was slightly worse for ICU survivors than for controls; elective and nonelective patients did not differ significantly. Although the cost of ICU hospitalization was high, additional medical care was not excessive. Nonelective patients required more continuing care than elective patients, and both groups required more than controls.

Is intensive care worth it? An assessment of input and outcome for the critically ill.

The high cost of treatment in an ICU is clearly recognized; the ultimate benefit of that care in prolonging meaningful life is not as well quantified. We evaluated 337 mixed medical-surgical ICU patients for severity of illness and intensity of therapy and assessed their survival and quality of life 16 to 20 months after discharge. Mortality was 36.9% for emergency surgical and medical patients and 13.9% for elective surgical patients. A total of 140 patients responded to follow-up; 62.2% of patients not retired or homemakers were working full-time. Quality of life was good using both subjective and objective standards. There were few significant differences between elective surgical and other patients. Survival and life quality were related inversely to severity of illness and cost of treatment. Acute health on ICU admission predicted survival well; chronic health and age were better predictors of life quality.

Cost-effectiveness of fine needle biopsy of the breast.

Although fine needle aspiration (FNA) biopsy of the breast has been shown to be a safe and accurate technique, many surgeons question whether it is reliable enough to replace excisional biopsy. If FNA biopsy is followed by excisional biopsy for confirmation, it would seem that the cost of diagnostic work-up would be increased. In this study, however, the authors show that the major economic benefit of FNA biopsy is not that it replaces excisional biopsy, but that it allows the surgeon to triage which patients should have a 1-stage inpatient procedure with frozen section and which patients should have an excisional biopsy as an outpatient under local anesthesia. Over the past 2 years, the average cost at the East Carolina University School of Medicine of excisional outpatient biopsy (negative) was +702 +/- 348; inpatient biopsy (negative) was +1410 +/- 262; inpatient 1-stage procedure (positive) was +4135 +/- 361; and outpatient biopsy (positive) followed by inpatient procedure was +4822 +/- 586. The authors' last 100 FNA biopsies were read as 23 positive, three suspicious, 65 negative, and nine insufficient. There were no false-positives and four false-negatives, for a sensitivity of 87%, specificity of 100%, and accuracy of 96%. Using the above figures, it is possible to calculate the cost per case if all 100 cases had been biopsied by the 1-stage inpatient technique (+2227), by the 2-stage outpatient method (+1938), or guided by the FNA biopsy where positive and suspicious readings are followed by an inpatient 1-stage procedure and negative and insufficient readings followed by an outpatient 2-stage procedure (+1759). Since the FNA biopsy costs +75, it resulted in a savings per case of +393 over routine inpatient biopsy and +104 per case over routine outpatient biopsy. Computer analysis revealed that the FNA biopsy would still be economically favorable if the sensitivity of the test fell as low as 37%, the specificity as low as 80%, or if the percentage of cases of cancer in the population biopsied fell as low as 13%. Since FNA biopsy is cost effective even when followed by an excisional or frozen section biopsy for confirmation, it would be safe and reasonable to expand its use to smaller hospitals where the personnel may be initially less experienced with the technique.

Case mix, costs, and outcomes. Differences between faculty and community services in a university hospital.

To gain insight into the possible consequences of prospective payment for university hospitals, we studied 2025 admissions to the faculty and community services of a university hospital, measuring differences in case mix, costs, and mortality in the hospital. The faculty service had more of the patients with costly diagnoses, but even after adjustment for diagnosis-related groups (DRGs), costs were 11 per cent higher on the faculty service (95 per cent confidence limits, 4 to 18 per cent). The percentage differential was greatest for diagnostic costs. The differential was particularly large--70 per cent (95 per cent confidence limits, 33 to 107 per cent)--for patients with a predicted probability of death of 0.25 or greater. The in-hospital mortality rate was significantly lower on the faculty service after adjustment for case mix and patient characteristics (P less than 0.05); the difference was particularly large for patients in the high-death-risk category. Comparison of a matched sample of 51 pairs of admissions from the high-death-risk category confirmed the above results with respect to costs and in-hospital mortality, but follow-up revealed that the survival rates were equal for the two services at nine months after discharge. The effect of prospective payment on the cost of care will be closely watched; we conclude that is will also be important to monitor the effect on outcomes, including hospital mortality rates.