Financial and educational impact of the COVID-19 pandemic in an academic hospital-based tertiary cytopathology practice.

BACKGROUND: The ongoing COVID-19 pandemic has led to a dramatic shift in volumes and practice patterns for hospitals around the globe. We analyzed its effect on the cytopathology subspecialty practice and resident education at our institution. DESIGN: Specimen volumes were analyzed for the cytology practice for 2019 and 2020. Patient registration and elective and scheduled surgery volumes were also included in the analysis for 2020. The impact of innovative concepts, such as virtual teaching, on resident teaching was evaluated using a survey consisting of 5 multiple choice questions with 4 possible responses each. RESULTS: The total number of specimens decreased by 28% in March 2020 (P < 0.00001), with a continuing decline in April (66% decrease year-over-year, P < 0.00001), followed by recovery in May and return to baseline within June 2020. Specimen volumes continued to show an upward trend thereafter. Improved specimen volumes correlated with patient registration and surgical volumes. The majority of residents considered virtual teaching conferences (75%) and self-study sets (58%) as beneficial and did not view absence of one-on-one microscope learning (58%) as significantly affecting their education. CONCLUSION: The recovery curve for our cytopathology service was V-shaped, essentially the most ideal response to an economic downturn. The majority of residents viewed virtual teaching conferences and self-study sets favorably and did not regard absence of one-on-one microscope learning as adversely affecting their education.

The medical student's guide to pathology residency, fellowships, and careers.

Recent studies have shown that relatively few MD, DO, and underrepresented in medicine (URM) students and physicians are matching into pathology residency in the United States (US). In the 2021 Main Residency Match, just 33.6% of filled pathology residency positions were taken by senior year students at US allopathic medical schools. This has been attributed to the fact that pathology is not a required rotation in most US medical schools, pathology is often taught in an integrated curriculum in the US where is does not stand out as a distinct field, and because the COVID-19 pandemic led to a suspension of in-person pathology rotations and electives. Ultimately, many US medical students fail to consider pathology as a career pathway. The objective of this article is to provide medical students with basic information, in the form of frequently asked questions (FAQs), about pathology training and career opportunities. This was accomplished by forming a team of MD and DO pathology attendings, pathology trainees, and a medical student from multiple institutions to create a pathology guide for medical students. This guide includes information about post-sophomore fellowships, 5 major pathology residency tracks, more than 20 fellowship pathways, and allopathic and osteopathic board examinations. This guide also contains photographs and descriptions of major pathology sub-specialties, including the daily and on-call duties and responsibilities of pathology residents. The exciting future of pathology is also discussed. This guide supports the agenda of the College of American Pathologists' (CAP) Pathologist Pipeline Initiative to improve student recruitment into pathology.

Cost-effectiveness analysis of primary human papillomavirus testing in cervical cancer screening: Results from the HPV FOCAL Trial.

The Human Papillomavirus FOr CervicAL cancer (HPV FOCAL) trial is a large randomized controlled trial comparing the efficacy of primary HPV testing to cytology among women in the population-based Cervix Screening Program in British Columbia, Canada. We conducted a cost-effectiveness analysis based on the HPV FOCAL trial to estimate the incremental cost per detected high-grade cervical intraepithelial neoplasia of grade 2 or worse lesions (CIN2+). A total of 19,009 women aged 25 to 65 were randomized to one of two study groups. Women in the intervention group received primary HPV testing with reflex liquid-based cytology (LBC) upon a positive finding with a screening interval of 48 months. Women in the control group received primary LBC testing, and those negative returned at 24 months for LBC and again at 48 months for exit screening. Both groups received HPV and LBC co-testing at the 48-month exit. Incremental costs during the course of the trial were comparable between the intervention and control groups. The intervention group had lower overall costs and detected a larger number of CIN2+ lesions, resulting in a lower mean cost per CIN2+ detected ($7551) than the control group ($8325), a difference of -$773 [all costs in 2018 USD]. Cost per detected lesion was sensitive to the costs of sample collection, HPV testing, and LBC testing. The HPV FOCAL Trial results suggest that primary HPV testing every 4 years produces similar outcomes to LBC-based testing every 2 years for cervical cancer screening at a lower cost.

Artificial intelligence (AI) in medicine, current applications and future role with special emphasis on its potential and promise in pathology: present and future impact, obstacles including costs and acceptance among pathologists, practical and philosophical considerations. A comprehensive review.

BACKGROUND: The role of Artificial intelligence (AI) which is defined as the ability of computers to perform tasks that normally require human intelligence is constantly expanding. Medicine was slow to embrace AI. However, the role of AI in medicine is rapidly expanding and promises to revolutionize patient care in the coming years. In addition, it has the ability to democratize high level medical care and make it accessible to all parts of the world. MAIN TEXT: Among specialties of medicine, some like radiology were relatively quick to adopt AI whereas others especially pathology (and surgical pathology in particular) are only just beginning to utilize AI. AI promises to play a major role in accurate diagnosis, prognosis and treatment of cancers. In this paper, the general principles of AI are defined first followed by a detailed discussion of its current role in medicine. In the second half of this comprehensive review, the current and future role of AI in surgical pathology is discussed in detail including an account of the practical difficulties involved and the fear of pathologists of being replaced by computer algorithms. A number of recent studies which demonstrate the usefulness of AI in the practice of surgical pathology are highlighted. CONCLUSION: AI has the potential to transform the practice of surgical pathology by ensuring rapid and accurate results and enabling pathologists to focus on higher level diagnostic and consultative tasks such as integrating molecular, morphologic and clinical information to make accurate diagnosis in difficult cases, determine prognosis objectively and in this way contribute to personalized care.

The corporatization of dermatopathology.

The corporatization of dermatopathology has long preceded that of dermatology and has been driven by federal legislation and economic influences. Although the Clinical Laboratory Improvement Amendments and the Stark Law limited physician-owned laboratories, loopholes via the Safe Harbor Exemptions outlined in the Anti-Kickback Statute allowed corporate laboratories to flourish through relationships built by health information technology donations. The rise of corporatization has had widespread effects on the fields of dermatopathology and dermatology, resulting in reduced numbers of dermatology-trained dermatopathologists and decreased caseloads in academic institutions, potentially compromising dermatology residency education. Although there have been efforts to counteract these effects, more global changes will be required to alter the direction of this subspecialty.

Teaching Laboratory Stewardship in the Medical Student Core Clerkships Pathology-Teaches.

CONTEXT.­: Current health care spending is unsustainable, and there is a need to teach high-value care principles to future physicians. Pathology-Teaches is an educational intervention designed to teach laboratory stewardship early in clinical training, at the level of the medical student in their core clinical clerkships. OBJECTIVE.­: To assess the pilot implementation of case-based educational modules in 5 required core clerkships at our institution. DESIGN.­: The online cases were developed by using a multidisciplinary approach. In the Pathology-Teaches educational module, students make decisions regarding the ordering or interpretation of laboratory testing within the context of a clinical scenario and receive immediate feedback during the case. The intervention was assessed by using pretest and posttest. Student feedback was also collected from end-of-rotation evaluations. RESULTS.­: A total of 203 students completed the Pathology-Teaches pilot, including 72 in Family Medicine, 72 in Emergency Medicine, 24 in Internal Medicine, 24 in Neurology, and 11 in Obstetrics-Gynecology (OB-GYN). Pathology-Teaches utility was demonstrated by significantly increased improvement between pretest and posttest scores (mean, 63.1% versus 83.5%; P < .001; Hedge g effect size = 0.93). Of the 494 students who completed the Pathology-Teaches questions on the end-of-rotation evaluation, 251 provided specific feedback, with 38.6% (97 of 251) rating the activity as "extremely valuable" or "very valuable," and 41.4% (104 of 251) as "some/moderate value." Qualitative feedback included 17 positive comments with 6 requests to scale up or include more cases, 16 constructive comments for improvement mainly regarding the technical aspects, and 5 negative comments. CONCLUSIONS.­: Pathology-Teaches effectively teaches stewardship concepts, and most students perceived value in this educational intervention.

What is the cost benefit ratio of sending adeno-tonsillar tissues for histology: does adenoid/tonsillar tissue in children undergo malignant transformation?

Due to the enormous amount spent on histology of adenoid and tonsillar samples from children with adeno-tonsillectomy with no confirmed result of malignancy, it has become expedient to reconsider sending such tissues for histologyThe objective of this study was to determine the necessity of sending tissues of adenoid and tonsils for histology by means of ascertaining the prevalence of malignancy among children with adeno-tonsillectomy. This was a retrospective study done in three private hospitals that provide care for children in Enugu. Data was obtained from the medical records of 72 patients who had undergone tonsillectomy and/or adenoidectomy from September 2011 to May 2018. All the surgical cases done had their samples sent immediately for histology. A total of 72 adeno-tonsillar tissues were taken for histology of which all showed lymphoid hyperplasia with none showing any form of malignancy. Age group ranged from 6 months-18 years with 57 males and 15 females. Histology of the adeno-tonsillar tissue specimen was done among all the children with each costing 9000 Naira (26 US dollars). There were 3 tonsillectomies, 1 adenectomy and 68 adeno-tonsillectomies done. Indications for surgery were mainly upper airway obstruction for 69 cases and recurrent tonsillectomy for 3 cases. Histology revealed lymphoid hyperplasia for all cases. None of the patients in our study had histologic evidence of malignancy. Routine histopathologic examination in adeno-tonsillectomy specimens among children may be dispensable as it showed a negative cost-benefit ratio.

Development of Functional Requirements for Ex Vivo Pathology Applications of In Vivo Microscopy Systems: A Proposal From the In Vivo Microscopy Committee of the College of American Pathologists.

CONTEXT.­: In vivo microscopy (IVM) allows direct, real-time visualization of tissue histology in living patients without the need for tissue removal, processing, or staining. The IVM technologies in clinical use include confocal microscopy and optical coherence tomography. These technologies also show promise for use with pathology specimens (ex vivo microscopy [EVM]). However, few systems designed for EVM are commercially available, at least in part because of the lack of defined minimal functional requirements (FRs). OBJECTIVE.­: To develop minimal FRs for likely high-volume pathology applications of EVM. DESIGN.­: The IVM Committee of the College of American Pathologists identified potential EVM pathology applications based on the published literature. A subcommittee of IVM and EVM early adopters and experts then defined FRs for the most likely EVM applications. RESULTS.­: Potential EVM applications include assessment of margins, adequacy of needle biopsies and aspirates for diagnosis, and transplant tissues; selection of tissue for molecular studies or biorepository; and guidance in block selection from gross specimens. The first 3 applications were selected for development of FRs. The FRs were identified based on existing laboratory practices and guidelines and input from experts in the field and included device footprint and portability, specimen preparation, imaging time, field of view or resolution, morphologic diagnostic capability, yield, accuracy, ease of use, safety, and cost. CONCLUSIONS.­: Consensus was achieved on FRs that would accommodate the selected EVM applications. Publication and dissemination of those FRs will provide guidance to engineers, researchers, and vendors on how to optimally adapt IVM technologies for EVM for widespread adoption by pathologists.

In Vivo and Ex Vivo Microscopy: A Business Plan to Justify the Introduction of Similar Emerging Technologies Into Pathology Practice.

CONTEXT.­: Our patients are now demanding value for their medical diagnoses and treatment in terms of optimal costs, quality, and outcomes. The financial justification for the introduction of new emerging technologies that may better meet these needs will depend on many factors, even if there is an established reimbursement code. In vivo and ex vivo microscopic technologies (IVM and EVM, respectively) will be used as examples of potentially transforming technologies. OBJECTIVE.­: To describe the components of a business plan that ensures all of the ramifications of introducing a new technology into pathology practice have been considered. As well as the financial justification, such a plan should include strategic vision and congruence, the advantages and drawbacks of introducing such technology, and how plans for marketing, implementation, and verification can be operationalized. DATA SOURCES.­: Unlike many pathologists, administrative directors in clinical laboratories already know the components of a financially sound business plan. In addition to the financial justifications, other considerations of such a plan include expense reductions, multiyear buildups in revenue generation, the replacement of other technologies, improved productivity and workflows, additional space, new capital, retrained personnel, and the impact on other departments. CONCLUSIONS.­: Pathologists will learn a business plan format to improve their confidence in making the sound financial justifications needed to consider the introduction of an emerging technology into pathology practice, even when there is initially no obvious revenue stream because formal reimbursement codes have not been established.

Global Health Pathology Research: Purpose and Funding.

Like in all areas of science, it is important for funders and investigators of pathology to work together to develop a well-designed, well-executed clinical research agenda. In the first section of this article, the authors discuss how the National Institutes of Health (NIH) peer-review process applies to global health pathology research projects. Then, the authors present an illustrative sampling of NIH-funded projects with performance sites in low- and middle-income countries with 2 examples focused on cancer and anatomic pathology. Finally, the authors relate the research agenda to overarching strategic recommendations for enhancing global pathology.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

An Essential Pathology Package for Low- and Middle-Income Countries.

Objectives: We review the current status of pathology services in low- and middle-income countries and propose an "essential pathology package" along with estimated costs. The purpose is to provide guidance to policy makers as countries move toward universal health care systems. Methods: Five key themes were reviewed using existing literature (role of leadership; education, training, and continuing professional development; technology; accreditation, management, and quality standards; and reimbursement systems). A tiered system is described, building on existing proposals. The economic analysis draws on the very limited published studies, combined with expert opinion. Results: Countries have underinvested in pathology services, with detrimental effects on health care. The equipment needs for a tier 1 laboratory in a primary health facility are modest ($2-$5,000), compared with $150,000 to $200,000 in a district hospital, and higher in a referral hospital (depending on tests undertaken). Access to a national (or regional) specialized laboratory undertaking disease surveillance and registry is important. Recurrent costs of appropriate laboratories in district and referral hospitals are around 6% of the hospital budget in midsized hospitals and likely decline in the largest hospitals. Primary health facilities rely largely on single-use tests. Conclusions: Pathology is an essential component of good universal health care.

The Vital Role of Pathology in Improving Reproducibility and Translational Relevance of Aging Studies in Rodents.

Pathology is a discipline of medicine that adds great benefit to aging studies of rodents by integrating in vivo, biochemical, and molecular data. It is not possible to diagnose systemic illness, comorbidities, and proximate causes of death in aging studies without the morphologic context provided by histopathology. To date, many rodent aging studies do not utilize end points supported by systematic necropsy and histopathology, which leaves studies incomplete, contradictory, and difficult to interpret. As in traditional toxicity studies, if the effect of a drug, dietary treatment, or altered gene expression on aging is to be studied, systematic pathology analysis must be included to determine the causes of age-related illness, moribundity, and death. In this Commentary, the authors discuss the factors that should be considered in the design of aging studies in mice, with the inclusion of robust pathology practices modified after those developed by toxicologic and discovery research pathologists. Investigators in the field of aging must consider the use of histopathology in their rodent aging studies in this era of integrative and preclinical geriatric science (geroscience).

Citizens' Perspectives on Disinvestment from Publicly Funded Pathology Tests: A Deliberative Forum.

BACKGROUND: Deliberative forums can be useful tools in policy decision making for balancing citizen voice and community values against dominant interests. OBJECTIVE: To describe the use of a deliberative forum to explore community perspectives on a complex health problem-disinvestment. METHODS: A deliberative forum of citizens was convened in Adelaide, South Australia, to develop criteria to support disinvestment from public funding of ineffective pathology tests. The case study of potential disinvestment from vitamin B12/folate pathology testing was used to shape the debate. The forum was informed by a systematic review of B12/folate pathology test effectiveness and expert testimony. RESULTS: The citizens identified seven criteria: cost of the test, potential impact on individual health/capacity to benefit, potential cost to society, public good, alternatives to testing, severity of the condition, and accuracy of the test. The participants not only saw these criteria as an interdependent network but also questioned "the authority" of policymakers to make these decisions. CONCLUSIONS: Coherence between the criteria devised by the forum and those described by an expert group was considerable, the major differences being that the citizens did not consider equity issues and the experts neglected the "cost" of social and emotional impact of disinvestment on users and the society.

A call for a value based approach to laboratory medicine funding.

All areas of healthcare, including pathology, are being challenged by the reality that the days of ever increasing budgets are over and the key debate is about how to provide value for money. As originally described by Porter and Tiesberg, value-based healthcare is defined as maximising outcomes over cost by moving away from fee for service models to ones that reward providers on the basis of outcomes (1). While production efficiencies will continue to evolve, the opportunities for future stepwise improvements in production costs are likely to have diminished. The focus now is on delivering improved testing outcomes in a relatively cost neutral or at least cost effective way. This brings pathology into line with other health services that focus on value for money for payers, and maximising health outcomes for consumers. This would signal a break from the existing pathology funding model, which does not directly recognise or reward the contribution of pathology towards improved health outcomes, or seek to decommission tests that offer little clinical value. Pathology has a direct impact on clinical and economic outcomes that extend from testing and it is important to garner support for a new approach to funding that incentivises improvements of the overall quality and contribution of the pathology service.

Reagent and labor cost optimization through automation of fluorescence in situ hybridization (FISH) with the VP 2000: an Italian case study.

In the modern molecular diagnostic laboratory, cost considerations are of paramount importance. Automation of complex molecular assays not only allows a laboratory to accommodate higher test volumes and throughput but also has a considerable impact on the cost of testing from the perspective of reagent costs, as well as hands-on time for skilled laboratory personnel. The following study tracked the cost of labor (hands-on time) and reagents for fluorescence in situ hybridization (FISH) testing in a routine, high-volume pathology and cytogenetics laboratory in Treviso, Italy, over a 2-y period (2011-2013). The laboratory automated FISH testing with the VP 2000 Processor, a deparaffinization, pretreatment, and special staining instrument produced by Abbott Molecular, and compared hands-on time and reagent costs to manual FISH testing. The results indicated significant cost and time saving when automating FISH with VP 2000 when more than six FISH tests were run per week. At 12 FISH assays per week, an approximate total cost reduction of 55% was observed. When running 46 FISH specimens per week, the cost saving increased to 89% versus manual testing. The results demonstrate that the VP 2000 processor can significantly reduce the cost of FISH testing in diagnostic laboratories.