Immediate on‐site interpretation of fine‐needle aspiration smears

BACKGROUND A significant body of literature exists supporting the cost effectiveness of fine‐needle aspiration (FNA) cytology in the work‐up of patients with potential neoplastic disease. Several authorities have stated that immediate, on‐site smear evaluation by cytopathologists optimizes diagnostic accuracy and minimizes the technique's insufficiency rate. This favorable effect on FNA diagnostic accuracy is most pronounced for deep body sites, where FNA is guided by computed tomography (CT), ultrasound, bronchoscopy, or endoscopy. Little data exist regarding 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. METHODS The authors studied a series of 142 fine‐needle aspirates with immediate, on‐site evaluations performed under a variety of clinical settings. These included 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 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. RESULTS On average, an intraprocedural FNA evaluation for a CT‐guided biopsy required 48.7 minutes, an ultrasound‐guided biopsy required 44.4 minutes of pathologist 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 clinic FNA performed by a clinician required 34.7 minutes. The average frozen section required 15.7 minutes of pathologist time for performance and interpretation. With the exception of FNA performed in clinic by the cytopathologist, time costs exceeded compensation by $40–50 per procedure. Clinic aspirates performed by a clinician and immediately evaluated by a pathologist resulted in a deficit of approximately $18 over actual time cost. CO