Work-related musculoskeletal disorders and injuries among emergency medical technicians and paramedics: A comprehensive narrative review.

The aim of this article was to review the current knowledge relating to work-related musculoskeletal disorders (WRMDs) and non-fatal injuries in emergency medical technicians and paramedics (EMTs-Ps). A literature search was conducted in PubMed, Google Scholar, and Clinical Key. The annual prevalence of back pain ranged from 30% to 66%, and back injuries and contusions from 4% to 43%. Falls, slips, trips, and overexertion while lifting or carrying patients or instruments ranged from 10% to 56%, with overexertion being the most common injury. Risk factors were predominantly lifting, working in awkward postures, loading patients into the ambulance, and cardiopulmonary resuscitation procedures. Lack of job satisfaction and social support was associated with WRMDs and injuries. EMTs-Ps had the highest rate of worker compensation claim rates compared to other healthcare professionals. Positive ergonomic intervention results included electrically powered stretchers, backboard wheeler, descent control system, and the transfer sling.

Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?

BACKGROUND: South Africa has a high burden of traumatic injuries that is predominantly managed in the public healthcare system, despite the relative disparity in human resources between the public and private sectors. Because of budget and theatre time constraints, the trauma waiting list often exceeds 50 - 60 patients who need urgent and emergent surgery in high-volume orthopaedic trauma centres. This situation is exacerbated by other surgical disciplines using orthopaedic theatre time for life-threatening injuries because of lack of own theatre availability. One of the proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. OBJECTIVES: To establish the volume of work done by an orthopaedic registrar during a 3-month trauma rotation, and to calculate the implant and theatre costs, as well as compare the salary of a registrar with the theoretical private surgeon fees for procedures performed by the registrar in the 3-month period. METHODS: In a retrospective study, the surgical logbook of a single registrar during a 3-month rotation, from 14 January to 14 April 2019, was reviewed. Surgeon fees were calculated for these procedures, according to current medical aid rates, without additional modifier codes being added. RESULTS: During the 3-month study period, a total of 157 surgical procedures was performed, ranging from total hip arthroplasty to debridement of septic hands. Surgeon fees amounted to ZAR186 565.10 per month ‒ double the gross salary of a registrar. Total implant costs amounted to ZAR1 272 667. Theatre costs were ZAR1 301 976 for the 3-month period. CONCLUSIONS: Although this analysis was conducted over a short period, it highlights the significant amount of trauma work done by a single individual at a high-volume tertiary orthopaedic trauma unit. With increasing budget constraints, pressure on theatre time and a growing population, cost-effective expansion of resources is needed. From this study, it appears that increasing capacity in the state sector could be cheaper than private outsourcing, although a more in-depth analysis needs to be conducted.

Adjunct diagnostic strategies in improving diagnostic yields in image-guided biopsies of musculoskeletal neoplasms-A cost-effectiveness analysis.

BACKGROUND: Routine use of adjunct intraprocedural fresh frozen biopsy (FFP) or point-of-care (POC) cytology at the time of image-guided biopsy can improve diagnostic tissue yields for musculoskeletal neoplasms, but these are associated with increased costs. OBJECTIVE: This study aimed to ascertain the most cost-effective adjunctive test for image-guided biopsies of musculoskeletal neoplasms. METHODS: This expected value cost-effectiveness microsimulation compared the payoffs of cost (2020 United States dollars) and effectiveness (quality-adjusted life, in days) on each of the competing strategies. A literature review and institutional data were used to ascertain probabilities, diagnostic yields, utility values, and direct medical costs associated with each strategy. Payer and societal perspectives are presented. One- and two-way sensitivity analyses evaluated model uncertainties. RESULTS: The total cost and effectiveness for each of the strategies were $1248.98, $1414.09, $1980.53, and 80.31, 79.74, 79.69 days for the use of FFP, permanent pathology only, and POC cytology, respectively. The use of FFP dominated the competing strategies. Sensitivity analyses revealed FFP as the most cost-effective across all clinically plausible values. CONCLUSIONS: Adjunct FFP is most cost-effective in improving the diagnostic yield of image-guided biopsies for musculoskeletal neoplasms. These findings are robust to sensitivity analyses using clinically plausible probabilities.

Compensation claims in pediatric orthopedics in Norway between 2012 and 2018: a nationwide study of 487 patients.

Background and purpose - In Norway all compensation claims based on healthcare services are handled by a government agency (NPE, Norsk Pasientskade Erstatning). We provide an epidemiological overview of claims within pediatric orthopedics in Norway, and identify the most common reasons for claims and compensations.Patients and methods - All compensation claims handled by NPE from 2012 to 2018 within pediatric orthopedics (age 0 to 17 years) were reviewed. Data were analyzed with regard to patient demographics, diagnoses, type of injury, type of treatment, reasons for granted compensation, and total payouts.Results - 487 compensation claims (259 girls, 228 boys) within orthopedic surgery in patients younger than 18 years at time of treatment were identified. Mean age was 12 years (0-17). 150 out of 487 claims (31%) resulted in compensation, including 79 compensations for inadequate treatment, 58 for inadequate diagnostics, 12 for infections, and 1 based on the exceptional rule. Total payouts were US$8.45 million. The most common primary diagnoses were: upper extremity injuries (26%), lower extremity injuries (24%), congenital malformations and deformities (12%), spine deformities (11%), disorders affecting peripheral joints (9%), chondropathies (6%), and others (12%).Interpretation - Most claims were submitted and granted for mismanagement of fractures in the upper and lower extremity, and mismanagement of congenital malformations and disorders of peripheral joints. Knowledge of the details of malpractice claims should be implemented in educational programs and assist pediatric orthopedic surgeons to develop guidelines in order to improve patient safety and quality of care.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

BACKGROUND: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. QUESTIONS/PURPOSES: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? METHODS: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. RESULTS: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. CONCLUSION: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. LEVEL OF EVIDENCE: Level II, prognostic study.

Workers' Compensation Claim Rates and Costs for Musculoskeletal Disorders Related to Overexertion Among Construction Workers - Ohio, 2007-2017.

Overexertion is a leading cause of work-related musculoskeletal disorders (WMSDs) among construction workers. Nearly 90% of construction jobs require manual handling of materials for approximately one half of the worker's time (1). In 2015, overexertion from lifting and lowering materials caused 30% of WMSDs among construction workers; overexertion involving pushing, pulling, holding, carrying, and catching materials caused an additional 37% of WMSDs (1). This study examined the rate and cost of WMSD claims from overexertion among Ohio construction workers during 2007-2017. Workers' compensation claims related to overexertion that were submitted to the Ohio Bureau of Worker's Compensation (OHBWC) by workers in the construction industry for injuries and illnesses occurring during 2007-2017 were analyzed. Rates and costs of allowed claims were measured by age group. Workers aged 35-44 years experienced the highest claim rate: 63 per 10,000 full-time employees (FTEs) for WMSDs from overexertion. However, claims by workers aged 45-54 years and 55-64 years were more costly on average and resulted in more days away from work. Ergonomic design improvements and interventions are needed to ensure that the majority of construction workers can safely perform jobs throughout their careers. Age-specific WMSD prevention and risk communication efforts also might be helpful.

Overcoming Overuse Part 4: Small Business Survival.

SUMMARY: The challenge of overuse raises important questions for those in the business of musculoskeletal health care. What is the right number of physical therapy visits for a given condition? Can a practice provide "less" but still be profitable? In this, the editorial on overcoming overuse of musculoskeletal health care, we consider the economic drivers of overuse in the private sector. We propose actions that could support small business leaders to overcome overuse and build profitable, high-quality services. J Orthop Sports Phys Ther 2021;51(1):1-4. doi:10.2519/jospt.2021.0101.

Comparing fly-in fly-out and telehealth models for delivering advanced-practice physiotherapy services in regional Queensland: An audit of outcomes and costs.

INTRODUCTION: Recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities in Queensland, Australia remains a challenge. To overcome this barrier, two different service delivery models (Fly-In, Fly-Out (FIFO), Telehealth) were trialled by one regional facility. This study aims to describe the economic- and service-related outcomes of these two methods of service delivery. METHODS: A retrospective audit was conducted where two nine-week time periods were selected for each service delivery model. Outcomes of interests include patient demographics and case-mix, service utilisation, clinical actions, adverse events and costs. Net financial position for both models was calculated based upon costs incurred and revenue generated by service activity. RESULTS: A total of 33 appointment slots were recorded for each service delivery model. Patient case-mix was variable, where the Telehealth model predominately involved patients with musculoskeletal spinal conditions managed from a neurosurgical waiting list. Appointment slot utilisation and pattern of referral for further investigations were similar between models. No safety incidents occurred in either service delivery model. An estimated cost-savings of 13% for the Telehealth model could be achieved when compared to the FIFO model. DISCUSSION: Telehealth is a safe, efficient and viable option when compared to a traditional in-person outreach service, while providing cost-savings. Telehealth should be seen as a service delivery medium in which sustainable recruitment of advanced-practice physiotherapists to regional and rural healthcare facilities can be achieved.

Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis.

OBJECTIVE: Direct access to physical therapy provides an alternative to physician-first systems for patients who need physical therapy for musculoskeletal disorders (MSDs). Direct access across multiple countries and the United States (US) military services has produced improved functional outcomes and/or cost-effectiveness at clinical and health care system levels; however, data remain scarce from civilian health care systems within the United States. The purpose of this study was to compare evidence regarding costs and clinical outcomes between direct access and physician-first systems in US civilian health services. METHODS: A database search of PubMed, CINAHL, Cochrane Reviews, and PEDro was conducted through May 2019. Studies were selected if they specified civilian US, physical therapy for MSDs, direct access or physician-first, and extractable outcomes for cost, function, or number of physical therapy visits. Studies were excluded if interventions utilized early or delayed physical therapy access compared with physician-first. Five retrospective studies met the criteria. Means and standard deviations for functional outcomes, cost, and number of visits were extracted, converted to effect sizes (d) and 95% CI, and combined into grand effect sizes using fixed-effect or random-effects models depending on significance of the Q heterogeneity statistic. RESULTS: Direct access to physical therapy showed reduced physical therapy costs (d = -0.23; 95% CI = -0.35 to -0.11), total health care costs (d = -0.19; 95% CI = -0.32 to -0.07), and number of physical therapy visits (d = -0.17; 95% CI = -0.29 to -0.05) compared to physician-first systems. Disability decreased in both direct access (d = -1.78; 95% CI = -2.28 to -1.29) and physician-first (d = -0.89; 95% CI = -0.92 to -0.85) groups; functional outcome improved significantly more with direct access (z score = 0.89; 95% CI = 0.40 to 1.39). CONCLUSIONS: Direct access to physical therapy is more cost-effective, resulting in fewer visits than physician-first access in the United States, with greater functional improvement. IMPACT: These findings within civilian US health care services support a cost-effective health care access alternative for spine-related MSDs and can inform health care policy makers.

Health behaviours and psychosocial working conditions as predictors of disability pension due to different diagnoses: a population-based study.

BACKGROUND: To investigate whether the clustering of different health behaviours (i.e. physical activity, tobacco use and alcohol consumption) influences the associations between psychosocial working conditions and disability pension due to different diagnoses. METHODS: A population-based sample of 24,987 Swedish twins born before 1958 were followed from national registers for disability pension until 2013. Baseline survey data in 1998-2003 were used to assess health behaviours and psychosocial Job Exposure Matrix for job control, job demands and social support. Cox proportional hazards models were used to calculate hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: During follow-up, 1252 disability pensions due to musculoskeletal disorders (5%), 601 due to mental diagnoses (2%) and 1162 due to other diagnoses (5%) occurred. In the models controlling for covariates, each one-unit increase in job demands was associated with higher (HR 1.16, 95%CI 1.01-1.33) and in job control with lower (HR 0.87, 95%CI 0.80-0.94) risk of disability pension due to musculoskeletal disorders among those with unhealthy behaviours. Among those with healthy behaviours, one-unit increase of social support was associated with a higher risk of disability pension due to mental and due to other diagnoses (HRs 1.29-1.30, 95%CI 1.04-1.63). CONCLUSIONS: Job control and job demands were associated with the risk of disability pension due to musculoskeletal disorders only among those with unhealthy behaviours. Social support was a risk factor for disability pension due to mental or other diagnoses among those with healthy behaviours. Workplaces and occupational health care should acknowledge these simultaneous circumstances in order to prevent disability pension.

What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

BACKGROUND: Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs. QUESTIONS/PURPOSES: (1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU? METHODS: An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true "bottom-up" micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission. RESULTS: The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission. CONCLUSIONS: Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU. LEVEL OF EVIDENCE: Level, IV, economic and decision analyses.

Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?

BACKGROUND: Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited. QUESTIONS/PURPOSES: This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED? METHODS: This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation. RESULTS: After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting. CONCLUSIONS: There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Burden of Pediatric Musculoskeletal Diseases Worldwide.

Global burden of disease (GBD) refers to the economic and human costs resulting from poor health. The disability-adjusted life year is a measure of life lost from premature death and life not lived at 100% health. Surgery has long been neglected in the distribution of resources for global health. Because of years of life lived with a disability and the large proportion of children in a population, pediatric musculoskeletal conditions early in life can contribute to the GBD. Fortunately, the World Health Organization has recently promoted essential surgical services through its Emergency and Essential Surgical Care Project and Global Initiative.

Step-downs reduce workers' compensation payments to encourage return to work: are they effective?

OBJECTIVE: To determine whether step-downs, which cut the rate of compensation paid to injured workers after they have been on benefits for several months, are effective as a return to work incentive. METHODS: We aggregated administrative claims data from seven Australian workers' compensation systems to calculate weekly scheme exit rates, a proxy for return to work. Jurisdictions were further subdivided into four injury subgroups: fractures, musculoskeletal, mental health and other trauma. The effect of step-downs on scheme exit was tested using a regression discontinuity design. Results were pooled into meta-analyses to calculate combined effects and the proportion of variance attributable to heterogeneity. RESULTS: The combined effect of step-downs was a 0.86 percentage point (95% CI -1.45 to -0.27) reduction in the exit rate, with significant heterogeneity between jurisdictions (I2=68%, p=0.003). Neither timing nor magnitude of step-downs was a significant moderator of effects. Within injury subgroups, only fractures had a significant combined effect (-0.84, 95% CI -1.61 to -0.07). Sensitivity analysis indicated potential effects within mental health and musculoskeletal conditions as well. CONCLUSIONS: The results suggest some workers' compensation recipients anticipate step-downs and exit the system early to avoid the reduction in income. However, the effects were small and suggest step-downs have marginal practical significance. We conclude that step-downs are generally ineffective as a return to work policy initiative.Postprint link: https://www.medrxiv.org/content/10.1101/19012286.

Epidemiology and Financial Burden of Musculoskeletal Injuries as the Leading Health Problem in the Military.

INTRODUCTION: Musculoskeletal injuries (MSIs) have direct impact on occupational readiness and task performance in military populations. Until this date, no epidemiologic data have been published concerning MSI incidence in the Netherlands Armed Forces (NAF). The aim of this study was to assess the MSI incidence and related costs in the NAF. METHODS: In this descriptive epidemiologic study, we collected injury surveillance data from the electronic patient records of multiple military units of the NAF. Using data of all new consultations with a military physician from January 1, 2014 to December 31, 2016, we calculated MSI incidence rates per 100 person-years, with a 95% confidence interval (CI). Physician care costs were determined based on the number of physician consults and the charge per appointment. We used two methods to determine productivity costs; the top-down microcosting method and the friction cost method. RESULTS: Our study sample included 22% (n = 8,847) of the total NAF population of 2016 (n =40,178). In this sample, consultations of MSIs accounted for 23.2% (n = 7,815) of all new consultations (n = 33,666). MSI incidence rates per unit ranged from 12.5 to53.3 per 100 person-years. In the total sample, MSI incidence rates were highest in the back (6.73, 95% CI 6.39-7.10), knee (5.04, 95% CI 4.74-5.35), and foot (4.79, 95% CI 4.50-5.10). The estimated costs for physician visits for MSIs in our sample were €0.69 million. Limited duty days accounted for €1.10 million productivity costs using top-down microcosting method. CONCLUSION: Our study provided evidence that MSIs result in substantial financial burden. Injuries of the back, knee, and foot account for the majority of demands on curative care for MSIs.

Physical therapy musculoskeletal imaging authority: A survey of the World Confederation for Physical Therapy Nations.

OBJECTIVES: Medical evidence largely supports PTs in expanded roles, however, healthcare policy within the United States (USA) typically restricts PTs from ordering musculoskeletal (MSK) imaging. It is unknown how MSK imaging policy in the USA compares to other World Confederation for Physical Therapy (WCPT) member nations. The primary objective of our study was to investigate the authority of PTs to order MSK imaging. A secondary objective was to identify factors associated with the authority for PTs to order MSK imaging. METHODS: 111 WCPT member nations were surveyed over a 2-month period on the authority of PTs ordering MSK imaging within their nation. A secondary analysis utilizing a step-wise binary regression compared member nation demographic statistics to MSK imaging authority. RESULTS: 81 member nations responded to the survey. 31 (38.3%) of member nations reported having some level of PT MSK imaging authority while 50 (61.7%) did not. Member nations with lower per capita healthcare costs were significantly more likely to allow PTs to order MSK imaging (p = 0.02). Those with direct access authority were 7.4 times more likely to authorize PTs to order MSK imaging (p < 0.01). Entry-level clinical degree and years of entry-level collegiate credit were not associated with imaging authority. CONCLUSION: This is the first study to report MSK imaging policy within the WCPT member nations. While many nations within the WCPT allow PTs to order MSK imaging, the majority of nations still restrict PTs from such practice. Lower per capita healthcare costs and direct access authority were significant predictors of MSK imaging authority, however, causation cannot be established within the confines of this study. Future studies should consider issues such as restrictive policy origin (i.e. governmental vs. institutional), insurance reimbursement (i.e. private vs. public sector policy), and limitations on imaging modality.

Measuring Productivity Costs in Patients With Musculoskeletal Disorders: Measurement Properties of the Institute for Medical Technology Assessment Productivity Cost Questionnaire.

BACKGROUND: The Institute for Medical Technology Assessment Productivity Cost Questionnaire (iPCQ) was recently developed to cover all domains of productivity costs; absenteeism, presenteeism and productivity costs related to unpaid work. The original iPCQ has not been tested with respect to neither content or construct validity, nor reliability, and there is no Norwegian version of the questionnaire. OBJECTIVES: To translate and cross-culturally adapt the iPCQ into Norwegian and to test its measurement properties among patients with musculoskeletal disorders. METHODS: Translation and cross-cultural adaptation was conducted according to guidelines, and measurement properties were investigated using a cross-sectional design including a test-retest assessment. Patients with musculoskeletal disorders were recruited from secondary care. Data quality, content validity (10 patients evaluated comprehensibility, 2 researchers and 1 clinician evaluated relevance and comprehensiveness), construct validity (factor analysis, internal consistency, divergent hypothesis testing), and test-retest reliability (intraclass correlation coefficient two-way random average agreement, Cohen's unweighted kappa) were assessed. RESULTS: In total, 115 patients with a mean age (SD) of 46 (9) years were included, and 62 responded to the retest. The questionnaire was feasible, with little missing data and no floor or ceiling effects. Content validity displayed good comprehensibility and relevance and sufficient comprehensiveness. Factor analysis revealed a 3-component solution accounting for 82% of the total variance; items loaded as expected and supported the original structure of the iPCQ. Internal consistency was acceptable for the 3 components of productivity cost, with an inter-item correlation ranging from 0.42 to 0.62. Further, a total of 91% of our hypotheses were verified. The intraclass correlation coefficient values ranged from 0.88 to 0.99 for all items except one; kappa ranged from 0.61 to 0.92, indicating overall good reliability of the questionnaire. CONCLUSIONS: The Norwegian iPCQ showed good measurement properties among patients with musculoskeletal disorders from secondary care in Norway. We therefore recommend the iPCQ as a useful tool for measuring productivity costs in patients with musculoskeletal disorders.

Characterizing Direct-to-Consumer Stem Cell Businesses in the Southwest United States.

There are currently hundreds of businesses across the United States offering direct-to-consumer stem cell treatments that have not been through regulatory approval by the Food and Drug Administration (FDA). Here, we provide a detailed characterization of nearly 170 stem cell businesses operating in the Southwest United States. We draw specific attention to two as-yet understudied facets of these businesses. First, we identify differences in the degree to which a given business focuses their practice on stem cell treatments. Second, we compare the stated expertise of the care providers in stem cell businesses with the range of conditions they purport to treat. These findings deepen our knowledge of the growing industry around unapproved stem cell treatments, and are used here to offer suggestions for how the FDA might target its resources with respect to regulatory oversight.