Mastering your fellowship: Part 4, 2024.

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations for the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

Mastering your fellowship: Part 2, 2024.

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination.

Health budget cuts will be paid for by the most vulnerable.

No abstract available.

Negative Perceptions of Peer Relationships as Mechanisms in the Association Between Maltreatment Timing and the Development of Psychopathology.

Despite findings that developmental timing of maltreatment is a critical factor in predicting subsequent outcomes, children's developmental stage is understudied in maltreatment research. Moreover, childhood maltreatment is associated with the development of maladaptive peer relationships and psychopathology, with social cognition identified as a process underlying this risk. The current study utilizes structural equation modeling to examine the impact of developmental timing of maltreatment (i.e., infancy through preschool versus elementary and middle school years) on psychopathology via negative perceptions of peer relationships. Multi-informant methods were used to assess 680 socioeconomically disadvantaged children. Results did not support differential effects of early versus later maltreatment on children's internalizing symptomatology or disruptive behavior, but indicated that chronic maltreatment, relative to episodic maltreatment, has more severe consequences for children's internalizing symptomatology. Results further support the mediating role of children's perceptions of relationships in the effect of maltreatment on negative developmental outcomes.

Financial burden of anterior cruciate ligament reconstructions in football (soccer) players: an Australian cost of injury study.

OBJECTIVES: To estimate the financial burden of anterior cruciate ligament (ACL) reconstructions in amateur football (soccer) players in Australia over a single year, including both direct and indirect cost. METHODS: Available national direct and indirect cost data were applied to the annual incidence of ACL reconstructions in Australia. Age-adjusted and sex-adjusted total and mean costs (ACL and osteoarthritis (OA)) were calculated for amateur football (soccer) players in Australia using an incidence-based approach. RESULTS: The estimated cost of ACL reconstructions for amateur football players is $A69 623 211 with a mean total cost of $A34 079. The mean indirect costs are 19.8% higher than the mean direct costs. The mean indirect costs are lower in female (11.5%, $A28 628) and junior (15.3%, $A29 077) football players. The mean ACL costs are 3-4-fold greater than the mean OA costs ($A27 099 vs $A6450, respectively), remaining consistent when stratified by sex and age group. Our model suggests that for every 10% increase in adherence to injury prevention programmes, which equates to approximately 102 less ACL injuries per year, $A9 460 224 in ACL costs could be saved. CONCLUSION: While the number of ACL reconstructions per year among football players in Australia is relatively small, the annual financial burden is high. Our study suggests that if injury prevention exercises programmes are prioritised by stakeholders in football, significant cost-savings are possible.

Incidence, characteristics and cost of head, neck and dental injuries in non-professional football (soccer) using 3 years of sports injury insurance data.

AIM: This descriptive epidemiological study aimed to quantify the incidence, characteristics and costs of head, neck and dental injuries in non-professional football players. METHODS: Injury data were coded (using Orchard Sports Injury and Illness Classification System) from a de-identified insurance database containing three seasons (2018-2020) of data. Cost data included direct and indirect costs presented by type of injury, age group and sex using means ± SD, range of costs ($AU) and total costs ± SE. Chi-squared tests were used to analyse the data (significance level p < .05) with injury incidence rates (IR) calculated per 1000 match hours and per 1000 injury insurance claims. RESULTS: A total of 388 injuries affecting 240 players were sustained. Of these, 43% (n = 102) of players also sustained one or more secondary injuries, mainly to the head or neck area. Dental injuries (n = 143, 39%, IR = 0.008) accounted for the highest number of primary and secondary injuries and the highest mean direct cost per injury ($AU1152), while head and facial injuries accounted for the highest proportion of total costs ($AU434,101). Players who sustained one or more secondary injuries had the highest direct and indirect mean cost per injury. CONCLUSIONS: Given the frequency and cost of dental injuries in non-professional football players, injury prevention initiatives warrant further investigation.

Patient, Provider, and Practice Characteristics Predicting Use of Diagnostic Imaging in Primary Care: Cross-Sectional Data From the National Ambulatory Medical Care Survey.

OBJECTIVE: To determine imaging utilization rates in outpatient primary care visits and factors influencing likelihood of imaging use. METHODS: We used 2013 to 2018 National Ambulatory Medical Care Survey cross-sectional data. All visits to primary care clinics during the study period were included in the sample. Descriptive statistics on visit characteristics including imaging utilization were calculated. Logistic regression analyses evaluated the influence of a variety of patient-, provider-, and practice-level variables on the odds of obtaining diagnostic imaging, further subdivided by modality (radiographs, CT, MRI, and ultrasound). The data's survey weighting was accounted for to produce valid national-level estimates of imaging use for US office-based primary care visits. RESULTS: Using survey weights, approximately 2.8 billion patient visits were included. Diagnostic imaging was ordered at 12.5% of visits with radiographs the most common (4.3%) and MRI the least common (0.8%). Imaging utilization was similar or greater among minority patients compared with White, non-Hispanic patients. Physician assistants used imaging at higher rates than physicians, in particular CT at 6.5% of visits compared with 0.7% for doctors of medicine and doctors of osteopathic medicine (odds ratio 5.67, 95% confidence interval 4.07-7.88). CONCLUSION: Disparities in rates of imaging utilization for minorities seen in other health care settings were not present in this sample of primary care visits, supporting that access to primary care is a path to promote health equity. Higher rates of imaging utilization among advanced-level practitioners highlight an opportunity to evaluate imaging appropriateness and promote equitable, high-value imaging among all practitioners.

The Role of Peer- and Self-Appraisals in the Association Between Maltreatment and Symptomatology.

Recent research highlights the use of artificial boundaries between distinct types of adverse experiences, including forms of maltreatment. Commonly-utilized methods that isolate the impact of one maltreatment subtype over others and fail to consider the often co-occurring nature of maltreatment may not adequately capture the complex heterogeneous nature of maltreatment and may obscure understanding of developmental pathways. Moreover, childhood maltreatment is associated with the development of maladaptive peer relationships and psychopathology, with negative conceptions of relationships identified as a risk pathway. The current study utilizes structural equation modeling to examine the impact of an adapted threat versus deprivation framework for conceptualizing maltreatment via children's negative conceptions of relationships, which have not been previously tested as mechanisms in the context of this conceptual framework. Participants included 680 socioeconomically disadvantaged children who attended a week-long summer camp. Multi-informant methods were used to assess children's symptomatology and interpersonal functioning. Results did not support differences between threatening versus depriving maltreatment experiences, but indicated that all groups of children who experienced maltreatment, including those enduring both threatening and depriving experiences, showed more maladaptive functioning and more negative conceptions of relationships relative to non-maltreated peers. Results of the current study support the mediating role of children's appraisals of the self and peers in the effect of maltreatment on children's internalizing and externalizing symptomatology.

Insurance cost and injury characteristics of anterior cruciate ligament injuries in sub-elite football: A population analysis involving 3 years of Australian insurance data.

OBJECTIVES: To investigate the injury characteristics and insurance cost of anterior cruciate ligament injuries in sub-elite football players in New South Wales, Australia. DESIGN: Descriptive epidemiological study. METHODS: Three years of insurance records (2018-2020) was used to describe anterior cruciate ligament injury costs and characteristics. Concomitant injuries and the mechanism of injury were determined by analysing the injury descriptions. Claim characteristics and costs are presented by age group (junior = 7-17 years, senior = 18-34 years, and veteran = 35 + years) and sex. Categorical data (including age-groups and sex) are presented as counts and percentages and analysed using a Chi squared or Fisher's exact test. Cost data are reported as means ±â€¯standard deviation with 95 % confidence intervals. RESULTS: Over the course of three football seasons (2018-2020), 786 anterior cruciate ligament injuries were reported to the injury insurance company. The total insurance cost was AU$3,614,742 with direct injury insurance costs accounting for 36.3 % of the total costs. The mean indirect insurance costs were six-fold higher than direct insurance costs (AU$11,458 vs AU$1914). Isolated injuries had an average cost of $4466 whilst concomitant injuries had an average cost of $4951. Surgical costs are excluded from direct cost calculations. The peak injury count occurred in the first month of all three football seasons, immediately after the pre-season. CONCLUSIONS: Anterior cruciate ligament injuries represent a substantial economic burden to the insurer and individual. The cost data provided can be used for future economic and modelling studies.

Cost-effectiveness Analysis in Diagnostic Musculoskeletal Radiology: A Systematic Review.

Diagnostic musculoskeletal imaging represents a large economic expenditure within the health care system. Cost-effectiveness analysis can identify the most efficient use of imaging resources, but the literature is not well summarized. The purpose of this study was to summarize the existing literature on this topic and identify areas for future research. A systematic review of the literature was performed for 1995 - 2020. Data was extracted and summarized from those studies meeting inclusion criteria including publication and analysis characteristics and clinical topics. The search found 27 studies meeting inclusion criteria of which 16 (59%) were published in the last 5 years. Studies were clustered around specific topics with 21 (78%) of studies analyzing either osteoporosis screening (n = 9, 33%), cancer imaging (n = 4, 15%), inflammatory arthritis (n = 4, 15%), or spinal trauma (n = 4, 15%). Only 4 studies (15%) were published in radiology journals. Although 12 studies (44%) had a radiologist author, only 8 (30%) had a radiologist as first or senior author. Existing cost-effectiveness analyses in musculoskeletal radiology are clustered around a small number of topics and few studies are led by radiologists. Future research should target under-represented clinical topics and radiologists should actively pursue involvement in this field to apply their unique expertise and understanding of imaging.

Mastering Your Fellowship: Part 4, 2022.

The 'Mastering Your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa examination. The series is aimed at helping family medicine registrars prepare for this examination.

Mastering your fellowship: Part 3, 2022.

The series, 'Mastering your Fellowship', provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP SA) examination. The series is aimed at helping family medicine registrars (and their supervisors) prepare for this examination.

Direct and indirect costs associated with injury in sub-elite football in Australia: a population study using 3 years of sport insurance records.

OBJECTIVES: To determine the direct and indirect costs of injuries in sub-elite footballers in New South Wales (NSW), Australia, stratified by injury location, type, sex and age groups. DESIGN: Descriptive epidemiological study. METHODS: A de-identified insurance database containing three seasons (2018-2020) of football injuries in NSW was used to determine injury costs. Injuries were coded using the Orchard Sports Injury and Illness Classification System. Claim costs are presented by age group (Junior = 7-17 years, Senior = 18-34 years, and Veteran = 35+ years), sex and injury location and type. Cost data are reported as means ±â€¯standard deviation (SD) with 95 % Confidence Intervals (CI). RESULTS: There were 4145 total injury claims, totalling AU$13,716,173, at a mean cost of $3309 (95 % CI 3042-3577) per injury. Joint sprains accrued the largest costs ($6,665,938) with knee injuries accounting for just under half of the total costs of all injuries over the three-season period (49.1 %). ACL injuries accounted for 26.2 % of total costs with a high mean cost per injury ($4564 SD ±â€¯346) alongside lower limb fractures ($4787 SD ±â€¯425) and tendon ruptures ($4659 SD ±â€¯1053). Despite only 22.5 % of injuries accruing indirect costs, these costs accounted for 70.2 % of the total cost ($9,623,665) with the mean indirect cost per injury being ten-times higher than the mean direct cost per injury ($10,337 vs. $987, respectively). CONCLUSIONS: Knee injuries (mainly ACL ruptures), joint sprains, fractures and tendon ruptures are the costliest injuries in sub-elite football in NSW. With effective preventative measures available, there is potential to reduce injury rates and subsequent costs.

Patient Race or Ethnicity and the Use of Diagnostic Imaging: A Systematic Review.

OBJECTIVE: To summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity. METHODS: The authors performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using key words and derivatives focused on imaging and patient race. Retrieved citations were reviewed by abstract and then full text to identify articles that evaluated the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results was extracted and summarized. RESULTS: The structured search identified 2,938 articles, of which 206 met inclusion criteria. Most studies (87%, 179 of 206) were conducted in the United States, and the majority (72%, 149 of 206) found decreased or inappropriate imaging use in minority groups. Breast cancer screening was the most common clinical setting (50%, 104 of 206), followed by cancer care (10%, 21 of 206) and general imaging use (9%, 19 of 206). Government-administered surveys were the most common data source (40%, 82 of 206). Only a small minority of studies (8%, 17 of 206) evaluated strategies to mitigate the unequal use of imaging based on patient race and ethnicity. DISCUSSION: The existing literature shows decreased or inappropriate use of diagnostic imaging for minority patients across a wide variety of clinical settings. Although the number of articles on the topic is large, the majority are clustered around specific topics, and few articles evaluate potential strategies to reduce the inequitable use of diagnostic imaging.

Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS.

OBJECTIVE: To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS: Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION: Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.

Ultrasound-Guided Injection Treatments Versus Surgical Neurectomy for Morton Neuroma: A Cost-Effectiveness Analysis.

BACKGROUND. Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. OBJECTIVE. The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas when conservative management has failed. METHODS. An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three selective injection strategies in which one or more ultrasound-guided injection therapies was tried first before surgery for patients who did not respond to treatment. The three selective injection strategies were selective steroid injection, selective alcohol injection, and selective steroid/alcohol injection in which both steroid injections and alcohol sclerosing injections were trialed successively before surgical neurectomy. The direct-to-surgery approach was compared with the three different selective injection strategies and with a no-treatment strategy in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuroma in whom conservative management had failed. Model parameters, including treatment costs, effectiveness, complication rates, and health utility states, were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality-adjusted life year (QALY) with a time horizon of 3 years. A societal cost perspective was adopted with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses for key model parameters were performed. RESULTS. For the base input values, the steroid/alcohol selective injection strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401.61/QALY compared with no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective injection strategy became most cost-effective. CONCLUSION. A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared with proceeding directly to surgical neurectomy. CLINICAL IMPACT. Ultrasound-guided injection therapies are indicated as first-line treatment of patients with symptomatic Morton neuromas when conservative management fails.

Economic burden of enhanced practices of duodenoscopes reprocessing and surveillance: balancing risk and cost containment.

Background and study aims Recent outbreaks attributed to contaminated duodenoscopes have led to the development of enhanced surveillance and reprocessing techniques (enhanced-SRT) aimed at minimizing cross-contamination. Common enhanced-SRT include double high-level disinfection (HLD), ethylene oxide (EtO) gas sterilization, and culture-based monitoring of reprocessed scopes. Adoption of these methods adds to the operational costs and we aimed to assess its economic impact to an institution. Methods We compared the estimated costs of three enhanced-SRT versus single-HLD using data from two institutions. We examined the cost of capital measured as scope inventory and frequency of scope use per unit time, the constituent reprocessing costs required on a per-cycle basis, and labor & staffing needs. The economic impact attributable to enhanced-SRT was defined as the difference between the total cost of enhanced-SRT and single HLD. Results Compared to single HLD, adoption of double HLD increased the costs approximately by 47 % ($80 vs $118). Similarly, culture and quarantine and EtO sterilization increased costs by 160 % and 270 %, respectively ($80 vs $208 and $296). Enhanced-SRT introduced significant scope downtime due to prolonged techniques, necessitating a 3.4-fold increase in the number of scopes needed to maintain procedural volume. The additional annual budget required to implement enhanced-SRT approached $406,000 per year in high-volume centers. Conclusions While enhanced-SRT may reduce patient risk of exposure to contaminated duodenoscopes, it significantly increases the cost of performing ERCP. Future innovation should focus on approaches that can ensure patient safety while maintaining the ability to perform ERCP in a cost-effective manner.

The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey.

BACKGROUND: An established body of literature has shown evidence of implicit bias in the health care system on the basis of patient race and ethnicity that contributes to well documented disparities in outcomes. However, little is known about the influence of patient race and ethnicity on the decision to order diagnostic radiology exams in the acute care setting. This study examines the role of patient race and ethnicity on the likelihood of diagnostic imaging exams being ordered during United States emergency department encounters. METHODS: Publicly available data from the National Hospital Ambulatory Medical Care Survey Emergency Department sample for the years 2006-2016 was compiled. The proportion of patient encounters where diagnostic imaging was ordered was tabulated by race/ethnicity, sub-divided by imaging modality. A multivariable logistic regression model was used to evaluate the influence of patient race/ethnicity on the ordering of diagnostic imaging controlling for other patient and hospital characteristics. Survey weighting variables were used to formulate national-level estimates. RESULTS: Using the weighted data, an average of 131,558,553 patient encounters were included each year for the 11-year study period. Imaging was used at 46% of all visits although this varied significantly by patient race and ethnicity with white patients receiving medical imaging at 49% of visits and non-white patients at 41% of visits (p < 0.001). This effect persisted in the controlled regression model and across all imaging modalities with the exception of ultrasound. Other factors with a significant influence on imaging use included patient age, gender, insurance status, number of co-morbidities, hospital setting (urban vs non-urban) and hospital region. There was no evidence to suggest that the disparate use of imaging by patient race and ethnicity changed over the 11-year study time period. CONCLUSION: The likelihood that a diagnostic imaging exam will be ordered during United States emergency department encounters differs significantly by patient race and ethnicity even when controlling for other patient and hospital characteristics. Further work must be done to understand and mitigate what may represent systematic bias and ensure equitable use of health care resources.

Mastering your fellowship.

The series, 'Mastering your Fellowship', provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.