Adherence to Urgent Eye Visits during the COVID-19 Pandemic: A Population Characteristics Study.

PURPOSE: To explore individual and community factors associated with adherence to physician recommended urgent eye visits via a tele-triage system during the COVID-19 pandemic. METHOD: We retrospectively reviewed acute visit requests and medical exam data between April 6, 2020 and June 6, 2020. Patient demographics and adherence to visit were examined. Census tract level community characteristics from the U.S. Census Bureau and zip code level COVID-19 related death data from the Cook County Medical Examiner's Office were appended to each geocoded patient address. Descriptive statistics, t-tests, and logistic regression analyses were performed to explore the effects of individual and community variables on adherence to visit. RESULTS: Of 229 patients recommended an urgent visit, 216 had matching criteria on chart review, and 192 (88.9%) adhered to their visit. No difference in adherence was found based on individual characteristics including: age (p = .24), gender (p = .94), race (p = .56), insurance (p = .28), nor new versus established patient status (p = .20). However, individuals who did not adhere were more likely to reside in neighborhoods with a greater proportion of Blacks (59.4% vs. 33.4%; p = .03), greater unemployment rates (17.5% vs. 10.7%; p < .01), and greater cumulative deaths from COVID-19 (56 vs. 31; p = .01). Unemployment rate continued to be statistically significant after controlling for race and cumulative deaths from COVID-19 (p = .04). CONCLUSION: We found that as community unemployment rate increases, adherence to urgent eye visits decreases, after controlling for relevant neighborhood characteristics. Unemployment rates were highest in predominantly Black neighborhoods early in the pandemic, which may have contributed to existing racial disparities in eye care.

Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction.

BACKGROUND: Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone. METHODS: A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.). RESULTS: Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases. CONCLUSION: Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.

Eliminating Visual Acuity and Dilated Fundus Examinations Improves Cost Efficiency of Performing Optical Coherence Tomogrpahy-Guided Intravitreal Injections.

PURPOSE: The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)-guided intravitreal injections. DESIGN: Comparative cost analysis. METHODS: Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models. RESULTS: Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient. CONCLUSION: Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day.

Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost.

BACKGROUND: Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes. OBJECTIVE: The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG). METHODS: De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule. RESULTS: A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment. CONCLUSION: H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

The Italian preparticipation evaluation programme: diagnostic yield, rate of disqualification and cost analysis.

INTRODUCTION: Italian law mandates that every competitive athlete must undergo annual preparticipation evaluation (PPE) to identify cardiovascular (CV) diseases that pose a risk of sudden death (SD) during sport and other conditions that may threaten the athlete's health. We investigated the diagnostic yield, rate of disqualification and costs of our PPE. METHODS: We included 5910 consecutive apparently healthy athletes (61% males, mean age 15±4 years) who underwent annual PPE performed by a sports medicine specialist. The PPE included history, physical examination, weight, height and blood pressure measurement, test of visual acuity, spirometry, urine chemistry, resting 12-lead ECG and exercise testing with ECG monitoring. In cases of abnormal findings, we carried out second-line investigations. RESULTS: During a 12-month study period, 5.326 (90.2%) athletes were cleared for competition after a normal first-line evaluation and 584 (9.8%) underwent one or more further examinations. Of those, 88 (1.5%) were diagnosed to have a CV disease (including 18 (0.3%) at-risk of SD) and 31 (0.5%) had a non-CV diagnosis. A total of 32 (0.5%) athletes were temporarily (n=15) or permanently (n=17) disqualified from competitive sports. The average cost per athlete was €79, which consisted of €64 (80%) for first-line evaluations and €15 (20%) for additional investigations. CONCLUSION: PPE according to the Italian model identified a range of diseases in 2.0% of apparently healthy athletes at an average cost of €79.

Validating a low-cost, consumer force-measuring platform as an accessible alternative for measuring postural sway.

The Zibrio SmartScale is a low-cost, portable force platform designed to perform an objective assessment of postural stability. The purpose of the present study was to validate the center of pressure (COP) measurements in the Zibrio SmartScale. Simultaneous COP data was collected by a Zibrio SmartScale and a laboratory-grade force platform (LFP) under the dynamic motion of an inverted pendulum device intended to mimic the sway of a standing human. The inverted pendulum was placed on the Zibrio SmartScale which was placed on the LFP. The pendulum was then displaced to angles of 3° and 5° in both the anterior-posterior (AP) and medial-lateral (ML) directions. The findings of this study show low mean average error (MAE) among the measures taken simultaneously upon the LFP and Zibrio SmartScale with no appreciable difference in error in either AP or ML COP directions. Averaged over repeated trials, the MAE did not surpass 0.5 mm. This represented 0.4% of the total range (±50 to 60 mm in 5° displacement trials) of simulated COP. The results of this study strongly indicate that the Zibrio SmartScale can perform adequately as a light-weight and low-cost alternative method of COP measurement in comparison to a traditional LFP.

A mobile-phone based high-resolution microendoscope to image cervical precancer.

Nearly 90% of cervical cancer cases and deaths occur in low- and middle-income countries that lack comprehensive national HPV immunization and cervical cancer screening programs. In these settings, it is difficult to implement screening programs due to a lack of infrastructure and shortage of trained personnel. Screening programs based on visual inspection with acetic acid (VIA) have been successfully implemented in some low-resource settings. However, VIA has poor specificity and up to 90% of patients receiving treatment based on a positive VIA exam are over-treated. A number of studies have suggested that high-resolution cervical imaging to visualize nuclear morphology in vivo can improve specificity by better distinguishing precancerous and benign lesions. To enable high-resolution imaging in low-resource settings, we developed a portable, low-cost, high-resolution microendoscope that uses a mobile phone to detect and display images of cervical epithelium in vivo with subcellular resolution. The device was fabricated for less than $2,000 using commercially available optical components including filters, an LED and triplet lenses assembled in a 3D-printed opto-mechanical mount. We show that the mobile high-resolution microendoscope achieves similar resolution and signal-to-background ratio as previously reported high-resolution microendoscope systems using traditional cameras and computers to detect and display images. Finally, we demonstrate the ability of the mobile high-resolution microendoscope to image normal and precancerous squamous epithelium of the cervix in vivo in a gynecological referral clinic in Barretos, Brazil.

Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014.

OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes. RESEARCH DESIGN AND METHODS: We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam. RESULTS: Among the 298,383 insured patients with type 2 diabetes and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR were 24.4% and 15.8%, respectively, for patients with type 2 diabetes and 54.0% and 33.4% for patients with type 1 diabetes. CONCLUSIONS: The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.

Effect of periodic health exam on provider management of preventive services.

RATIONALE AND OBJECTIVE: To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period when Medicare did not cover annual physicals (before 2011). METHODS: Electronic medical records of patients aged 65 years and older from a US health care system were extracted for the 2001 to 2007 period. A fixed-effects logistic model was used to assess the relationship between receipt of periodic health examination (PHE) and receipt of provider recommendation for mammogram screening for 6466 female Medicare beneficiaries. Logistic regression models were used to assess the relationship between receipt of PHE and receipt of provider recommendation for colonoscopy screening and pneumococcal vaccination for 10 318 Medicare beneficiaries. Nine primary care providers from the network were also interviewed, selected by random sampling stratified by care model. RESULTS: Electronic medical record analyses suggest that patients with a PHE were more likely to obtain provider recommendations for mammogram screening (OR = 2.17, P < 0.0001), colonoscopy screening (OR = 1.54, P < 0.0001), and pneumococcal vaccination (OR = 1.10, P < 0.0001). Providers suggested that prevention care quality improves with the PHE because certain screening measures (eg, skin cancer screening, breast exam) would be neglected without it, and healthy patients could miss recommended preventive services entirely. Without the PHE, some providers reported having tried to incorporate discussions of preventive services by scheduling more frequent follow-up chronic care visits than they would have otherwise, and some routinely charged Medicare for a more complex follow-up visit than they would have charged without the preventive service discussions. CONCLUSION: Periodic health examination is important in connecting patients to recommended preventive services. Provider interviews suggested that, indirectly, Medicare ended up paying for the PHE via greater frequency of follow-up visits or higher visit charges from providers integrating the services with other visits.

Cost-effectiveness evaluation of the 45-49 year old health check versus usual care in Australian general practice: A modelling study.

OBJECTIVES: To assess the potential cost-effectiveness of the 45-49 year old health check versus usual care in Australian general practice using secondary data sources. METHOD: Risk factor profiles were generated for a hypothetical Australian cohort using data from the National Health Survey. Intervention effects were modelled based on a meta-analysis on risk factor changes in the 5 years after a health check. The Framingham Risk Equation was applied to estimate the 5-year cardiovascular disease (CVD) incidence in the health check and usual care group respectively. A Markov model was then constructed to extrapolate long-term CVD outcomes, health care costs and Quality Adjusted Life Years (QALYs) in both groups. Health check-related costs, applied to the health check group, were estimated from clinical guideline and experts' opinion. Lifetime costs, applied to both groups, included costs of hospitalization for CVD events and associated post-event health service use. The Incremental Cost-Effectiveness Ratio (ICER) was calculated for male and female patients respectively. RESULTS: Compared to usual care, the health check reduced CVD incidence for both males (RR = 0.87) and females (RR = 0.91) over a 5-year time. In a lifetime projection, health check led to an average 0.008 and 0.003 QALYs gained per male and female participants respectively. The estimates ICERs were AU $42,355 and AU $133,504 per QALY gained for males and females, respectively. A probabilistic sensitivity analysis demonstrated a probability of cost-effectiveness of 17.5% and 0% for male and female attendees, assuming a willingness to pay threshold of AU $28,000 per QALY gained. CONCLUSION: The 45-49 year old health check is associated with a small expected QALY gain per participant, though the persons avoiding CVD events experience large health gains. The mean ICER is larger than an empirical estimate of the threshold ICER and the evaluated health check is highly unlikely to be cost-effective.

TotShots: An Innovative Pediatric Free Clinic Providing High Patient Satisfaction to the Underserved.

BACKGROUND AND OBJECTIVES: The University of Arizona College of Medicine-Tucson TotShots clinic is a student-developed, student-directed free clinic that provides sports physicals and vaccines to uninsured pediatric patients in Tucson, Arizona. TotShots runs under the greater umbrella of the Commitment to Underserved People Program, which aims to teach medical students how socioeconomic and cultural factors impact health and access to health care. Our objective was to study cost savings and patient satisfaction of this clinic. METHODS: Value of care provided through sports physicals and vaccine administration was calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule and Centers for Disease Control Vaccines for Children Decisions Analysis Model. In addition, patient satisfaction was measured through the utilization of an optional three-question survey completed by patients in their preferred language at the resolution of their visit. Vaccines and sports physicals were administered from April 2017 to November 2017. RESULTS: TotShots administered 51 vaccines and completed 115 sports physicals resulting in a value of $415.65 of administration fees and $5,878.80 of sports physical examinations. Sixty-three of 66 total patients completed patient satisfaction surveys. Of those patients, 57 (90.5%) were highly satisfied with their provider's communication, 58 (92%) rated their perception of the quality of medical care they received as excellent, and 54 (85.7%) of patients were highly satisfied with their overall TotShots experience. CONCLUSIONS: TotShots fills a valuable role in increasing access to vaccines and sports physicals while maintaining high patient satisfaction and high value of cost savings.

[Deterioration of Healthcare Service Quality Provided by Occupational Physicians Due to Dumping by Health Checkup and Switching Health Checkup Organizations].

INTRODUCTION: From 2007, competitive bidding for procurement became widely employed by the Japanese Government, and health check providers for government workers are selected every year by this method. Deterioration of health check quality due to excessive price competition is a serious concern. The National Federation of Industrial Health Organization (Zeneiren) conducted an investigative research on the contracting of health check providers and occupational physicians in workplaces in 2015-2016 in an effort to prevent low-cost but low-quality health checks. The report of the research is available on the homepage of Zeneiren. In this paper, we provide a brief overview of the report, and deterioration of health check quality due to dumping by and switching of health check providers is discussed from economic and legal viewpoints. METHOD: Information was obtained from articles in print and on the Internet. RESULTS: A questionnaire survey of health check providers revealed that excessive discounts due to both competitive bidding and demand from companies commissioning health checks occurred on a routine basis, and some providers were concerned about worsening business conditions in the future. In a separate questionnaire survey of occupational physicians, it was discovered that they were able to evaluate the quality of health checks, whereas administrative officials responsible for selecting the providers were seldom able to adequately evaluate the health check quality, resulting in contracting providers of questionable quality, which in turn caused considerable dissatisfaction on the part of occupational physicians. Moreover, when health check providers were switched, the reporting format of health check results changed. The physicians did not favor such a change because of the considerably increased workload involved in coordinating past and current data and the risk of decreased occupational health service quality. DISCUSSION: Dumping makes the management of health check providers very difficult and is a cause of loss of social capital. If health check providers of good quality withdraw from the market, the supply of high-quality health checks decreases. This corresponds to external diseconomy caused by dumping on the part of the health check providers and loss of social surplus (economic surplus). CONCLUSIONS: To avoid deterioration of occupational health service due to low-quality health checks and changes in the reporting format, occupational physicians must actively engage in the selection of health check providers of good quality.

Needs survey on the priority given to periodical medical examination items among occupational physicians in Japan.

OBJECTIVES: To clarify the priority given to periodical medical examination items among occupational physicians in Japan. METHODS: Sixty-two occupational physicians who participated in this study selected statutory and non-statutory items within two types of budget plans: one lower (8,500 yen) than the total fee of statutory medical examinations (9,250 and 11,290 yen), and the other higher (12,000 yen) than the total fee. Medical fee points were used to set the cost of each medical examination item. A three round Delphi method was used from May to July 2016 to clarify the consensus opinion of occupational physicians. RESULTS: The statutory items (selection rate: between 66 and 100%), except for waist circumference (15%) and sputum examination (0%), and serum creatinine (58%, non-statutory item) were included in the smaller budget plan (8,500 yen). In the larger budget plan (12,000 yen), the statutory items (selection rate: between 92 and 100%), except for waist circumference (39%) and sputum examination (0%), and some non-statutory items, namely serum creatinine (95%), leukocytes (92%), uric acid (89%), and fecal occult blood reaction (81%), had a selection rate over 80%. In addition, statutory items with higher accuracy were preferred, which included the following: air conduction pure-tone audiometry (92%), imaging diagnosis of thoracic X-ray examinations by a specialist (97%), glycated hemoglobin levels (98%), and electrocardiogram assessment by a specialist (100%). CONCLUSION: The statutory items, except for waist circumference and sputum examination, and some of the non-statutory items (e.g., serum creatinine) were given higher priority among occupational physicians in Japan.

A Modeling Study of the Cost-Effectiveness of a Risk-Stratified Surveillance Program for Melanoma in the United Kingdom.

BACKGROUND: Population-wide screening for melanoma is unlikely to be cost-effective. Nevertheless, targeted surveillance of high-risk individuals may be. OBJECTIVES: To estimate the cost-effectiveness of various surveillance strategies in the UK population, stratified by risk using a simple self-assessment tool scoring between 0 and 67. METHODS: A decision model comparing alternative surveillance policies from the perspective of the UK National Health Service over 30 years was developed. The strategy with the highest expected net benefit for each risk score was identified, resulting in a compound risk-stratified policy describing the most cost-effective population-wide strategy. The overall expected cost and quality-adjusted life-years (QALYs), the incremental cost-effectiveness ratio, and associated uncertainty were reported. RESULTS: The most cost-effective strategy is for those with a Williams score of 15 to 21 (relative risk [RR] of 0.79-1.60 vs. a mean score of 17 in the United Kingdom) to be offered a one-off full-body skin examination, and for those with a score of 22 or more (RR 1.79+) to be enrolled into a quinquennial monitoring program, rising to annual recall for those with a risk score greater than 43 (RR 20.95+). Expected incremental cost would be £164 million per annum (~0.1% of the National Health Service budget), gaining 15,947 additional QALYs and yielding an incremental cost-effectiveness ratio of £10,199/QALY gained (51.3% probability <£30,000). CONCLUSIONS: The risk-stratified policy would be expensive to implement but cost-effective compared with typical UK thresholds (£20,000-£30,000/QALY gained), although decision uncertainty is high. Phased implementation enrolling only higher risk individuals would be substantially less expensive, but with consequent foregone health gain.

Time cost of child rearing and its effect on women's uptake of free health checkups in Japan.

Women of child-rearing age have the lowest uptake rates for health checkups in several developed countries. The time cost incurred by conflicting child-rearing roles may contribute to this gap in access to health checkups. We estimated the time cost of child rearing empirically, and analyzed its potential impact on uptake of free health checkups based on a sample of 1606 women with a spouse/partner from the dataset of a population-based survey conducted in the greater Tokyo metropolitan area in 2010. We used a selection model to estimate the counterfactual wage of non-working mothers, and estimated the number of children using a simultaneous equation model to account for the endogeneity between job participation and child rearing. The time cost of child rearing was obtained based on the estimated effects of women's wages and number of children on job participation. We estimated the time cost to mothers of rearing a child aged 0-3 years as 16.9 USD per hour, and the cost for a child aged 4-5 years as 15.0 USD per hour. Based on this estimation, the predicted uptake rate of women who did not have a child was 61.7%, while the predicted uptake rates for women with a child aged 0-3 and 4-5 were 54.2% and 58.6%, respectively. These results suggest that, although Japanese central/local governments provide free health checkup services, this policy does not fully compensate for the time cost of child rearing. It is strongly recommended that policies should be developed to address the time cost of child rearing, with the aim of closing the gender gap and securing universal access to preventive healthcare services in Japan.

Balance assessment during squatting exercise: A comparison between laboratory grade force plate and a commercial, low-cost device.

Testing balance through squatting exercise is a central part of many rehabilitation programs and sports and plays also an important role in clinical evaluation of residual motor ability. The assessment of center of pressure (CoP) displacement and its parametrization is commonly used to describe and analyze squat movement and the laboratory-grade force plates (FP) are the gold standard for measuring balance performances from a dynamic view-point. However, the Nintendo Wii Balance Board (NWBB) has been recently proposed as an inexpensive and easily available device for measuring ground reaction force and CoP displacement in standing balance tasks. Thus, this study aimed to compare the NWBB-CoP data with those obtained from a laboratory FP during a dynamic motor task, such as the squat task. CoP data of forty-eight subjects were acquired simultaneously from a NWBB and a FP and the analyses were performed over the descending squatting phase. Outcomes showed a very high correlation (r) and limited root-mean-square differences between CoP trajectories in anterior-posterior (r > 0.99, 1.63 ±â€¯1.27 mm) and medial-lateral (r > 0.98, 1.01 ±â€¯0.75 mm) direction. Spatial parameters computed from CoP displacement and ground reaction force peak presented fixed biases between NWBB and FP. Errors showed a high consistency (standard deviation < 2.4% of the FP outcomes) and a random spread distribution around the mean difference. Mean velocity is the only parameter which exhibited a tendency towards proportional values. Findings of this study suggested the NWBB as a valid device for the assessment and parametrization of CoP displacement during squatting movement.

Cost description of clinical examination and MRI in wrist ligament injuries.

OBJECTIVE: The total number and cost of wrist MRIs in the catchment area of the Västra Götaland Region in Sweden (population 1 723 000) during 1 year was analysed, together with the number and content of referrals. METHODS: Six radiology departments reported the numbers and rate of all MRI investigations intended to diagnose wrist ligament injuries (n = 411) and other injuries to the wrist. RESULTS: The additional cost of the difference between MRIs and a clinical examination by a hand surgeon, plus indirect costs for patients with suspected wrist ligament injuries, was calculated as 957 000 euros. CONCLUSIONS: It is recommended that MRI should only be used in patients in whom there are clinical difficulties in terms of diagnosing wrist ligament injuries. It is suggested that patients with suspected wrist ligament injuries should be referred directly to an experienced hand surgeon, capable of performing a standardised wrist examination and, when needed, diagnostic arthroscopy and final treatment. The proposed algorithm for the diagnosis and treatment of suspected wrist ligament injuries presented in the present study could save time for the patient and for the radiology departments, as well as reducing costs. The ability to implement the early and appropriate treatment of acute ligament injuries could be improved at the same time.

Age related prevalence of hand osteoarthritis diagnosed by photography (HOASCORE).

BACKGROUND: Hand photography has been used in a number of studies to determine the presence and severity of hand osteoarthritis (HOA). The aim of this study was to present age and gender specific prevalences of HOA diagnosed by this method. METHODS: Six thousand three hundred forty three photographs (from 3676 females and 2667 males aged 40-96) were scored for hand osteoarthritis by a 0-3 grade (0 = no evidence of OA, 1 = possible OA, 2 = definite OA and 3 = severe OA) for each of the three main sites, distal interphalangeal joints (DIP), proximal interphalangeal joints (PIP) and thumb base (CMC1). An aggregate score of 0-9 was thus obtained (HOASCORE) to reflect the severity of HOA in each case. RESULTS: DIP joints were most commonly affected, followed by the thumb base and the PIP joints. Having definite DIP joint OA starts at a younger age compared with the other two sites, and there is a marked female preponderance in the age groups from 55 to 69, but after 70 the gender differences are less marked and the prevalence is fairly stable. PIP joint prevalence also indicates a female preponderance from 60 to 79. Thumb base OA has a more marked female preponderance and a rising prevalence thoughout life. The prevalence of individuals with no evidence of photographic OA (HOASCORE = 0) drops from 88% to 57% between the age categories 40-49 and 50-54 and decreased to 33% in the 70-74 age group with a slower decline after that age. DIP and PIP prevalence were strongly associated with each other with an OR of 16.6(12.8-21.5),p < 0.001 of having definite OA at the other site. This was less marked for the thumb base with an OR of 2.2(1.8-2.7, p < 0.001), and 2.7(2.0-3.5, p < 0.001) of having definite DIP or PIP HOA respectively. CONCLUSIONS: The prevalence of hand OA in DIP, PIP and thumb base joints obtained by the photographic HOASCORE method is higher in women and increases after the age of fifty. These results are in line with those obtained by clinical examination and radiography. The advantage of the method lies in easy applicability and low cost.