Debate: School Screening for Scoliosis Should be Abandoned

Transcription

1 Debate: School Screening for Scoliosis Should be Abandoned Ann & Robert H. Lurie Children s Hospital of Chicago Division of Orthopedic Surgery and Sports Medicine September 29, 2018

2 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do not intend to discuss unapproved use of a commercial device in this presentation 2

3 SRS / AAOS / POSNA /AAP Position Statement on Screening for Early Detection of Scoliosis in Adolescence (December, 2015) AAOS, SRS, POSNA, and AAP believe that screening examinations for spine deformity should be part of the medical home preventive services visit for females at age 10 and 12 years, and males once at age 13 or 14 years AAOS, SRS, POSNA, and AAP believe that effective screening programs must have well trained screening personnel who can utilize forward bending tests and scoliometer measurements to correctly identify and appropriately refer individuals with AIS for further evaluation This Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

4 Minnesota 1970s - average of 250,000 children screened yearly for 8 years 3.4 per cent were referred for evaluation scoliosis was found in 1.2 per cent cost of the program averaged 6.6 cents per student screened Reduction in number of children needing surgery for AIS was reported Lonstein JE et al J Bone Joint Surg Am 1982 Apr;64(4): Future governor Future president

5 2242 students: positive predictive value of the school screening program for the identification of treated scoliosis was 0.05 Yawn et al JAMA 1999 Oct 20;282(15): Adams test + Scoliometer, 33,500 students : PPV was 28.3% for scoliosis of 10 degrees or more, 4% for 20 degrees or more with 5 degrees angle of trunk rotation as the criterion for referral Huang Spine 1998

6 Ending School Screening Not Associated with Increased Scoliosis Curve Magnitudes: A Population-Based Study (Mayo Clinic, Rochester, Minnesota) (school screening present): 514 children were seen by a pediatric orthopedist for AIS. Mean curve magnitude was 20 ; From (school screening absent): 247 children were seen, mean thoracic curve of % patients in the screened group required surgery, compared to 1.2% after school screening was discontinued (p>0.05). In this population-based cohort, cessation of school screening did not result in more severe disease at presentation or a higher rate of surgical treatment for AIS patients. Thomas JJ, et al. Spine Deformity 6 (2018): 403-8

7 Determining the Prevalence and Costs of Unnecessary Referrals in Adolescent Idiopathic Scoliosis. Meirick TM, et al 337 patients presented for initial evaluation of AIS during 2 year period 16 % had a Cobb angle <10 degrees 39 % had a Cobb angle <20 degrees. Neither insurance status nor race affected the rate of unnecessary referrals mean total cost of an unnecessary referral was $ Conclusion: Nearly half of all referrals for AIS are medically unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system

8 Anxiety and School Screening for Scoliosis children and parents referred through the SSS program experience significantly elevated levels of state-anxiety Of the 27 patients, 14 (52%) were negative for AIS (over half false-positive referrals) Of the 13 true-positives, 4 (30.8%) were determined to have curves measuring between 10 and 19 Hines T et al. Spine ;21:

9 Approximately 602,884 visits to physician offices / yr. More than $ 420 million per year As many as half do not have a curve at all Approx 28% actually need treatment SSS programs have been implemented for over 60 yr to identify AIS early

10 The disease AIS is not a serious threat to the health of American children

11 The screening tests Adams forward bend test: Not validated, by itself is not reliable Many practitioners do not use an inclinometer

12 The treatment Bracing is indicated for a select group of patients Number needed to treat: 3 if fully compliant, at least 9 if not Efficacy has been demonstrated in girls There is little evidence for efficacy in boys Not clearly effective in obese patients

13 The cost Main problem with school screening, after 40 + years, continues to be un-necessary referrals, un-necessary radiograms, anxiety, repeat visits, costs, etc.

14 U.S. Schools are not health care providers Education is the funded mandate Public schools have many other issues which affect more of their students

15 Was a nice idea at the time

16 Rebuttal

17 The 1970s

18 The 2010s

19 Reality check Inner city U.S. Public schools have serious problems: attendance, nutrition, behaviour, security, standardized tests, metrics for teachers, etc. Cyberschools Charterschools Home schools

20 Rebuttal 20

21 KYA ( Know Your Audience) OR ( Know Your Adversary) 21

22 SCREENING FOR DISEASE A Great Idea BUT Where and how 22

23 Criteria for Screening Disease long term health consequences Screening tool reliable, reproducible Treatment available and more effective if earlier 23

24 Criteria for Screening Disease long term health consequences Screening tool reliable, reproducible Treatment available and more effective if earlier Prostate Cancer 24

25 The Golf Pro at a Seniors Tournament 25

26 Rebuttal School screening an idea whose time has come And gone