Abstract
Purpose
To verify if a “two step” school-based scoliosis screening procedure could reduce childhood radiation exposure and, if so, to estimate the subsequent reduction in radiogenic cancer fatalities and in socio-economic burden.
Material and methods
Data from two different scoliosis screening programs (A and B) performed on a total of 8,995 children (age range 9–14) were examined. Children in program A (5,731 children) were screened using a “two-step” procedure in which school physicians performed the first clinical examination and uncertain cases were referred to an orthopaedist. The school physicians were previously instructed by orthopaedists in the recognition of a number of simple clinical signs. Children in program B (3,264 children) were screened using a “one-step” procedure in which the initial clinical examination was performed directly by an orthopedist. In both programs, suspected cases of scoliosis were then ascertained by the orthopaedist with Radiography. To evaluate the lifetime attributable risk of cancer mortality the guidelines of the International Commission on Radiological Protection Publication 60 were followed. The economic cost of the performed X-ray examination was calculated assuming the current National Health Service’s reimbursement to hospitals of euro 35 per X-Ray exam. The statistic significance of the difference in these estimates between the two programs was assessed using the proportions z-test. The issues of the relative sensitivity and specificity of the two programs were also examined.
Results
In programs A and B, 86 (1.5 %) and 95 (2.91 %) X-ray examinations were performed respectively (z=4.452, p<0.001). Based on these observations, a screening of 10,000 children directly performed by orthopaedists would result in 291 X-ray exams (2.91 %). A screening of the same number of children using a two-step procedure would result in 150 X-ray exams (1.5 %), with a savings of euro 4,935 for the National Health Care System, a reduction of 0.283 Sv of collective dose, and an estimated 50% reduction in the number of radiogenic malignant tumours.
Conclusions
Using a two-step scoliosis screening procedure provides reasonable sensitivity and specificity while reducing costs and radiation exposure to children.
Riassunto
Obiettivo
Verificare se il ricorso ad un metodo di screening scolastico per la scoliosi “a due tappe” riduce l’esposizione a radiazioni ionizzanti e, se è così, determinare la conseguente riduzione del rischio di cancro radio-indotto e del costo economico.
Materiali e metodi
Abbiamo esaminato i dati relativi a due programmi di screening (A e B) attuati su 8995 ragazzi (range di età, 9–14 anni). I ragazzi del gruppo A (5731 ragazzi) sono stati sottoposti ad un programma “a due tappe”. I medici scolastici, dopo essere stati istruiti da ortopedici sulla semeiotica clinica elementare, hanno effettuato la prima valutazione clinica ed hanno inviato allo specialista tutti i casi dubbi. Per i ragazzi del gruppo B (3264 ragazzi) è stato utilizzato un programma “ad una sola tappa”, cioè, la valutazione clinica è stata effettuata direttamente dall’ortopedico. In entrambi i programmi, soltanto l’ortopedico ha richiesto gli esami radiografici. Per valutare il successivo rischio di mortalità per cancro, sono state seguite le linee guida della Pubblicazione 60 della Commissione Internazionale sulla Protezione Radiologica. Per calcolare il costo economico degli esami radiografici effettuati, ci si è basati sull’attuale rimborso del Servizio Sanitario Nazionale agli ospedali che è di 35 euro ad esame. La significatività statistica delle differenze tra i due programmi, è stato calcolata con lo z test per le proporzioni. Inoltre, è stata considerata la sensibilità e specificità dei due metodi.
Risultati
Nei programmi A e B sono stati eseguiti rispettivamente 86 (1,5%) e 95 (2,91%) esami radiografici (z=4,452, p<0,001). Sulla base di queste osservazioni, uno screening di 10000 bambini effettuato direttamente dall’ortopedico, comporterebbe 291 esami radiografici (2,91%). Lo screening di uno stesso numero di ragazzi, utilizzando il programma “a due tappe”, comporterebbe invece 150 esami radiografici con un risparmio di 4935 euro per il Sistema Sanitario Nazionale, una riduzione della dose collettiva di 0,283 Sv ed una riduzione stimata del 50% del numero di tumori maligni radio-indotti.
Conclusioni
Il ricorso al programma di screening “a due tappe” presenta una buona sensibilità e specificità, riduce i costi e, soprattutto, l’esposizione a radiazioni dei ragazzi.
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Leone, A., Aulisa, A., Perisano, C. et al. Advantages of a two-step procedure for school-based scoliosis screening. Radiol med 115, 238–245 (2010). https://doi.org/10.1007/s11547-009-0429-z
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DOI: https://doi.org/10.1007/s11547-009-0429-z