The cost of the school screening program
in a general hospital

GRIVAS T.B., MAZIOTOU C., KARATHANOU S., BIRLI E., ARVANITI A., VASILIADIS E.
"Thriasio" General Hospital, Elefsis

ABSTRACT
The purpose of this report is to analyze the cost of performing the school screening program in our hospital. A further aim is the assessment of the cost and benefit relationship of such a program.
Method and material: The examining group is mainly staffed by properly trained Health visitors and occasionally by Orthopaedic and General Medicine trainees and by physiotherapists.
During the period of 1-1-2000 to 1-1-2003, 3364 pupils were screened at school for spinal deformities.
The angle of trunk inclination (ATI) during the bending test was assessed using the Pruijs scoliometer. Re-examination at the scoliosis clinic of the hospital was recommended for pupils who had a threshold reading of ATR >_70.
Results: During the last 3 years 20 examiners were involved in the program in total. The total number of working hours was 255. The fees per hour for trainee doctors were 6.80, for health visitors 6.70and for physiotherapists 5.50in current prices. The examiners' transportation expenditures to the schools were assessed to be 32per year. The total cost for the examination of each child for the three years of the study amounted to 1.45, a price that derives from the total number of working hours, the transportation expenditure and the total number of the examined children.
Discussion: The available literature is reviewed and the cost of our school screening program is compared with that of other greek and international programs. The cost of our program is noticed to be lower than that of similar programs performed at Crete in Greece.
Conclusion: The school screening program for scoliosis is recommended not only because of the obvious preventive medicine benefits but due to the low cost of the program as well.

Key words: Scoliosis, school screening, cost.

INTRODUCTION
The purpose of a screening test is to identify the individuals at risk for a disease[1,16,17].
School screening is a valuable tool for the identification of children with idiopathic scoliosis[1,16,17]. Through the assessment of hump during the bending test, it detects the children who are at increased risk, although it is not a diagnostic method. Moreover, except for the early detection of scoliotic children, school screening has contributed to the collection of information regarding the natural history of scoliosis[18,26].
Early detection and conservative treatment decrease the number of scoliotic children who need surgical treatment and thus decrease the total cost of treatment. Early onset of conservative treatment, by application of a brace, restrains the progression of the deformity and minimizes surgical treatment, if an aggressive form of treatment is finally required[19].
The purpose of this report is to analyze the cost of performing the school-screening program in our hospital. A future aim is the assessment of the cost-benefit relationship of such a program.

METHOD - MATERIAL
The program took place at District Schools (Primary - Secondary - High school) in the district around Thriasio Hospital that belong to Western Attica. Thriassio field is an area with important oppositions, because its inhabitants form an extremely heterogeneous population, concerning their professional occupation (rural-urban) and their origins (natives, immigrants from former Eastern countries and foreigners). Therefore, every form of preventive medicine is beneficial and improves the quality of life of this population.
Obtaining permission to access the schools and informing in extent the teachers, parents and pupils is absolutely necessary and is done firstly, through the distribution of informative material and lectures. The collaboration of all the above mentioned people is mandatory for the greater acceptance of this voluntary program and thus for a success and cost effective performance.
The examiners: The program is performed by Health visitors, after a long period of training. They form the main examining group, which is also occasionally staffed by Orthopaedic and General Medicine trainees and by physiotherapists. The examiners team is very well trained and experienced in detection methods, thus very effective. Training was performed by the first of the writers (Th.B.G.), during his participation in the examiners group in the first years (1997-1999) of the program.
Preparation for school screening: Two weeks before carrying out the program the schoolmaster was informed about the program, by the Health visitors and informative material was distributed. Then the pupils were informed about the program and the way it would be performed and they were given special forms including questionnaires about their personal data. Thus, when the team arrived at every school there were no problems that could delay them, as the director, the teachers and the pupils were appropriately informed and prepared. The program was performed once a week.
The examined children: The program began in 1997 but complete registration of the cost of the program began in 2002. From 1/1/2000 to 1/1/2003 3.364 pupils were screened for spinal deformities. Both sexes were included regardless of the expected different rate of scoliosis among them. Children from 6 to 18 years were examined. The program took place in schools during school period (September to June). A predefined protocol was strictly followed. On a specific card, information about the pupil's characteristics (exact age, sex, degree of puberty, eye and hair color, height, weight, handedness) and information about socioeconomic parameters (parents' age, origin and profession) were registered.
The measurements. The detection of scoliosis and recommendations for further investigation through clinical and radiographic examination at the hospital were done after assessment and recording of the existing trunk asymmetry. This was performed by the bending test in standing and sitting position and the angle of trunk inclination (ATR) was measured using the Pruijs scoliometer. Re-examination at the scoliosis clinic of the hospital was recommended for pupils who had a threshold reading of ATR >_70.
Pupils were examined during the period of their class, to avoid any psychological impact. Boys and girls were examined in different teams. During examination, they were wearing trousers and T-shirts. Groups of 15-20 pupils were subsequently invited into the examination room, having with them the questionnaire regarding their personal data completed. At first, the child was inspected in a standing position for possible deformities of the extremities, shoulder or pelvic asymmetry, lateral body inclination and asymmetry of the distance of the elbows from the trunk. Then, bending test in standing and sitting position was performed, by asking the child to freely bend forward hanging his hands to the ground, for the inspection of a possible hump. The results were recorded in the specific protocol.
Children with trunk asymmetry more than 70 were invited to hospital for re-evaluation after informing teachers and parents and obtaining their consent.
The assessed parameters were: a) the number of the examiners, b) the working hours, c) the fees per hour according to the specialty of the examiner, d) the examinersΥ transportation expenditures to the schools (mean kilometer distance, and fuel cost), and finally e) the cost of examination per child.

RESULTS
During the last 3 years (1/1/2000 Π 1/1/2003) 20 examiners were involved in the program, in total.
In the year 2000, the total number of working hours was 92. The examiners were 10 doctors (Orthopaedic and General Medicine trainees), 5 Health visitors (HV) and 5 physiotherapists. The participation of doctors had also a training purpose. They contributed to the program occasionally. Working hours for each specialty were 104 for doctors, 187 for HV (3 HV participated in every visit and 2 occasionally) and 83 for physiotherapists who also took part occasionally.
The fees per hour were calculated from the salary of every specialty as it was reported by the salary office of our hospital. For trainee doctors were 6.80, for Health visitors 6,70and for physiotherapists 5.50in current prices. The total cost for each specialty was estimated according to the working hours and fees per hour and it was 707.20for trainee doctors, 1252.90for HV and 456.50for physiotherapists.
The examiners' transportation expenditures, that result from the number of school visits, the mean kilometer distance, and mean fuel cost per kilometer, were assessed to be 31.2.
The cost for the examination per child for this year amounted to 1.99, a price that derives from the total number of working hours of each specialty, the transportation expenditure and the total number of the examined children during the year 2000 (n=1227 children).
In the year 2001, the total number of working hours was 75. The examiners were 2 Health visitors (HV) and 2 physiotherapists. 88 working hours correspond to HV and 14 to physiotherapists. The total cost was 1179.20for HV and 77for physiotherapists. The examiners' transportation expenditures were assessed to be 30. The cost for the examination per child for this year amounted to 1.15(n=1111 children).
In the year 2002, the total number of working hours was 88. The examiners were 2-3 Health Visitors (HV) for 167 working hours. Total cost was 118.90. The examiners' transportation expenditures were assessed to be 25.20. The cost for the examination of each child for this year was anagogued up to 1.11(n=1026 children)
The total cost of the program for each pupil amounted to 1.45, a price that derives from the total number of working hours, the transportation expenditure and the total number of examined children per year.

DISCUSSION
When school screening for scoliosis is performed by trained professionals by using simple and cost effective tests (bending test and use of the scoliometer) and with the knowledge of recent bibliography, it can trace the children who need further investigation and treatment, without the risk of false negative results[18].
To the assessment of the cost of such a program contributes the sensitivity, that is the ability of a screening test to identify children with scoliosis, and the specificity, that is the ability of the test to show a negative result when the child does not have scoliosis[27]. The use of scoliometer contributed significantly to the improvement of sensitivity and specificity of school screening, therefore its use is recommended[2].
We believe that great importance should be given to the training of the examiners, because their best performance will make school screening program more effective (with fewer false negative results, which means that we don't lose scoliotic children) and thus cost effective from a narrow financial and from a general social point of view (fewer false negative results lead to less unnecessary demand of health services and to smaller psychological stress of the whole family).
Our main examining group was constituted by Orthopaedic Doctors of the "Thriassio" hospital and it is also staffed by Orthopaedic and General Medicine trainees, Health visitors and physiotherapists. The HV were trained to become independent in the performance of the school screening program, a function which is included in their performing field.
During the performance of the program, there have been particular problems concerning the lack of special examining rooms, the existence of mixed population of pupils, the refusal of children having various problems (obesity, psychological problems) to be examined and the limited but existing reluctance of some parents to their children's examination. Discretion was a rule during the examination and during the invitation for evaluation to the hospital.
The program of school screening, except for its first and main purpose, has also a training component. It helps to train the non specialized personnel that occasionally join the examining team in scoliosis screening. This helps to the expansion of knowledge of the trainees on that disease. Constant literature update, study of rules of epidemiology and follow up of relevant courses-seminars, which have been organised by the Orthopaedic department of "Thriassio" hospital[3,5,6], aim at creating reliable examiners.
The cost of school screening is relatively insignificant compared to the rest of the procedures for further investigation. Primary screening of children depends on the sensitivity and the specificity of the method used. Nevertheless the method and its consequent cost are determined by factors such as: patient's discipline, doctor's judgment, the follow up criteria and the effectiveness of treatment[2].
The cost of treatment may be the cost of school screening only or it may also be the cost of further investigation (hospital visits, X-rays etc.), or the follow up of conservative or surgical treatment. In the present study, we only assessed the cost of school screening which is estimated to be low, 1.45for each child, according to our results.
According to the literature that scoliosis prevalence in Greece is 2%, 980 children will need conservative treatment with a brace and 41 surgical treatment5.
In order to compare the cost of conservative and surgical treatment for each child to the cost of school screening, one should consider that conservative treatment with a hard brace (eg. modified Boston with antirotatory blades) costs about 800 -1000each, while soft braces (eg. spinecor) cost about 2200each. Surgical treatment which includes the cost of a) preoperative evaluation (radiographs, CT, MRI and other exams), b) hospitalization, c) implants for posterior fusion and d) perioperative monitoring of nervous system by the use of somatosensory evoked potentials raises the cost to 30-35000for each child.
By multiplying the cost for each child with the total number of children that need therapy, one can realize the huge amount of money that is necessary for treatment, comparing to the small cost of our school screening program. It should also be highlighted that conservative treatment alters the natural history of scoliosis[4,13,21]. Detection of small curves and early onset of conservative treatment reduces the number of children that will need surgical management.
The study of data from the screening program, except for the already mentioned economical benefits, contributed to a better knowledge of curve progression, and thus of the natural history of scoliosis and also turned out to be a strong tool for research on etiology[7-12,14,15,22-25].
We emphasize that not only direct but also indirect cost should be considered.
Especially the psychological and social consequences after the diagnosis of scoliosis or after any treatment are difficult to evaluate. We can understand how undesirable are the false negative results that can happen during the program performance, compared to the social cost, which is difficult to be quantitatively estimated[18].
The investigation of cost-benefit in the present program (by the use of scoliometer) in comparison to other forms of examinations is not the purpose of the present article, but it is reported elsewhere[19].
The available literature is reviewed and the cost of our school screening program is compared with that of other greek[24] and international[28] programs. The cost of our program is noticed to be lower than that of similar programs performed. 5$ for every child in Greece15 and 2.31$ for every child in Canada[20].
In conclusion, the school-screening program for scoliosis is recommended for a general hospital, not only because of the obvious preventive medicine benefits but due to the low cost of the program as well.

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