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New Innovations in Sports Medicine

2010; Lippincott Williams & Wilkins; Volume: 9; Issue: 4 Linguagem: Inglês

10.1249/jsr.0b013e3181e7cb75

1537-8918

Robert J. Johnson,

Foot and Ankle Surgery

INTRODUCTION New technology and procedures provide added hope for the injured athlete's recovery. Their widespread use and popularity, however, often precede supporting evidence. Case in point: the treatment of a Pittsburgh Steelers wide receiver prior to the 2009 Super Bowl. After a regenerative therapy injection of platelet-rich plasma, he returned successfully to the playing field and contributed to his team's victory. The media grasped the treatment modality, and almost instantaneously, platelet-rich plasma became the new "sweetheart" treatment in sports medicine circles. Similarly, the clinical use of musculoskeletal ultrasound (MSK US) has grown rapidly in popularity, especially among nonoperative sports medicine physicians. MSK US has expanded the capability of the clinician to perform rapid, safe procedures for both diagnosis and treatment. MSK US provides the clinician with diagnostic capabilities (both static and, more importantly, dynamic techniques) and treatment via image-guided injections of both soft tissue and joints. A third innovation I will use as an example, not nearly as recent as the others, is computerized neurocognitive testing in managing concussion, which is still controversial in its application but widely used. Each of these procedures/technologies carries a significant price tag beyond the evaluation and management fee. Is the added expense (read: income for the clinician) justified by improved outcomes? ECONOMIC ISSUES Acknowledging the seductive risk of "new technology," I had considered an optional title for this commentary - "See My New Hammer." This is derived from the axiom, simply paraphrased, "With my new hammer, everything I see is a nail," implying that developing a new clinical or diagnostic skill/tool is accompanied by an inordinately increased use of that specific skill or tool. Reports have identified the escalating use of new magnetic resonance imaging (MRI) scanners concomitant with the recent purchase of the equipment, especially when purchased by a group of nonradiological physicians: use is 4.0 to 4.5 times higher than radiologist utilization (4). Consciously or otherwise, increased utilization pays for the equipment and enhances profitability. Daily, newspaper headlines, network and cable news programs, and news Web sites lead with stories of the "health care crisis," and proposed solutions. The crisis is misnamed. A more appropriate name is the "cost-of-illness-and-injury crisis." Health is inexpensive. Illness and injury diagnosis and treatment are not. (The current estimate is that the cost of the recently passed health care reform bill will exceed $1 trillion dollars.) As a physician, I tend to lay blame at the feet of some favorite targets - insurance companies, administrators, and the government, to name just a few. But then, I also observe physician behaviors with new technologies and procedures, and I question how much blame we should accept in the cost crisis. And, importantly, to what degree is the use (or overuse) of the aforementioned treatments and technologies guided by income enhancement? THE PROBLEM Let me place my comments in the proper context. I am a salaried employee of a university. I have no productivity incentive. Half of my time is clinical practice; the other half is devoted to directing a sports medicine fellowship that includes teaching fellows, residents, and students. Not being driven by incentives likely has shaped my attitude. Traditional reimbursement practices foster the behavior that is the subject of my scrutiny. By tradition, insurers have reimbursed procedures at a much higher rate than cognitive encounters. Those who enter medicine often consider this inequity when choosing a career specialty. Classically, the surgical and procedural specialties and subspecialties live at the top of the medical "food chain." Thus, many who practice ambulatory medicine look for the "golden egg" that can enhance income. Advances in technology over the past decade have enabled clinicians to improve dramatically the care delivered to their patients. A legitimate concern stems from the overuse of these technologies when they may not be clinically necessary. When is the use of MSK US necessary to improve patient care? Do we have outcome studies demonstrating efficacy to support the use? USING THE NEEDLE There is abundant online discussion on sports medicine listservs regarding the use of regenerative therapy injections (hypertonic dextrose, sodium morrhuate, autologous blood, and platelet-rich plasma) for tendinopathies. Case series and anecdotal experience suggest generally favorable results for various soft tissues maladies but lack Level I or II evidence (2). Most patients receiving these therapies are personally responsible for the cost of the procedure. Interestingly and coincidentally, the most popular, most discussed, and most expensive of these is platelet-rich plasma: $500 to $2000 per injection, based on my informal survey. There is evidence to show efficacy of all the injection therapies, yet no study shows that one is superior to the others (7). Why, then, the fascination with platelet-rich plasma? Is it the favorable effect on the practitioner's bottom line? In comparison, autologous blood injections (anecdotally quite successful in treating chronic tendinopathies) cost less than $130 at sites where I practice. ULTRASOUND Intuitively, those who use ultrasound for injections feel their accuracy is better, suggesting "better" results, but so are the relative value units (RVUs). Studies of the accuracy of injections suggests benefit for some but not all (3). One third of knee and ankle injections "missed the target" and were extraarticular, while one half of wrist injections were extraarticular. Interestingly, approximately one half of the extraarticular injections resulted in satisfactory outcomes, yielding acceptable results in 82% of the knee and ankle injections and almost 75% for wrist injections. Not bad! This, then, raises the question of how injection accuracy correlates with favorable outcomes. In contrast, another study has suggested improved outcomes when using MSK US to guide subacromial injections (6). This same review determined success in subacromial space injections between a woeful 29% to a solid 83% when landmark-guided. Accuracy and outcomes, however, were not correlated. Soft tissue injections for de Quervain's tenosynovitis had better outcomes with image-guided injections, but plantar fasciitis and trigger finger injections showed no difference when comparing landmark- to image-guided injections (3). The accuracy of landmark-guided knee injections can be improved by altering the approach. In 2002, Jackson and his colleagues improved accuracy to 93% by using a superolateral approach compared with inferomedial and inferolateral techniques, suggesting that image-guided injections may not offer a benefit for accuracy (5). Differentiating outcomes from accuracy is an important discussion point based on a recent study comparing fluoroscopic-guided corticosteroid/anesthetic trochanteric bursa injections versus landmark-guided injections (1). The results were identical, but the cost of the fluoroscopic-guided injections was $1000 more. Granted, MSK US injections cost significantly less ($150-$350) than fluoroscopy, but do they guarantee better outcomes? Few question the importance of image-guided hip and glenohumeral injections. The use of MSK US for these injections can lower the cost significantly for these intraarticular sites. Soft tissue injections using anything from corticosteroids to autologous blood to platelet-rich plasma are performed with and without ultrasound guidance. MSK US can actually visualize the material being delivered to the area of tendinosis or within the sheath of that patient with de Quervain's tenosynovitis. Having performed these injections with ultrasound, I can say that it's a beautiful thing. Accuracy may be improved, but are the outcomes better? If outcomes are better in all procedures in which MSK US is used, the additional cost is justified. If selected procedures show superior efficacy with MSK US, they should be used and can be warranted economically. The challenge is to be objective and use technology when justified by outcome studies, not by anecdote or revenue. TESTING THE BRAIN Periodically, the American Medical Society for Sports Medicine's (AMSSM) listserv has questions asked about billing codes regarding neurocognitive testing in the office. Again, neurocognitive testing is another tool that is being used in office settings. Physicians are billing for the service, and yet these computerized tests have not been shown to affect outcomes after return to sport, nor have they been able to compare favorably to the gold standard - physician assessment and decision-making. Another distressing application is the use of neurocognitive testing in the emergency department (ED) to assess an athlete after a concussion (8). Picture an athlete brought from an athletic event to an ED with the sideline diagnosis of concussion. Computerized neurocognitive testing was a part of the evaluation. Not surprisingly, the tests were uniformly abnormal. The conclusion - neurocognitive testing in the emergency department is a useful diagnostic tool. Computerized neurocognitive testing was never designed for concussion diagnosis. Nor is it unexpected to have an athlete who is acutely symptomatic to perform poorly on the test. Neurocognitive testing is not prognostic nor is it diagnostic. There is no rationale for use in this setting. Again, a billable procedure of no clinical importance in that setting is added to an already expensive ED visit. FINAL COMMENTS These are three examples in which the use of new technology should be questioned as to purpose. Is the use clinically justified, or is the use for a more "mercenary" purpose - to increase income? I urge clinicians to avoid the seduction of rationalizing technology/procedure for economic benefit. These new tools can be very useful to improve the care we give our athlete-patients. Nevertheless, we must find balance as we consider our ethical and social responsibility in controlling illness and injury costs.