Orthopedic Perspectives of Musculoskeletal Ultrasound

Cost-Benefit Analysis of Ultrasonography in the Hand Clinic

BACKGROUND

Despite previous studies demonstrating the benefit of office-based ultrasonography for musculoskeletal evaluation, many hand surgery clinics have yet to adopt this practice. The authors conducted a cost-benefit analysis of establishing an ultrasound machine in a hand clinic.

METHODS

The authors used the Medicare Physician Fee Schedule, Physician/Supplier Procedure Summary, and Physician Compare National Downloadable File databases to estimate provider reimbursement and annual frequency of office-based upper extremity-related ultrasound procedures. Ultrasound machine cost, maintenance fees, and consumable supply prices were gleaned from the literature. The primary outcomes were net cost-benefit difference and benefit-cost ratio at 1 year, 5 years, and 10 years after implementation. Sensitivity analyses were performed by varying factors that influence the net cost-benefit difference.

RESULTS

The estimated total initial expense to establish ultrasonography in the clinic was $53,985. The overall cost-benefit difference was -$49,530 per practice at the end of the first year (benefit-cost ratio, 0.3), -$1049 after 5 years (benefit-cost ratio, 1.0), and $52,022 after 10 years (benefit-cost ratio, 1.4). Benefits primarily accrued because of physician reimbursements. One-way sensitivity analysis revealed machine price, annual procedure volume, and reimbursement rate as the most influential parameters in determining the benefit-cost ratio. Ultrasonography was cost beneficial when the machine price was less than $46,000 or if the billing frequency exceeded six times per week. A societal perspective analysis demonstrated a large net benefit of $218,162 after 5 years.

CONCLUSIONS

Implementation of office-based ultrasound imaging can result in a positive financial return on investment. Ultrasound machine cost and procedural volume were the most critical factors influencing benefit-cost ratio.

Role of sonographic imaging in occupational therapy practice

Occupational therapy practice is grounded in the delivery of occupation-centered, patient-driven treatments that engage clients in the process of doing to improve health. As emerging technologies, such as medical imaging, find their way into rehabilitation practice, it is imperative that occupational therapy practitioners assess whether and how these tools can be incorporated into treatment regimens that are dually responsive to the medical model of health care and to the profession's foundation in occupation. Most medical imaging modalities have a discrete place in occupation-based intervention as outcome measures or for patient education; however, sonographic imaging has the potential to blend multiple occupational therapy practice forms to document treatment outcomes, inform clinical reasoning, and facilitate improved functional performance when used as an accessory tool in direct intervention. Use of medical imaging is discussed as it relates to occupational foundations and the professional role within the context of providing efficient, effective patient-centered rehabilitative care.

A training, assessment and feedback package for the trainee shoulder sonographer

Diagnostic ultrasound of the shoulder is recognised as being one of the most technically challenging aspects of musculoskeletal ultrasound to master. It has a steep learning curve and makes gaining competency a time-intensive training process for both the trainee and their trainer. This article describes a training, assessment and feedback package developed within the framework of a Consortium for the Accreditation of Sonographic Education approved post-graduate ultrasound course. The package comprises: (i) a shoulder diagnostic ultrasound scan protocol with definition of findings, differential diagnosis and pro forma for recording scan findings, (ii) an assessment form for performance of shoulder diagnostic ultrasound scans with assessment criteria and (iii) a combined performance assessment and scan findings form, for each tissue being imaged. The package has been developed using medical education principles and provides a mechanism for trainees to follow an internationally recognised protocol. Supplementary information includes the differential diagnostic process used by an expert practitioner, which can otherwise be difficult to elicit. The package supports the trainee with recording their findings quickly and consistently and helps the trainee and trainer to explicitly recognise the challenges of scanning different patients or pathologies. It provides a mechanism for trainers to quantify and trainees to evidence their emerging competency. The package detailed in this article is therefore proposed for use in shoulder ultrasound training and its principles could be adapted for other musculoskeletal regions or other ultrasound disciplines.

Quantification of sonographic echogenicity by the gray-level histogram in patients with supraspinatus tendinopathy

PURPOSE

The aim of this study was to compare the gray-level value of the supraspinatus tendon of a painful shoulder with that of a normal shoulder measured by ultrasonography, and to investigate whether a low mean gray-level value of the supraspinatus tendon could indicate a partial-thickness or incomplete full-thickness tear.

METHODS

Two hundred and ten patients had significant unilateral shoulder pain with the clinical suspicion of rotator cuff tendinopathy. They underwent bilateral shoulder ultrasonography, and the mean echogenicity of the histogram was calculated on the screen. The mean gray-level value of each patient's contralateral asymptomatic shoulder was compared with that of the painful shoulder.

RESULTS

Based on the scan of transverse and longitudinal planes, a significant difference existed between the symptomatic shoulder and contralateral asymptomatic shoulder (p < 0.0001). The mean gray-level values of symptomatic shoulders showed no statistically significant difference between the patients who underwent surgery and the patients who underwent conservative treatment.

CONCLUSIONS

We demonstrated that the ultrasound gray-level histogram is a promising tool for detecting the hypoechogenic appearance of supraspinatus tendinopathy. A decrease in the mean gray-level value on the symptomatic shoulder may be used as an alternative sonographic indicator of rotator cuff partial-thickness tear or tendinopathy.

LEVEL OF EVIDENCE

Diagnostic level III.