TO THE EDITOR:
I read with great interest "School-Screening for Scoliosis. A Prospective Epidemiological Study in Northwestern and Central Greece" (79-A: 1498—1503, Oct. 1997), by Soucacos et al. The size of the cohort is very large and the immediate follow-up is complete. However, the cost analysis appears to be incomplete (and similar to analyses done previously by proponents of school-based screening programs1). The authors commented that the cost for the entire program was only about $25,000, which mainly reflected the cost of transportation. This is not comparable with the costs that would be associated with actual school-based screening programs. For example, the initial screening of 82,901 children resulted in the rescreening of 5803 children by the senior staff, but all of these examinations were done at no charge. In addition, 4185 children were sent for radiographic evaluation, but the cost of the radiographs does not appear to have been considered in the cost assessment. Even if one assumes a very modest estimate of $100 per radiograph, the expenditure would have been $418,500 for radiographs alone. The induced costs of medical care also were not considered in the analysis. The authors advised the 1347 children who had a curve of 1 to 9 degrees to have a clinical evaluation every year and advised the 1255 children who had a curve of 10 to 19 degrees to have such an evaluation every four to six months. The cost of all of these examinations should have been included in the analysis as they were induced by the screening process.
The data presented by Soucacos et al. are interesting but should not be used to justify school-based screening programs on the basis of cost. In addition, the fact that medical residents, orthopaedic surgery fellows, and senior staff went to the schools does not allow the findings of this report to be generalized to school-screening as performed in the United States.
Barbara P. Yawn, M.D., M.Sc.: Olmsted Medical Center, Rochester, Minnesota 55906
Dr. P. N. Soucacos, Dr. P. K. Soucacos, Dr. Zacharis, Dr. Beris, and Dr. Xenakis reply:
Dr. Yawn's favorable comments regarding the size of the study sample and the quality of the follow-up are appreciated, and we agree with many of her observations concerning the costs of school-screening in the United States. In our study, the cost of the entire screening program, which was performed in northwestern Greece, was estimated to be about $25,000 (United States dollars). This estimate included the costs related to a number of factors: the screeners' time (not counting that of medical students who volunteered their services for extracurricular credit), materials and paperwork, the time needed for follow-up activity, radiographs, and transportation to the schools. Because the team frequently traveled to small, peripheral towns, transportation was the primary expense of the study.
Although we concur with Dr. Yawn that the costs encountered in our study may not be comparable with those associated with a school-based study in the United States, a detailed cost analysis of school-screening in Greece was not intended (and may not be considered relevant to the conditions in the United States). Rather, a brief mention of cost was meant to underscore the overall benefits of screening in Greece. Indeed, it is unlikely that the economics of any study could be made comparable in an easy or valid way, especially when countries such as Greece, the United States, and even Sweden have very different scales of income, costs of living, and medical costs. (To keep things in perspective, the monthly income of an assistant professor at the Greek University is approximately $1200 [United States dollars].)
In addition to some of the parameters noted by Dr. Yawn, we believe that a full cost-benefit analysis should include an assessment not only of follow-up expenses but also of the impact on expenses associated with subsequent operative procedures and non-operative treatment. With regard to the latter, the preliminary findings of our study indicated that the number of operative procedures performed in the district of the University Hospital decreased from twelve in the three-year period immediately before the screening process to four in the three-year period after the screening. This decrease in the number of operations has been associated with an overall decrease in the total expense associated with scoliosis. Nonetheless, we doubt that a comparison of the numbers here with those in the United States would be meaningful.
Finally, it is noteworthy that, after excluding the cost to the state for the time spent on screening, a cost of only 6.6 cents per student screened was estimated in 1980 for school-screening in Minnesota1. When the salary of the screening staff was included in the analysis, however, the average cost per student was thirty-five cents. (As correctly observed by Dr. Yawn, the costs in Greece in the early 1990s were similar to those reported in the United States several years earlier.) The bottom line is that estimates of the direct and indirect costs of screening vary according to the definition of terms, the economy of a particular nation, and the impact of the screening process (in other words, the effectiveness of early treatment). Although we agree with Dr. Yawn that this is meaningful information, it was not within the scope of our study.
Panayotis N. Soucacos, M.D.; Panayotis K. Soucacos, M.D.;
Konstantinos C. Zacharis, M.D.; Alexandros E. Beris, M.D.;
Theodore A. Xenakis, M.D.: Department of Orthopaedic Surgery,
University of Ioannina School of Medicine, Ioannina 451 10,
Greece