Improving Healthcare: When Cost Savings & Patient Welfare Coincide

You would hope that the 3 million Americans visiting primary care doctors or emergency rooms for acute knee or ankle pain each year would get appropriate x-rays from their referring physicians.  Ditto the millions more people seen for back problems. But you’d be unpleasantly surprised.

Much too often, patients arrive at appointments with orthopedic and sports medicine specialists, bearing the wrong kind of x-rays along with their pain.  Their images were performed while they were lying table-top, rather than bearing weight.   

“The difference is critical to treatment,” said Robert Franks, DO, FAOASM, sports medicine expert at the Rothman Institute and team physician for USA Wrestling.

Dr. Franks estimates that he must order additional weight-bearing x-rays for as many as 30-40 percent of his patients.

At Einstein Healthcare Network, Gene Shaffer, MD tossed a quick “80 percent” when asked what percentage of his patients required re-do of x-rays to weight-bearing.   Offered a chance later to revise his hasty response, he noted, “It would be upward.”  Dr. Shaffer has served on the sports medicine staff for the Philadelphia Flyers and the Phantoms, and as one of the team physicians at Temple University, and later, LaSalle University.  

Stand for X-Rays

X-rays of patients lying down “can fool the clinician, who needs to see truly what the joint space looks like,” explained Dr. Franks.  Body parts look different when they’re supporting the body’s weight.  Given how common arthritis is in the population, Franks emphasized how vital it is for treatment to know if and how much degenerative joint disease the patient has.   

Non-weight-bearing x-rays minimize such problems.

In evaluating treatment options, it’s essential to see the narrowing of space in the joint, added Shaffer.  He said that x-rays taken while the patient is standing also provide important information about alignment.  Such information can make the difference in his decision on whether to use a cast or perform surgery on a patient.  Nor would he ever perform a procedure like bunion surgery without weight-bearing x-rays.

Act on It

Here’s an area where healthcare cost savings and patient welfare coincide.  Consider the cost of wasteful duplication when inappropriate x-rays are performed the first time:  $100 - $250 a crack, many million times a year.

Consider sparing patients the unnecessary over-exposure to x-rays, many millions of times a year if providers had performed the right x-rays the first time.

“Weight-bearing x-rays should be the standard for non-traumatic lower extremities,” maintains Dr. Shaffer.  (That includes for back, hip, knee, ankle and foot.)  

Of course, there’s a learning curve to this, acknowledged the specialists.  Not all radiology technicians know the set-up required for weight-bearing x-rays under different circumstances.  And many primary care physicians, eager to respond to their patients immediately or prepare them for referral, prescribe x-rays without fully understanding when and why weight-bearing images are best practice.

Material for continuing education and medical journal news blasts.

Meanwhile, “Just give us a call first and we’ll tell you,” urged Dr. Franks in a most collegial manner. 

Expert Asides:

• Back pain and sprained ankles are among the most common ailments seen in orthopedics and sports medicine.  Americans suffer approximately 25,000 sprained ankles daily.
• Help prevent injuries with an appropriate stretching and strengthening program.
• Early treatment can help prevent further damage and is usually easier on the patient and on healing.
• X-rays - though currently de-emphasized by a population infatuated by more sophisticated technologies like MRIs and CT scans – are a key tool for doctors.  They perform a crucial role, providing vital information for treatment that other technologies don’t.