1. Appropriateness of the referral patterns to a scoliosis clinic
Marie Beauséjour, M.A.Sc. *†
Marjolaine Roy-Beaudry M.Sc. *, Lise Goulet M.D. Ph.D *†,
Hubert Labelle M.D.*†
* Hôpital Sainte-Justine, Montréal
† Université de Montréal
Programme d’orthopédie Édouard-Samson
Montréal, May 6th 2005

2. Background
In the 1970’s, school scoliosis screening programs were implemented in Canada
Children (grades 7 and 8) presenting a rib hump on the Adams test were referred to a scoliosis clinic
In 1979, the Canadian Task Force on the Periodic Health Examination reported that school screening programs were not cost-effective, and they were progressively discontinued :
The ability of the detection procedure to identify the target condition
The ability of a treatment intervention to achieve a favourable outcome
In the 1970’s, school scoliosis screening programs were implemented in Canada in the wake of the American Society of Orthopaedic Surgeons endorsing this practice.
Briefly, the screening protocol consisted in a clinical inspection of the symmetry of the back on performing the Adams forward bending test and positive cases were referred to an orthopedist.
Since 1979, cchool scoliosis screening programs were progressively discontinued in Canada because they were not considered to be cost-effective by the Canadian Task Force on the Periodic Health Examination.
Indeed, it appears that the Adams test showed insufficient specificity leading to the referral of a considerable number of irrelevant cases. Secondly, at this time, no controlled studies had demonstrated the effectiveness of brace treatment for curve reduction or prevention of progression. In this situation, early referral to an orthopaedist was of limited interest.

3. Background
Since discontinuation of the school scoliosis screening programs in Canada, no evaluation has been conducted on the impact of this decision on the referral patterns of suspected cases to the treating physician.

4. Are referrals to a scoliosis clinic appropriate ?
Avoiding late referral : to ensure that patients susceptible to curve progression can benefit from an orthopeadic treatment with a reasonable probability of success
Fostering a responsible use of health services : to ensure that health resources use will correspond to recognized needs

5. Criteria : appropriateness
Gender
Skeletal maturity
Severity of curve at time of diagnosis
Type of curve
Factors associated with curve progression
Surgery :
Cobb > 40o - 45o
Dynamic brace : Immature patients Cobb [15o - 30o]
Treatment
indications
TLSO (Boston Brace) :
Immature patients Cobb [20o - 40o]
Clinical guidelines
Screening recommen- dations :
Children aged 12 or 13
Criteria for referral :
Angle of trunk rotation > 7o
Cobb > 20o
We consider at moderate to high risk of progression immature patients presenting a curve of less dans 30 degrees, and at very high risk of progression if the curve exceeds 30 degrees. High risk of progression is also present for not completely skelettally mature patients with a curve superior to 30 degrees.

6. Study objectives This study aims at :
Describing the population of patients at their initial visit to the scoliosis clinic of Sainte-Justine Hospital
Classifying patients with a confirmed diagnosis of idiopathic scoliosis according to criteria of appropriateness of referral

7. Study design
Initial patient base : All patients scheduling appointments at Sainte-Justine Hospital for suspected scoliosis between May 1st and April 30th 2004
Descriptive cross-sectional study : based on the review of the clinical and radiological examinations from patients at their initial evaluation to a scoliosis clinic with a focus on confirmed diagnosis of idiopathic scoliosis
Explicit referral by a general practitionner, a pediatrist or another health professional OR parental request AND no documented history of previous consultation in orthopedics for the suspected scoliosis
The medical files were double-reviewed

8. Sample composition * According to SRS criteria
735 patients on the list
Idiopathic scoliosis
n = 308
Non-idiopathic
scoliosis n = 107
* According to SRS criteria
No scoliosis* n = 206
Missing files n = 15
Inclusion criteria :
Suspected cases of scoliosis
First visit in scoliosis clinics
636 patients

9. Distribution of diagnosis
Non-idiopathic scolioses
(22%)
(17%)
(10%)
(5%)
(8%)
(6%)
(3%)
(2%)
(4%)
(1%)
n = 107

10. Idiopathic scoliosis : Variables
Gender
Age
Risser sign (0-5)
Elapsed time since onset of menses (in months)
Cobb angle of all curves in the frontal plane (as measured by the orthopaedic surgeon)
Curve type (location of main curve and convexity side)
Prescribed treatment
All measurements were made at time of first visit

11. Socio-demographic characteristics (Gender and age)
n % N Mode Mean(stdev) min max
Gender F
F %
M %
Age (years) (2.4)
< % % % % %
> %
The sample was composed of 82% boys and 18% girls.
The mean age at first visit was 13 and a half and the most represented group was 14 to 16 years old.

12. Maturation characteristics (Risser and menarche)
n % N Mode Mean(stdev) min max
Risser % % % % % %
missing %
Menarche (months) (17.5) %
< % % % %
> %
missing %
More than a half patients were skeletally immature, 36% being totally immature.
Menarche has not occurred yet in 37% of the girls and the average number of months elapsed since onset of menses was about 15

13. Main curve characteristics
(Location and side)
n % N Mode Mean(stdev) min max
Location and side Right Thoracic
Right Thoracic %
Left Thoraco-lumbar %
Left Lumbar %
Right Thoraco-lumbar %
Left Thoracic %
Right Lumbar %
Left Cervico-thoracic %
Right Cervico-thoracic %

14. Main curve characteristics
(Cobb angle)
n % N Mode Mean(stdev) min max
Cobb angle (degrees) (13.5) % % % % % % % %
> %
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51+ 20 40 60 80
20o
40o
The average Cobb angle at first visit is 26 degrees

15. Prescribed treatment (at first visit)
n % N Mode Mean(stdev) min max
Suggested treatment Observation
Observation %
Brace * %
Surgery ** %
Discharge %
Physical therapy %
Other %
With no monitoring of curve progression : arrived at Cobb >30
* Brace was recommended with no monitoring of curve progression
** Surgery was recommended for 20 patients at first visit and to an additional 10 patients at the second visit

16. Non-optimal use of health services
32% of referrals to a scoliosis clinic are characterized by non-clinically significant curves (Cobb  10o)
This lack of specificity may have an impact on :
Cost
Workload waiting time
Patients and family anxiety
In the context of school screening, the level of over-referral was also very high :
69% (Robitaille et al.,1984)
62% (Morais et al., 1985)
44% - using the scoliometer and 2 screening tests (Yawn et al. 1999)

17. In the idiopathic scoliosis group, Cobb > 10o
Practice Guidelines
In the idiopathic scoliosis group, Cobb > 10o
Maturity
48% over 14 y.o. (above recommended age for screening)
36% Risser > 2 (brace is indicated for skeletally immature)
28% more than 2 years post menarche (more than 3 years after the growth spurts; growth is completed)

18. In the idiopathic scoliosis group, Cobb > 10o
Practice Guidelines
In the idiopathic scoliosis group, Cobb > 10o
Curve severity
32% present curves of more than 30o (reduced efficiency of brace treatment)
In the context of school screening, severe curve at referral is rare :
Québec : 0.97% (Robitaille et al., 1984); 0.98% (Morais et al. 1985)
USA : 12% (Yawn et al., 1999); 8% (Velezis et al., 2002)

19. In the idiopathic scoliosis group, Cobb > 10o
Practice Guidelines
In the idiopathic scoliosis group, Cobb > 10o
Treatment
9% were appointed for surgery at first or second visit
25% brace treatment; 15% non-eligible for bracing
In the context of school screening, immediate treatment :
2.1% brace treatment and 0.2% surgery (Morais et al. 1985)
5.3% brace or surgery (Velezis et al. 2002)
24% were put on brace treatment

20. Limits Descriptive study Cross-sectional study (no follow-up)
Background map : École secondaire Père-Marquette, Montréal 61 31 3 1 4 7 30 42 6
Patients’ region of residency
Descriptive study
Cross-sectional study (no follow-up)
Normative study
Possible lack of consensus on the choice of criteria for late referral
Not designed as an “evaluation of effect” protocol
Only one metropolitan center

21. Recommendations
It appears relevant to reconsider the actual canadian politics with regards to screening and diagnosis of idiopathic scoliosis in terms of precocity and specificity
Re-establishment of school screening programs?
May reduce the number of surgeries (Weinstein, 1999)
Not cost-effective (Wynne, 1984) but may be cost-beneficial (Yawn et al., 2000)
“I” grade granted by the Canadian Task Force on the Periodic Health Examination in 2004 : “Insufficient evidence exists to allow a recommendation to be made.”

22. Recommendations
Work to do upstream of initial visit to increase the proportion of early and relevant referrals
Training, education and increased awareness of parents, teachers, nurses, family physicians and pediatricians (Howell et al., 1978; Morais et al. 1985)
Study of the factors associated with inappropriate referral of scoliotic patients in orthopaedic clinics in Quebec
Patterns of referral and history of health service use
Individual, familial, social and environmental factors involved in specialized care utilization
… and collaboration

23. Work in progress Multicenter prospective study supported by CIHR
‘‘Characterization of the referral patterns and study of the determinants of intervention on patients with adolescent idiopathic scoliosis’’
Labelle H., Feldman D., Fortier I., Goulet L., Grimard G., Rossignol M.
Multicenter prospective study supported by CIHR
Based on the Behavioral Model of health service utilization
(Andersen, 1995)

24. Acknowledgements CIHR Strategic training programs
Thanks to the co-authors
CIHR Operating Grant ( ) &
Canada Graduate Scholarships Doctoral Awards