The Cost of Return to Play Protocols in Collegiate Athletes Recovering from Coronavirus Disease 2019.

INTRODUCTION/PURPOSE: SARS-CoV-2 infection (COVID-19) can result in myocarditis. Protocols were developed to allow competitive athletes to safely return to play (RTP) after a COVID-19 infection, but the financial impact of these protocols is unknown. Our objective was to determine the differential cost of post-COVID-19 RTP protocols for competitive collegiate athletes. METHODS: This multicenter retrospective cohort study of clinical evaluation of 295 athletes after COVID-19 infection was performed at four institutions with three RTP protocols. Costs were calculated using adjusted Center for Medicare and Medicaid Services pricing. All athletes underwent electrocardiogram and clinical evaluation. A tiered approach performed cardiac imaging and biomarker analysis for major symptoms. A universal transthoracic echocardiogram (TTE) approach performed TTE and biomarkers for all athletes. A universal exercise stress echocardiogram (ESE) approach performed ESE and biomarkers for all athletes. RESULTS: The cost per athlete was $632.51 ± 651.80 ($44,908 total) in tiered group (n = 71), $1,072.30 ± 517.93 ($87,928 total) in the universal TTE group (n = 82), and $1357.38 ± 757.05 ($192,748 total) in the universal ESE group (n = 142) (P < 0.001). Extrapolated national costs for collegiate athletes would be $39 to 64 million higher for universal imaging approaches versus a tiered approach. Only seven athletes had probable/possible myocarditis with no significant difference between approaches. CONCLUSIONS: Cardiac screening in collegiate athletes after COVID-19 infection resulted in significant cost to the health care system. A tiered-based approach was more economical, and a universal exercise echocardiogram group detected slightly more myocardial abnormalities by cardiac magnetic resonance imaging. The clinical consequences of these approaches are unknown.

Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review.

OBJECTIVE: To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain. METHODS: We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting. RESULTS: Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format. CONCLUSIONS: Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.

Factors Associated with Grade Appeals: A Survey of Psychiatry Clerkship Directors.

PURPOSE: In an effort to provide medical students with opportunities for accurate grading, some psychiatry clerkship directors allow for grade appeals. The authors examined the appeals process from the clerkship directors' perspective. METHODS: A 23-item survey, consisting of multiple choice and narrative questions, was sent to allopathic and osteopathic accredited schools in North America. Questions included information about the medical school, the clerkship director, and the grade appeal processes. StatPlus sorted and analyzed the data, and grade challenge rates were compared between schools. The narrative responses were independently sorted by the authors. RESULTS: Sixty-one responses were received (35% of programs). A grade challenge rate was calculated for each response, using the number of appeals/students per year, allowing for further comparison of grade challenges. Clerkships with an honors/pass/fail grading schema had a higher grade challenge rate (p = 0.002) when compared to all other reported grading schemas. Clerkships where the grade appeal could result in a lower grade had a smaller grade challenge rate (p = 0.026) as compared to programs where a grade appeal could not result in a lower grade. The authors observed three common pathways for the processing of grade appeals and four common themes among clerkship directors as contributors to grade appeals. CONCLUSION: A grade appeal is often the final step in the grading process for medical students. By identifying factors that contribute to grade appeals, areas for targeted interventions in the evaluation process are potentially identified. Future study of grade appeals, including from the medical students' perspective, is warranted.