The sexy scalpel: unnecessary shoulder surgery on the rise

Responsiveness of the EQ-5D-3L in elective shoulder surgery: Does it adequately represent patient experience?

AIM

Generic patient-reported outcome measures (PROMs) allow comparison of health-related quality of life across populations and pathologies. For these comparisons to be valid, the PROM must be responsive; the score must change when the patient's quality of life changes. This study aims to assess the responsiveness of the EQ-5D-three level (3L) in elective shoulder surgery.

METHODS

Pre- and post-operative EQ-5D-3L and Oxford Shoulder Scores (OSS) were prospectively collected across a range of 204 elective shoulder surgeries. Internal responsiveness was assessed through significance testing of mean change scores and standardized response means (SRMs). External responsiveness of the EQ-5D-3L was assessed against the minimal clinically important difference in OSS, using receiver operating characteristic curve and change score correlation.

RESULTS

Both EQ-5D-3L and OSS scores improved significantly over time ( p < 0.05). The SRM for the EQ-5D was 1.27 (95% CI 1.14-1.41) and for OSS 2.36 (2.22-2.52). Area under the curve for EQ-5D was 0.49. Only a weak correlation was found between EQ-5D and OSS change scores ( r = 0.21).

DISCUSSION

The EQ-5D-3L is adequately internally responsive to change following elective shoulder surgery but is unable to differentiate patients demonstrating minimal clinically important change. The EQ-5D therefore only partially reflects patient experience.

Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources

OBJECTIVES

To illustrate the need for better evaluation of surgical procedures, we investigated the use and cost of subacromial decompression in England over the last decade compared with other countries and explored how this related to the conduct and outcomes of randomised, placebo-controlled clinical trials.

DESIGN

Longitudinal observational study using Hospital Episode Statistics linked to Payment by Results tariffs in England, 2007/2008 to 2016/2017.

SETTING

Hospital care in England; Finland; New York State, USA; Florida State, USA and Western Australia.

PARTICIPANTS

Patients with subacromial shoulder pain.

INTERVENTIONS

Subacromial decompression.

MAIN OUTCOME MEASURES

National procedure rates, costs and variation between clinical commissioning groups in England.

RESULTS

Without robust clinical evidence, the use of subacromial decompression in England increased by 91% from 15 112 procedures (30 per 100 000 population) in 2007/2008, to 28 802 procedures (52 per 100 000 population) in 2016/2017, costing over £125 million per year. Rates of use of subacromial decompression are even higher internationally: Finland (131 per 100 000 in 2011), Florida State (130 per 100 000 in 2007), Western Australia (115 per 100 000 in 2013) and New York State (102 per 100 000 in 2006). Two randomised placebo-controlled trials have recently (2018) shown the procedure to be no more effective than placebo or conservative approaches. Health systems appear unable to avoid the rapid widespread use of procedures of unknown effectiveness, and methods for ceasing ineffective treatments are under-developed.

CONCLUSIONS

Without good evidence, nearly 30 000 subacromial decompression procedures have been commissioned each year in England, costing over £1 billion since 2007/2008. Even higher rates of procedures are carried out in countries with less regulated health systems. High quality randomised trials need to be initiated before widespread adoption of promising operative procedures to avoid overtreatment and wasted resources, and methods to prevent or desist the use of ineffective procedures need to be expedited.