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Jones T, McNair A, McLeod H, Morley J, Rooshenas L, Hollingworth W. Identifying potentially low value surgical care: A national ecological study in England. J Health Serv Res Policy 2024:13558196241252053. [PMID: 38725100 DOI: 10.1177/13558196241252053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
OBJECTIVES High variation in clinical practice may indicate uncertainty and potentially low-value care. Methods to identify low value care are often not well defined or transparent and can be time intensive. In this paper we explore the usefulness of variation analysis of routinely-collected data about surgical procedures in England to identify potentially low-value surgical care. METHODS This is a national ecological study using Hospital Episode Statistics linked to mid-year population estimates and indices of multiple deprivation in England, 2014/15-2018/19. We identified the top 5% of surgical procedures in terms of growth in standardised procedure rates for 2014/15 to 2018/19 and variation in procedure rates between clinical commissioning groups as measured by the systematic component of variance (SCV). A targeted literature review was conducted to explore the evidence for each of the identified techniques. Procedures without evidence of cost-effectiveness were viewed as of potentially low value. RESULTS We identified six surgical procedures that had a high growth rate of 37% or more over 5 years, and four with higher geographical variation (SCV >1.6). There was evidence for two of the 10 procedures that surgery was more cost-effective than non-surgical treatment albeit with uncertainty around optimal surgical technique. The evidence base for eight procedures was less clear cut, with uncertainty around clinical- and/or cost-effectiveness. These were: deep brain stimulation; removing the prostate; surgical spine procedures; a procedure to alleviate pain in the spine; surgery for dislocated joints due to trauma and associated surgery for traumatic fractures; hip joint replacement with cemented pelvic component or cemented femoral component; and shoulder joint replacement. CONCLUSIONS This study demonstrates that variation analysis could be regularly used to identify potentially low-value procedures. This can provide important insights into optimising services and the potential de-adoption of costly interventions and treatments that do not benefit patients and the health system more widely. Early identification of potentially low value care can inform prioritisation of clinical trials to generate evidence on effectiveness and cost-effectiveness before treatments become established in clinical practice.
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Affiliation(s)
- Tim Jones
- Research Fellow, The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Research Fellow, Bristol Medical School, University of Bristol, Bristol, UK
| | - Angus McNair
- Associate Professor in Colorectal Surgery, Bristol Medical School, University of Bristol, Bristol, UK
- Consultant, North Bristol NHS Trust, Bristol, UK
| | - Hugh McLeod
- Senior Lecturer, NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Senior Lecturer, Bristol Medical School, University of Bristol, Bristol, UK
| | - Josie Morley
- PhD Student, NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- PhD Student, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Associate Professor, Bristol Medical School, University of Bristol, Bristol, UK
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Greif DN, Shaikh HJ, Neumanitis J, Ramirez G, Maloney MD, Bronstein RD, Giordano B, Nicandri GT, Voloshin I, Mannava S. Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients. JSES Int 2024; 8:304-309. [PMID: 38464455 PMCID: PMC10920123 DOI: 10.1016/j.jseint.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Background The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.
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Affiliation(s)
- Dylan N. Greif
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Hashim J.F. Shaikh
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - James Neumanitis
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Gabriel Ramirez
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Michael D. Maloney
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Robert D. Bronstein
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Brian Giordano
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Gregg T. Nicandri
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Ilya Voloshin
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Sandeep Mannava
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
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Geurkink TH, Marang-van de Mheen PJ, Nagels J, Wessel RN, Poolman RW, Nelissen RG, van Bodegom-Vos L. Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study. Arthrosc Sports Med Rehabil 2023; 5:100819. [PMID: 38023445 PMCID: PMC10661501 DOI: 10.1016/j.asmr.2023.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors. Methods Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision. Results A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors. Conclusions Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important. Clinical Relevance There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.
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Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ronald N. Wessel
- Department of Orthopaedics, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Geurkink TH, van Bodegom-Vos L, Nagels J, Liew S, Stijnen P, Nelissen RGHH, Marang-van de Mheen PJ. The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis. BMC Musculoskelet Disord 2023; 24:456. [PMID: 37270498 DOI: 10.1186/s12891-023-06577-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 05/27/2023] [Indexed: 06/05/2023] Open
Abstract
AIMS To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries. METHODS Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures. RESULTS A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients. CONCLUSION Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.
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Affiliation(s)
- Timon H Geurkink
- Department of Orthopaedics, Leiden University Medical Centre, Postbus, Leiden, 9600, 2300 RC, the Netherlands.
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Centre, Postbus, Leiden, 9600, 2300 RC, the Netherlands
| | - Susan Liew
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Australia
| | - Pieter Stijnen
- Department of Management Information and Reporting, University Hospital Leuven, Leuven, Belgium
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Postbus, Leiden, 9600, 2300 RC, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
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Signorino JA, Thompson AG, Hando BR, Young JL. Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review. Int J Sports Phys Ther 2023; 18:293-308. [PMID: 37020452 PMCID: PMC10069387 DOI: 10.26603/001c.73312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery. Purpose To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD. Study Design Scoping review. Methods An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted. Results Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months. Conclusion Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists. Level of Evidence n/a.
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Affiliation(s)
| | | | - Benjamin R Hando
- Division of Physical Therapy Shenandoah University
- DScPT Program Bellin College
- Special Warfare Training Wing
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Monu J, Sunil S. The Net Promoter Score with Friends and Family Test applied to arthroscopic shoulder surgery. Clin Shoulder Elb 2023; 26:20-24. [PMID: 36919503 PMCID: PMC10030985 DOI: 10.5397/cise.2022.01116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/14/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The Friends and Family Test (FFT) developed by the UK National Health Service evaluates whether patients are satisfied with a service provided, where improvements are needed, and how likely patients are to recommend the intervention. Calculated from the FFT, the Net Promoter Score (NPS) creates a recommendation metric for treatment. The primary aim of this prospective study is to evaluate NPS for arthroscopic subacromial decompression (ASD) and rotator cuff repair (RCR). Secondary aims are to postoperatively evaluate 1-year changes in patients' Oxford Shoulder Scores (OSSs) in terms of the proportion of patients satisfied with their surgery and correlation with FFT. METHODS During a 2-year period, all patients undergoing ASD or RCR completed questionnaires prospectively. Collected preoperatively and postoperatively at 1 year. RESULTS NPSs were 31 for ASD (n=32) and 52 for RCR (n=39). OSSs increased by 4.3 and 6.9 for ASD and RCR, respectively (P<0.001). Overall, 75% of ASD and 77% of RCR patients were either "satisfied" or "very satisfied," respectively, with procedure outcomes. Scores from FFT had a positive correlation with improvement in OSS and satisfaction scores among patients undergoing arthroscopic shoulder surgeries (P<0.001). CONCLUSIONS The current study shows positive NPS outcomes in patients with ASD and RCR. Scores from FFT correlate well with both satisfaction and OSS among patients. NPS can be an adjunct to traditional patient-reported outcome measures to provide global evaluation of patient experiences to aid in determining the clinical value of common procedures in shoulder orthopaedics.
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Affiliation(s)
- Jabbal Monu
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sharma Sunil
- NHS Fife, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
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Zadro JR, Karunaratne S, Harris IA, Jones CM, O'Keeffe M, Ferreira GE, Buchbinder R, McCaffery K, Thompson R, Maher CG, Hoffmann T. The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial. PATIENT EDUCATION AND COUNSELING 2022; 105:2951-2961. [PMID: 35589459 DOI: 10.1016/j.pec.2022.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/08/2022] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the effects of a patient decision aid for people considering shoulder surgery. METHODS Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes. RESULTS 409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome. CONCLUSIONS In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge. PRACTICE IMPLICATIONS Research is needed to understand reasons for the lack of anticipated effects. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).
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Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia.
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia; Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, New South Wales, Australia
| | - Caitlin Mp Jones
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia; Monash Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Victoria, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Rachel Thompson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
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Rees JL, Craig R, Nagra N, Baldwin M, Lane JCE, Price A, Beard DJ, Abram S, Judge A, Prieto-Alhambra D, Furniss D, Carr AJ. Serious adverse event rates and reoperation after arthroscopic shoulder surgery: population based cohort study. BMJ 2022; 378:e069901. [PMID: 35938625 PMCID: PMC9258605 DOI: 10.1136/bmj-2021-069901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To provide clinicians and patients with accurate risk estimates of serious adverse events after common elective shoulder arthroscopic procedures, including reoperation within one year. DESIGN Population based cohort study. SETTING Hospital Episode Statistics for NHS England, including civil registration mortality data from the Office for National Statistics. PARTICIPANTS 288 250 arthroscopic shoulder procedures performed in 261 248 patients aged ≥16 years between 1 April 2009 and 31 March 2017. Elective procedures were grouped into subacromial decompression, rotator cuff repair, acromioclavicular joint excision, glenohumeral stabilisation, and frozen shoulder release. MAIN OUTCOME MEASURES The primary outcomes were rates of serious adverse events (mortality, pulmonary embolism, pneumonia, myocardial infarction, acute kidney injury, stroke, and urinary tract infection) requiring inpatient care within 90 days post-surgery. Secondary outcomes were specific adverse event rates at 90 days, and reoperations (including for deep infection) within one year. RESULTS The overall rate of complications within 90 days after arthroscopic shoulder surgery (including reoperation) was low at 1.2% (95% confidence interval 1.2% to 1.3%), with one in 81 patients at risk, and varied according to type of procedure, from 0.6% (0.5% to 0.8%) for glenohumeral stabilisation to 1.7% (1.5% to 1.8%) for frozen shoulder release. After adjustment for age, comorbidities, and sex, no effect of procedure type was observed. Pneumonia was the most common adverse event (0.3%, 0.3% to 0.4%), with one in 303 patients at risk. Pulmonary embolic events were rare, at 0.1% (0.1% to 0.1%), with one in 1428 patients at risk. At one year, the overall rate for reoperation was 3.8% (3.8% to 3.9%), with one in 26 patients at risk, ranging from 2.7% (2.5% to 3.0%) for glenohumeral stabilisation to 5.7% (5.4% to 6.1%) for frozen shoulder release. The overall rate of further surgery for deep infection was low, at 0.1% (0.1% to 0.1%), with one in 1111 patients at risk, but was higher after rotator cuff repair (0.2%, 0.2% to 0.2%), with one in 526 patients at risk. Over the study period the number of arthroscopic shoulder procedures increased, except for subacromial decompression, which decreased. CONCLUSIONS The findings of this study suggest that risks of serious adverse events associated with common shoulder arthroscopy procedures are low. Nevertheless, serious complications do occur, and include the risk of reoperation in one in 26 patients within one year. STUDY REGISTRATION Clinical. TRIALS gov NCT03573765.
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Affiliation(s)
- Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Richard Craig
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Navraj Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jennifer C E Lane
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Simon Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Dominic Furniss
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
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Järvinen TLN. On Patient Safety: Shoulder "Impingement"-Telling a SAD Story About Public Trust. Clin Orthop Relat Res 2022; 480:1263-1266. [PMID: 35608482 PMCID: PMC9191362 DOI: 10.1097/corr.0000000000002262] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Teppo L N Järvinen
- Head, Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Helsinki, Finland
- Professor, Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Sørensen L, van Tulder M, Johannsen HV, Ovesen J, Enemark U, Blæhr EE, Oestergaard LG. Costs of shoulder disorders in Denmark; a nationwide cost-off-illness study investigating 617,334 patients and matched controls. Pain 2022; 163:2162-2171. [PMID: 35135991 DOI: 10.1097/j.pain.0000000000002610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Shoulder disorders are very common musculoskeletal conditions. Few studies have focused on the costs associated with shoulder disorders, and the economic burden has never been established in a nationwide cost-of-illness study. We aimed to evaluate the healthcare costs and costs of productivity loss (sick leave), and to evaluate if costs were higher for specific subgroups. Using national Danish registers, we identified individuals with shoulder disorders (subacromial pain, stiffness, fracture or dislocation) diagnosed between 2005 and 2017 and controls matched on age and gender without shoulder disorders. Health care usage, sick leave and related costs were estimated. During the 13-year inclusion period, 617,334 unique individuals were identified and the incidence rate was 1,215 per 100,000 person years in 2017. The expected additional societal costs were €1.21 billion annually. The mean additional total costs for the 6-years period were €11,334 (11,014; 11,654) for individuals aged ≥65 years and €25,771 (25,531; 26,012) for individuals aged <65 years. For individuals in the working age, the costs of sick leave accounted for approximately 70% of the total costs. Individuals aged ≥65 years had health care costs that were twice as high as individuals aged <65 years. Additionally, the 20% of cases accruing the highest costs accounted for 66% of the total costs. In conclusion, incidence rates of shoulder disorders were high and costs of sick leave accounted for a large proportion of total costs associated with illness in working age people. Furthermore, a minority of patients accounted for a substantial share of the total costs.
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Affiliation(s)
- Lotte Sørensen
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark Department of Clinical Medicine, Aarhus University, Denmark Department of Human Movement Sciences, Faculty Behavioural & Movement Sciences, Amsterdam Movement Sciences research institute, Vrije Universiteit Amsterdam, Netherlands Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark Department of Public Health, Aarhus University, Denmark DEFACTUM, Central Denmark Region, Aarhus, Denmark
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11
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Hunter DJ, Rivett DA, McKiernan S, Snodgrass SJ. Acromiohumeral distance and supraspinatus tendon thickness in people with shoulder impingement syndrome compared to asymptomatic age and gender-matched participants: a case control study. BMC Musculoskelet Disord 2021; 22:1004. [PMID: 34852803 PMCID: PMC8638187 DOI: 10.1186/s12891-021-04885-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/12/2021] [Indexed: 02/08/2023] Open
Abstract
Background Shoulder impingement syndrome (SIS) is the most common form of shoulder pain. Conservative and surgical treatments for SIS are often not effective. One such surgical intervention is subacromial decompression, aimed at widening the subacromial space (SAS). A better understanding of the changes in the SAS may help explain the relative ineffectiveness of current interventions. Objective: To measure the acromiohumeral distance (AHD) and supraspinatus tendon thickness (STT) in people with SIS using a case control study. Methods The AHD and STT of 39 participants with SIS ≥3 months and 39 age, gender and dominant arm matched controls were measured using ultrasound imaging. Between-group differences for AHD and STT were compared using t-tests. A linear regression was used to determine if there was a relationship between AHD and STT measures, with group as a covariate. Results Compared to controls (mean age 55.7 years, SD 10.6), individuals with SIS (mean age 57.1 years, SD 11.1) had a significantly larger AHD (mean difference 2.14 mm, 95% CI 1.21, 3.07, p < 0.001) and STT (mean difference 1.25 mm, 95% CI 0.60, 1.90, p < 0.001). The linear regression model indicated an association between AHD and STT (β = 0.59, 95% CI 0.29, 0.89, p < 0.01, R2 = 0.35, n = 78), suggesting that as STT increases in size, so does the AHD. Conclusion Individuals with SIS had a larger AHD and greater STT than controls. These results suggest the SAS is already wider in people with SIS and that the symptoms associated with SIS may be more related to an increased STT than a smaller SAS.
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Affiliation(s)
- Donald J Hunter
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Darren A Rivett
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Sharmaine McKiernan
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Suzanne J Snodgrass
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, NSW, 2308, Australia
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Zadro J, Jones C, Harris I, Buchbinder R, O'Connor DA, McCaffery K, Thompson RE, Karunaratne S, Teng MJ, Maher C, Hoffmann T. Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study. BMJ Open 2021; 11:e054032. [PMID: 34462283 PMCID: PMC8407224 DOI: 10.1136/bmjopen-2021-054032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To develop and user test a patient decision aid for people with subacromial pain syndrome that presents evidence-based information on the benefits and harms of subacromial decompression surgery and rotator cuff repair surgery. DESIGN Mixed-methods study outlining the development of a patient decision aid. SETTING We assembled a multidisciplinary steering group, and used existing decision aids and decision science to draft the decision aid. Participants were recruited through social media (not restricted by country nor setting), local hospitals and the authors' collaboration network. PARTICIPANTS People with shoulder pain and health professionals who manage people with shoulder pain. PRIMARY AND SECONDARY OUTCOMES We interviewed participants to gather feedback on the decision aid, assessed useability and acceptability (using qualitative and quantitative methods) and performed iterative cycles of redrafting the decision aid and reinterviewing participants as necessary. Interview data were analysed using thematic analysis. Quantitative data were summarised descriptively. RESULTS We interviewed 26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 general practitioners, 3 chiropractors and 1 osteopath) and 14 people with shoulder pain. Most health professionals and people with shoulder pain rated all aspects of decision aid acceptability as adequate-to-excellent (eg, length, presentation, comprehensibility). Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (eg, treatment options, summary of benefits, harms and practical issues, questions to ask a health professional, graphics, formatting). However, some aspects of the decision aid elicited divergent views among health professionals (eg, causes and symptoms of shoulder pain, evidence on benefits and harms). CONCLUSION This decision aid could be an acceptable and valuable tool for helping people with subacromial pain syndrome make informed treatment choices. A randomised controlled trial evaluating whether this decision aid reduces people's intentions to undergo shoulder surgery and facilitates informed treatment choices is underway.Trial registration number ACTRN12621000992808.
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Affiliation(s)
- Joshua Zadro
- Institute for Musculoskeletal Health, Sydney School of Public Health, University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Caitlin Jones
- Institute for Musculoskeletal Health, Sydney School of Public Health, University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Ian Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Dept of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Denise A O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Min Jiat Teng
- Institute for Musculoskeletal Health, Sydney School of Public Health, University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Robertson A, Birch M, Harris IA, Buchbinder R, Ferreira G, O'Keeffe M, Maher CG, Zadro JR. Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis. Arch Phys Med Rehabil 2021; 102:2141-2149.e2. [PMID: 34129832 DOI: 10.1016/j.apmr.2021.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To summarize the proportion of consumer webpages on subacromial decompression and rotator cuff repair surgery that make an accurate portrayal of the evidence for these operations (primary outcome), mention the benefits and harms of surgery, outline alternatives to surgery, and make various surgical recommendations. DESIGN Content analysis. SETTING Online consumer information about subacromial decompression and rotator cuff repair surgery. Webpages were identified through (1) Google searches using terms synonymous with "shoulder pain" and "shoulder surgery" and searching "orthopedic surgeon" linked to each Australian capital city and (2) websites of relevant professional associations (eg, Australian Orthopaedic Association). Two reviewers independently identified webpages and extracted data. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Whether the webpage made an accurate portrayal of the evidence for subacromial decompression or rotator cuff repair surgery (primary outcome), mentioned benefits and harms of surgery, outlined alternatives to surgery, and made various surgical recommendations (eg, delay surgery). Outcome data were summarized using counts and percentages. RESULTS A total of 155 webpages were analyzed (n=89 on subacromial decompression, n=90 on rotator cuff repair, n=24 on both). Only 18% (n=16) and 4% (n=4) of webpages made an accurate portrayal of the evidence for subacromial decompression and rotator cuff repair surgery, respectively. For subacromial decompression and rotator cuff repair, respectively, 85% (n=76) and 80% (n=72) of webpages mentioned benefits, 38% (n=34) and 47% (n=42) mentioned harms, 94% (n=84) and 92% (n=83) provided alternatives to surgery, and 63% (n=56) and 62% (n=56) recommended delayed surgery (the most common recommendation). CONCLUSIONS Most online information about subacromial decompression and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making.
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Affiliation(s)
- Andrew Robertson
- Notre Dame School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Michael Birch
- Clinical Governance Unit, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, New South Wales, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
| | - Giovanni Ferreira
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Christopher G Maher
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.
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14
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van den Bekerom MPJ, Poolman RW. No Indications for Subacromial Decompression in Rotator Cuff Tendinopathy: A Level I Evidence Clinical Guideline. Arthroscopy 2020; 36:1492-1493. [PMID: 32503763 DOI: 10.1016/j.arthro.2020.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/20/2020] [Indexed: 02/02/2023]
Affiliation(s)
| | - R W Poolman
- OLVG, Amsterdam, the Netherlands; LUMC, Leiden, the Netherlands
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Hohmann E, Shea K, Scheiderer B, Millett PJ, Imhoff A. Author Reply: Arthroscopic Subacromial Decompression. What Are the Indications? A Level V Evidence Clinical Guideline. Arthroscopy 2020; 36:1493-1495. [PMID: 32503764 DOI: 10.1016/j.arthro.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Erik Hohmann
- Department of Orthopaedic Surgery and Sports Medicine, Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates, School of Medicine, University of Pretoria, South Africa
| | - Kevin Shea
- Division of Sports Medicine and Shoulder Surgery, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Bastian Scheiderer
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | | | - Andreas Imhoff
- Department of Orthopaedic Sports Medicine, School of Medicine and Sports Science, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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