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Ozdag Y, Hayes DS, Garcia VC, El Koussaify J, Manzar S, Vaughan AK, Davis DE, Grandizio LC. Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair. J Hand Surg Am 2024; 49:465-471. [PMID: 38556963 DOI: 10.1016/j.jhsa.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.
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Affiliation(s)
- Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Daniel S Hayes
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Victoria C Garcia
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Jad El Koussaify
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Shahid Manzar
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | | | | | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA.
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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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Curtis DM, Bradley AT, Lin Y, Baker HP, Shi LL, Strelzow JA, Athiviraham A. National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair. Arthroscopy 2021; 37:3397-3404. [PMID: 34052380 DOI: 10.1016/j.arthro.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study was to investigate trends in the United States for arthroscopic subacromial decompression (aSAD) and open SAD (oSAD) with and without rotator cuff repair (RCR) between 2010 and 2018. METHODS The PearlDiver Mariner claims database was queried using CPT codes for open and arthroscopic subacromial decompression and rotator cuff repair. Patient cohorts were developed for those undergoing aSAD or oSAD between 2010 and 2018, then segmented by whether RCR was performed simultaneously. Annual incidence was analyzed, as were associated diagnosis codes, and concomitant shoulder-associated procedures performed on the same day. RESULTS The PearlDiver Mariner dataset from 2010 to 2018 included 186,932 patients that underwent aSAD, while 9,263 patients underwent oSAD. The total incidence of aSAD declined from 118.0 to 71.3 per 100,000 (39.6% decrease) (P < .001). This change was due primarily to a decreasing incidence of aSAD performed without RCR, which declined from 66.3 to 25.5 per 100,000 (61.5% decrease) (P < .001). During the same period, the incidence of aSAD combined with RCR remained relatively stable, from 51.7 to 45.8 per 100,000 (11.5% decrease) (P = .27). The overall incidence of oSAD declined from 7.1 to 2.2 per 100,000 (68.1% decrease) (P < .001). CONCLUSIONS The overall rate of aSAD has declined in recent years, primarily due to a large decrease in the incidence of aSAD without RCR as an isolated treatment for rotator cuff disorders. CLINICAL RELEVANCE Prior studies have demonstrated a rising incidence of SAD; however, high-level clinical evidence and clinical practice guidelines have challenged its efficacy. It is important for orthopaedic surgeons to understand evolving national trends in management among their peers.
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Affiliation(s)
- Daniel M Curtis
- Stanford University, Orthopaedic Surgery Department, Palo Alto, California, U.S.A
| | - Alexander T Bradley
- University of Chicago, Orthopaedic Surgery Department, Chicago, Illionis, U.S.A..
| | - Ye Lin
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, U.S.A
| | - Hayden P Baker
- University of Chicago, Orthopaedic Surgery Department, Chicago, Illionis, U.S.A
| | - Lewis L Shi
- University of Chicago, Orthopaedic Surgery Department, Chicago, Illionis, U.S.A
| | - Jason A Strelzow
- University of Chicago, Orthopaedic Surgery Department, Chicago, Illionis, U.S.A
| | - Aravind Athiviraham
- University of Chicago, Orthopaedic Surgery Department, Chicago, Illionis, U.S.A
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