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Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources
  1. Tim Jones1,2,
  2. Andrew J Carr3,
  3. David Beard3,
  4. Myles-Jay Linton1,2,
  5. Leila Rooshenas2,
  6. Jenny Donovan1,2,
  7. William Hollingworth1,2
  1. 1 The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  2. 2 Population Health Sciences, University of Bristol, Bristol, UK
  3. 3 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botany Research Centre, Oxford, UK
  1. Correspondence to Dr Tim Jones; Timothy.Jones{at}


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.

  • Subacromial decompression
  • arthroscopy
  • shoulder surgery
  • England
  • commissioning

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  • Contributors This publication is the work of the authors, who serve as guarantors for the contents of this paper. TJ contributed to study design, data cleaning, data analysis, interpretation of results and writing the manuscript. M-JL contributed to study design, data cleaning, interpretation of results and writing the manuscript. AJC contributed to study design, interpretation of results and writing the manuscript. DB, LR, and JD contributed to interpretation of results and writing the manuscript. WH contributed to study conceptualisation, study design, interpretation of results and writing the manuscript. TJ had full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West). The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at coi_disclosure.pdf and declare: TJ and JD had financial support from NIHR CLAHRC West for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent for publication Not required.

  • Ethics approval We were provided with routinely-collected Hospital Episode Statistics data under licence from NHS Digital (DARS-NIC-17875-X7K1V). The licence allows us to use the information under Section 261 of the Health and Social Care Act 2012, 2(b)(ii): “after taking into account the public interest as well as the interests of the relevant person, considers that it is appropriate for the information to be disseminated”.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available.

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