We interviewed 26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 general practitioners, 3 chiropractors and 1 osteopath) and 14 people with shoulder pain to help us develop a decision-making tool to help people with shoulder pain choose between non-surgical treatments (e.g. exercise) and shoulder surgery.
Shoulder pain affects up to 1 in 4 people at any given time. Two surgeries are often performed for people with common causes of shoulder pain like rotator cuff tears and impingement; subacromial decompression surgery and rotator cuff repair surgery. Recent high-quality scientific research suggests subacromial decompression surgery provides no more than a placebo effect and rotator cuff repair surgery is not superior to non-surgical treatments, such as exercise and activity modification. Despite this, use of subacromial decompression surgery and rotator cuff repair surgery has doubled in Australia since 2001 (7,455 subacromial decompression surgeries and 12,436 rotator cuff repairs were performed in 2019).
Decision-making tools that present evidence on the benefits and harms of different treatment options can improve patients’ knowledge and satisfaction with decision-making and reduce use of unnecessary treatment. We developed a decision-making tool to help people with shoulder pain make an informed choice between non-surgical treatments (e.g. exercise) and surgery. Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (e.g. 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 (e.g. causes and symptoms of shoulder pain, evidence on benefits and harms). This decision aid could be an acceptable and valuable tool for helping people with shoulder pain 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.
By eliciting the views of people with shoulder pain and health professionals, the aim of this project was to develop a decision-making tool that presents un-biased scientific information on the benefits and harms of shoulder surgery (e.g. subacromial decompression surgery and rotator cuff repair surgery) and non-surgical treatments for people with shoulder pain.
Previous research has demonstrated the benefits of decision-making tools for a variety of conditions. Decision-making tools help patients make informed choices about their healthcare, with no negative effects on their health or satisfaction with care. Once patients are informed of the benefits and harms of their options, they often choose more conservative (or less invasive) options.
We have developed the first decision-making tool people with shoulder pain considering surgery. Given the increasing rates of subacromial decompression surgery and rotator cuff repair surgery in Australia and globally, this tool could help patients make informed decisions and reduce the use of these surgeries.
By eliciting views of key stakeholders, we developed a patient decision aid that presents evidence-based information on the benefits and harms of subacromial decompression surgery and rotator cuff repair surgery for subacromial pain syndrome compared to non-surgical options. Most health professionals and people with shoulder pain rated all aspects of decision aid usability as adequate-to-excellent (e.g., length, amount of information, presentation, comprehensibility).
Interviews highlighted agreement among health professionals and people with shoulder pain on most aspects of the decision aid (e.g. 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 (e.g. causes and symptoms of shoulder pain, evidence on benefits and harms).
Highly consistent feedback included praise for including the practical issues of surgery and non-surgical options (e.g. time off work, anaesthetic) and a global summary of the benefits and harms of each, and praise for including a section on ‘questions to ask a health professional’. Health professionals and patients largely agreed with the presentation of non-surgical and surgical options, with some patients pleased to have ‘wait and see’ included as this aligned with their experience of pain that has resolved without treatment. Most health professionals and patients wanted non-surgical options listed before surgery to mimic treatment recommendations in real-life.
We found quite varied feedback on the causes and symptoms of shoulder pain and presentation of benefits. Most health professionals and patients thought the causes and symptoms of shoulder pain were accurate and easy to understand. However, some health professionals (mostly physiotherapists) thought the description of shoulder pain was inappropriate and used language that could cause fear and drive patients towards surgery. Some orthopaedic surgeons disagreed with the evidence we used on the benefits and harms of surgery, and thought the decision aid was biased against surgery. On the other extreme were some physiotherapists, who suggested that the same evidence underestimated the true harms of surgery.
Nearly 3 in 4 patients thought the decision aid was biased against surgery, likely because the evidence we presented shows subacromial decompression surgery and rotator cuff repair surgery are not superior to non-surgical management. This suggests tools for assessing perceived balance of decision aids may not be suitable when a decision aid presents information that counters prevailing norms.