When five Midlands CCGs wanted to better understand the clinical and cost effectiveness of shoulder surgery, compared to conservative treatment, Arden & GEM’s public health consultancy, Solutions for Public Health (SPH), was engaged to undertake a rapid evidence review.
By using an approach that not only identified and accessed the evidence but also supported commissioners in their understanding of the evidence, the CCGs are now able to effectively facilitate discussions with stakeholders about the procedure and its future role within the clinical pathway.
The challenge
Following an increase in the number of arthroscopic subacromial decompression (ASD) surgery procedures taking place and newly published evidence in this area, the CCGs for Birmingham and Solihull, Sandwell and West Birmingham, Walsall, Wolverhampton and Dudley needed a rapid evidence review.
The review would focus on the evidence of clinical and cost effectiveness for the procedure, compared to conservative treatment, in adults with impaired shoulder joint function and pain. The review findings would inform future commissioning policy for ASD across Birmingham and the Black Country.
Our approach
Drawing upon its multidisciplinary team of public health, clinical, research and analytical experts, SPH took the CCGs through a stepwise approach to identifying, accessing and appraising the evidence.
1. Context
We simply explained the anatomy and disease process associated with functional shoulder pain to CCG staff. Helping them to see, with the help of visual aids, how the ASD itself might theoretically resolve the patient's symptoms.
2. Existing policies
We searched forensically for relevant NICE guidance or guidelines which consider the use of arthroscopic subacromial decompression or arthroscopic acromioplasty for non-traumatic shoulder pain.
3. Epidemiology
We set out a clear and up-to-date summary of the epidemiological characteristics of non-traumatic shoulder pain, including:
- percentage of all GP consultations
- incidence of new patients consulting their GP for a shoulder condition
- patterns of attendance in primary care during the 3-year period following initial presentation
- percentage of patients referred to secondary care treatment characteristics by percentage of interventions.
4. The interventions
We carefully explained the terminology used to describe both the clinical pathology of the shoulder and also the available interventions themselves.
5. Findings
A highly detailed presentation of identified studies, their size and patient characteristics, along with interventions and comparators included was provided in both text and tabular formats. This was subdivided into analyses of:
- clinical effectiveness
- cost effectiveness
- safety
- equity issues
- finance and activity.
The outcomes
The evidence review was completed within the requested timescales and covered the agreed areas of focus.
The CCGs have been able to use the review findings to facilitate better engagement between surgeons and commissioners. Discussions about the surgical procedure and clinical pathway have already exposed wide variation in clinical practice across both providers and individual surgeons, as well as identifying important weaknesses in the existing pathway e.g. lack of access to physiotherapists with expertise in upper limb injury.
The review and subsequent engagement process have played an important role in reshaping commissioning policy to deliver efficiencies and better patient experience and outcomes.
Find out more about the service offered by Solutions for Public Health.