Surgeons, health authorities must reach agreement on expected surgical outcomes
Recently, the number of elective orthopaedic surgical procedures performed in Western European countries has grown exponentially. The reason for this increase has been speculated on by the health authorities, orthopaedic surgeons and medical economists. Although exactly why we are seeing these increases is surely multifactorial, it is recognized and discussed in some circles that this increased rate of surgeries has produced an additional economic burden to society.
In response to the economic impact of orthopaedic procedures on health care delivery systems, various actions have recently been taken across Europe to either halt or perhaps slow any further increases in elective orthopaedic surgeries. Some groups have even attempted to effect such change by keeping the numbers of referrals to orthopaedic surgeons as low as possible.
Patients undergoing impingement shoulder surgeries are now under scrutiny. The current debate centers on which procedure is indicated for shoulder impingement and who should be offered the surgical option. The main criticism is that outcomes are very poor. When surgeons have asked for evidence for such claims, the reply is that very few younger patients undergoing subacromial impingement treatment return to work after 3 months to 6 months.
Therefore, we have a conflict that needs to be resolved.
In Denmark, for example, we are experiencing a situation where the government probably guided by input from medical economists has been quoted as saying that shoulder surgery is not a beneficial treatment since fewer patients than expected return to their earlier work or jobs postoperatively. The government relies heavily on return-to-work as its main criteria for surgical success. However, the criteria for success that surgeons and patients primarily use is not that patients have resumed their earlier work, but that they have pain relief and have achieved a functional, satisfactory level of daily living.
Therein lays the dilemma for orthopaedic surgeons. Health authorities have spread the news that shoulder surgery is associated with low success rates and, therefore, should only be performed in a limited numbers of cases. We, as surgeons, disagree because surgical success depends on other criteria. Our patients are in pain and ask for a treatment that leads to pain relief, which is mostly what we address in surgical outcomes. Therefore, the pain relief should be listed among the success criteria for shoulder surgery.
We must use power and science to convince our patients and the health authorities in our countries that the main indication for surgery is not that the patient returns to the same level of work as before surgery, but that there is pain relief and increased mobility. In delivering these important surgical benefits, we will create new possibilities for our patients and society.