Authors' objectives: The objective of this report was to evaluate the clinical and economic effectiveness of subacromial decompression as a primary intervention to treat subacromial pain compared to conservative management, no treatment and placebo, and to consider legal, social, ethical and organisational issues associated with limiting access to the procedure.

Authors' results and conclusions: Clinical evaluation An existing Cochrane review by Karjalainen was included and critiqued. The meta-analyses performed in the Cochrane review were replicated, and analyses that could not be replicated were produced independently using novel data inputs. The clinical evaluation of efficacy outcomes was informed by 8 randomised controlled trials (RCTs); the clinical evaluation of safety outcomes was informed by 2 RCTs, 7 non-randomised trials and 12 single-arm trials. Effects reported in this executive summary are summarised at 12 months using new analyses replicated from the Cochrane review for pain, function and health-related quality of life (HRQoL), and reported in the Cochrane review for return to work, return to leisure activities and further progression of subacromial pain. Subacromial decompression versus conservative treatment Six RCTs compared subacromial decompression to conservative treatment (n=614). At 12 months there were no statistically significant differences reported for pain (low certainty evidence), function (very low certainty evidence), health-related quality of life (HRQoL) (low certainty evidence), return to work (very low certainty evidence), return to leisure activities (very low certainty evidence), progression of subacromial pain (very low certainty evidence). The main reason the evidence was downgraded was due to the risk of detection and performance bias, as participants were not blinded to their treatment allocations. Subacromial decompression versus placebo (sham surgery) Three RCTs compared subacromial decompression to placebo (n=406). At 12 months there were no statistically significant differences reported for pain (high certainty evidence), function (high certainty evidence), HRQoL (high certainty evidence), return to work (moderate certainty evidence), return to leisure activities (moderate certainty evidence). Progression of subacromial pain was not reported. The analyses in this section were at a low risk of bias, with some outcomes scored down due to imprecision. Subacromial decompression versus no treatment One RCT compared subacromial decompression to no treatment (n=210). At 12 months, there was a statistically significant difference in pain (MD=-1.2, 95% CI -2.04, -0.36, moderate certainty evidence), and a clinically important difference in function (MD=9.5, 95% CI: 2.66, 16.34, moderate certainty evidence) favouring decompression, but no difference for HRQoL (moderate certainty evidence), further progression of subacromial pain (moderate certainty evidence). Other outcomes were not reported. The outcomes in this section were scored down due to risk of detection bias, as participants were not blinded to their treatment allocation. Safety There were no statistically significant differences in the number of adverse events recorded for subacromial decompression and non-operative treatments (moderate certainty evidence). Serious adverse events were not reported in the selected RCTs (moderate certainty evidence). Costs and cost-effectiveness As the clinical evaluation found no clinically significant improvement in short-term HRQoL for subacromial decompression compared to placebo and conservative management, a cost comparison was conducted. The inpatient cost of subacromial decompression surgery of CHF8,633 was higher than the estimated conservative management cost of CHF1,350 (15 physiotherapy sessions at CHF90 per session). The outpatient delivery of subacromial decompression had a cost of CHF3,972, comprising CHF1,161 for TARMED 24.0710 arthroscopy and 24.0750 decompression; anaesthesia CHF750; and medicines, consumables and overheads CHF2,061. This cost was also higher than the cost of conservative management. Subacromial decompression has no clinical benefit, but has a higher cost, compared to the designated comparator (conservative management), so offers no economic advantage. A decision analytic model was developed to quantify the cost-effectiveness of subacromial decompression for inpatient-delivered rotator cuff disease compared to no treatment using incremental quality-adjusted life years (QALY). An incremental cost-effectiveness ratio (ICER) of CHF98,102 per QALY gained was estimated at 12 months for surgery compared to no treatment using results of the Can Shoulder Arthroscopy Work (CSAW) trial when no adjustment was made to uneven baseline utilities. With adjustment to these values, the ICER was estimated to be CHF107,913 per QALY gained. Probabilistic sensitivity analyses (PSA) determined with 49% probability that subacromial decompression was more cost-effective compared to no treatment using a hypothetical willingness-to-pay threshold of CHF100,000 per QALY gained. Univariate sensitivity analyses indicated the ICERs were most impacted by high and low QALY gained estimates, diagnosis-related group (DRG) cost variations and inclusion of costs for the intervention from the tariff system for outpatient medical services. A budget impact analysis using four substitution scenarios (in which subacromial decompression was substituted with no treatment and physiotherapy at different rates) was used to determine the financial implications of delisting the procedure for the payer. If subacromial decompression is delisted and half of all patients substitute to physiotherapy, then a net cost saving of CHF10.0 million would occur in 2020. This saving decreased to CHF9.6 million if 75% of subacromial decompression patients substituted to physiotherapy in this year, and CHF9.1 million when all patients substitute to physiotherapy. The saving from subacromial decompression delisting decreases as more patients are assumed to substitute to alternate treatments. Social, legal, ethical, organisational issues Limiting the use of subacromial decompression as a primary intervention to treat subacromial pain could impact workflow and utilisation of services, due to a likely increase in demand for physiotherapy services. Additionally, issues are related to how depression and anxiety could impact patient recovery, as well as how health communication affects a patient’s approach to undergoing physiotherapy. The final issue related to the possible limitation of subacromial decompression as a primary intervention, was ensuring that patients from specific population groups (e.g. the elderly) could access physiotherapy. Conclusion The evidence base provides limited to no evidence of clinically important benefits in support of the use of subacromial decompression as a primary or isolated intervention to treat subacromial pain compared to conservative treatment, placebo (sham surgery) or no treatment. Delisting the procedure would result in net cost savings – with the impact sensitive to the proportion of patients who would substitute to other treatments (physiotherapy) or resort to no treatment.

Project Status: Completed

URL for project: https://www.bag.admin.ch/bag/en/home/versicherungen/krankenversicherung/krankenversicherung-leistungen-tarife/hta/hta-projekte/subakromiale_dekompression.html

Year Published: 2021

URL for published report: https://www.bag.admin.ch/dam/bag/en/dokumente/kuv-leistungen/leistungen-und-tarife/hta/berichte/h0031impg-hta-report.pdf.download.pdf/h0031impg-hta-report.pdf

URL for additional information: https://www.bag.admin.ch/bag/en/home/versicherungen/krankenversicherung/krankenversicherung-leistungen-tarife/hta/hta-programm.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Switzerland

Organisation Name: Swiss Federal Office of Public Health (FOPH)

Contact Address: Federal Office of Public Health, Schwarzenburgstrasse 157, CH-3003 Berne, Switzerland

Contact Name: Stephanie Vollenweider

Contact Email: hta@bag.admin.ch

Copyright: Swiss Federal Office of Public Health