Why we need to improve the evaluation of surgical procedures using shoulder surgery as an example

Doctors combine their knowledge of the latest research evidence with their clinical judgement to offer the best care for each patient. Research needs to provide the best evidence and guidance possible to help doctors and patients make decisions about their healthcare and encourage the best use of limited NHS resources.

The UK has strict regulations to ensure new medicines work and are cost-effective before they are recommended for use in the NHS. However, surgical procedures are less strictly regulated, because it can be difficult to categorise procedures as ‘new’ rather than modifications, and outcomes may depend on the skill of the person performing the procedure. It can also take many years to change established practice and generate clinical evidence.

This study uses a type of surgery for shoulder pain called subacromial decompression as a case study to explore the relationship between evolving evidence and clinical practice, to illustrate the need for better evaluation of surgical procedures.

Project aims

This project aimed to explore the use of subacromial decompression for shoulder pain in England over the last 10 years, and how much money was spent on it before evidence from two randomised control trials questioned the procedure’s effectiveness. Randomised controlled trials are the best test of a medical intervention. We also compared the use of subacromial decompression in England with other countries.

What we did

We examined 10 years of hospital records to explore the use and cost of subacromial decompression across England, from 2007/8 to 2016/17.

What we found and what this means

In England, subacromial decompression nearly doubled from 15,112 procedures in 2007/8 to 28,802 procedures in 2016/17. These procedures now cost more than £125 million per year. Even higher rates of these procedures are carried out in countries with less regulated health systems.

The two randomised controlled trials published in 2018 showed subacromial decompression to be no more effective than having no surgery at all or placebo surgery. However, healthcare systems have been unable to avoid the rapid uptake of this procedure, even though there is no evidence that it is effective. Having unnecessary surgery exposes patients to avoidable risk of harm and wastes large amounts of money.

We conclude that high quality randomised trials are needed before new surgical procedures are widely adopted, to avoid over-treatment and wasted resources. We also need better regulations and tools to stop the use of ineffective procedures.

What next?

We recommend exploring how clinical trial evidence affects the development of local policies, national guidelines, and decision-making between surgeons and patients. The evidence from the recent trials should lead to a reduction in the use of subacromial decompression, but new studies could enhance and speed up the transfer of knowledge from trials into clinical practice.

Related research projects

This project is part of the larger releasing resources for optimal care project.

Links and downloads

Lead collaborators

  • Professor Andrew Carr, University of Oxford
  • Professor David Beard, University of Oxford
  • Professor Jenny Donovan, University of Bristol
  • Dr Myles Linton, University of Bristol
  • Dr Leila Rooshenas, University of Bristol

CLAHRC West staff

Partners on this project

University of Bristol

The University of Bristol is internationally renowned and one of the very best in the UK, due to its outstanding teaching and research, its superb facilities and highly talented students and staff. Its students thrive in a rich academic environment which is informed by world-leading research. It hosts the Elizabeth Blackwell Institute for Health Research.