Objectives Although recent high-quality studies found that subacromial decompression (SAD) surgery provides no significant improvement in pain or functionality in patients with subacromial pain syndrome (SAPS) compared with placebo surgery or non-surgical management, SAD surgery is still frequently performed. Activities are therefore undertaken in the Netherlands to reduce use of SAD surgery including clinical guideline changes and the recent withdrawal of reimbursement through a policy change (i.e. active disinvestment) by one of the large healthcare insurers. To be effective, such initiatives to reduce SAD surgery should address factors influencing surgeons’ decisions to perform surgery. Previous studies showed large variation between surgeons in their clinical decision-making to perform surgery, which may in part result from surgeons treating different patients. This study therefore presented the same clinical scenarios to orthopedic surgeons to provide further insight in factors influencing the variation in clinical decision-making to perform SAD surgery for SAPS patients.

Method Between November 2021 and February 2022, all 202 members of the Dutch Shoulder and Elbow Society were invited to participate in a cross-sectional web-based survey including four clinical scenarios of SAPS patients. Two reminder emails were sent to all members. The clinical scenarios varied with regard to patient characteristics, clinical presentation, physical examination, outcome of imaging tests and other contextual factors (e.g. reimbursement status of SAD surgery) and were pilot tested to reflect patients seen in daily practice. The respondents were asked for each scenario i) whether they would perform SAD surgery, ii) to indicate the probability of benefit of SAD surgery (i.e. pain reduction) and iii) harm (i.e. complications) and iv) to select and rank the five most important factors influencing their treatment decision.

Results A total of 78 (39%) respondents participated in the study. The percentage of respondents that would perform SAD surgery ranged from 4-25% between clinical scenarios. The median probability of perceived benefit ranged between 70-79% across scenarios for those indicating to perform surgery, compared with 15-29% for those indicating not to perform surgery. The difference in median probability of perceived harm ranged from 3-9% for those indicating to perform surgery compared with 8-13% among those indicating not perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g. duration of complaints, response to physical therapy and effectiveness of subacromial infiltration) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors (e.g. SAD surgery not indicated and non-surgical treatment better).

Conclusions Overall, Dutch orthopedic shoulder surgeons and residents are reluctant to perform SAD surgery for SAPS patients. However, there is still substantial variation in decision-making to perform SAD surgery for SAPS, which seems mainly due to differences in the perceived benefit of SAD surgery rather than differences in perceived harm. Surgeons who would perform SAD surgery mainly reported patient-related factors as most important, whereas surgeons who would not perform surgery referenced current clinical guidelines. These findings may provide helpful target points for future initiatives aiming to reduce the use of SAD surgery for SAPS.