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\begin{document}

\title{Clinical decision-making for shoulder surgery referral: an art or a
science?}



\author[1]{Karen Taylor}%
\author[1]{George David Baxter}%
\author[1]{Steve Tumilty}%
\affil[1]{University of Otago}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
Decision-making in musculoskeletal health care is complex, with
discrepancy among clinical providers, and variation in the per cent of
referrals for specialist care. To date there is an increased focus on
specialist referrals, risking overuse of expensive testing and
contributing to unnecessary treatment. This report will considerer the
difficulties of primary care musculoskeletal decision-making using
shoulder injuries as an example, presenting a solution based on
multi-criteria decision-making analysis with online software. The
associated issues involved in clinical decision-making are complex.
Contributing to the components of complexity are; the aetiology of
shoulders being multi-faceted, the experience and knowledge of
providers, and the burden of patient demands. Notwithstanding, funding
considerations, resource allocation availability, and other associated
issues around clinical decision-making. Considering there are many
facets involved in decision-making, this is an area where multi-criteria
decision-making analysis (MCDM) may be appropriate. MCDM which uses
mathematical analysis, is increasingly being used in health care and
could be applied to the challenges of musculoskeletal care. MCDM has the
potential to decrease variability in decision-making and be used as a
tool to augment clinical decisions. Furthermore, the key clinical
factors that decision-making is based on are to date unclear, therefore,
this preliminary report offers a start towards moving to a clarification
of the key factors, and an approach for implementing improved shoulder
clinical care decision-making which could then be adapted and applied to
other body sites.%
\end{abstract}%



\sloppy


\par\null

Decision-making in musculoskeletal health care is a complex process, and
therefore disagreement concerning the ideal treatment pathway is not
unexpected.\textsuperscript{1} Clinicians striving to provide
evidence-based patient care have multiple subjective factors to
consider, and these multiple factors complicate decision-making. To
date, there has been a focus on specialist referral for musculoskeletal
injuries, including shoulder lesions, leading to expensive testing and
-- potentially -- unnecessary
treatment.\textsuperscript{2-4}Decision-making for shoulder treatment
pathways has received little attention in the literature, and the key
clinical factors on which decision-making is based remain unclear. This
report will consider the difficulties associated with musculoskeletal
decision-making and present a possible solution to improve clinical
decisions based on~\emph{multi-criteria decision-making} , using
shoulder injuries as a model.

\textbf{Difficulties associated with musculoskeletal decision-making}

Currently, clinical decision-making is predominantly idiosyncratic, with
the risk of unnecessary imaging and overuse of surgical funding. In New
Zealand (NZ), elective surgeries have increased by around 30\% from
2010-2015.\textsuperscript{5} This situation is not unique to NZ: the
overuse of expensive musculoskeletal tests and treatments is considered
a common problem.\textsuperscript{2,3,6} Factors which have been
identified as contributing to the problems of increasing numbers of
patient referrals include clinicians with less experience, and
clinicians working in isolation.\textsuperscript{4}

The challenges in primary care are significant, with clinicians having
limited time for decision-making and patient information being complex
to synthesise. Additionally, processing information is complicated by
styles of communication, patients being unable to accurately recall
pertinent information, and providers misinterpreting the information.
Decision-making in musculoskeletal conditions is based upon a mix of
hypothetico-deductive reasoning and pattern recognition, regardless of
whether the decision-maker is a novice or an
expert.\textsuperscript{7}Irrespective of whether a novice or expert;
this leads to decision-making variability.

Clinical guidelines have been developed as an important tool to enhance
decision-making; however, these are often divisive. Guideline use can be
hindered for several reasons, including lack of awareness, clinical
knowledge beliefs, and additionally by not being up to date. Updating a
guideline requires considerable expertise\textsuperscript{8} and unless
regularly updated the guideline becomes redundant. Guidelines have their
place, however, they are not all-inclusive.

Other factors affecting decision-making include both the significant
influences of the patient and the health provider, with each having
their perspective and beliefs on the benefits of prospective treatment
pathways. This introduces decision-making bias: for example, the patient
may be fixed on one solution, such as imaging, and may compel the health
provider to feel obliged to refer for imaging.

Nonetheless, hypothetico-deductive reasoning, intuition, and the use of
clinical guidelines do not enable consistent transparent decision-making
as evidenced by the increasing numbers of imaging requests and
surgery,\textsuperscript{3,9} despite the apparent effectiveness of
conservative rehabilitation.\textsuperscript{10-12} Regardless of the
clinical pathway, it is recognised that clinical outcomes can be
variable. A recent study found little difference between operative and
non-operative treatment groups for full-thickness tears of the rotator
cuff, using the quality-of-life index score. At 5 years post enrolment
in the study, 75\% of participants responded to conservative treatment
and remained successfully treated.\textsuperscript{10}

\textbf{Multi-criteria decision-making}

Given such challenges, other options to enhance clinical decision-making
have been proposed. One option is multi-criteria decision-making (MCDM)
analysis,\textsuperscript{13-15} which could potentially be used to
improve consistency, reliability, and the efficiency of clinical
decision-making in an evidence-based method.

MCDM analysis can be a means to quantify clinical subjective information
and formalise decision-making. When clinically interpreting multiple
pieces of subjective information, this information can become more
explicit and transparent if structured into an ordered form using
decision-making tools. MCDM analysis has the additional benefit of using
mathematical modelling with ranking and scoring, to refine and provide
decision-making structure. Having structure and ranking of important
clinical information supports the clinician with decision-making which
is a step up from (potentially flawed) clinical
intuition.\textsuperscript{16}

The design of a model is beyond the scope of this report. However, we
can briefly consider the steps using the example of a clinical provider
undertaking decision-making from a musculoskeletal assessment. When
mathematical modelling is added to this scenario, as in MCDM analysis,
multiple subjective pieces of clinical information can be developed into
a set of decision-making factors called criteria, which in turn have
levels of choices. The levels of choices have a point value, that can
represent their relative importance,\textsuperscript{13} and there is
available software that can be used to attribute point values to the
refined clinical information.\textsuperscript{17} The point values give
a clear representation of the relative importance of each piece of
clinical information to allow alternatives to be
compared.\textsuperscript{18} This allows transparency, reliability, and
credibility for the decision-making process. While there are many
different MCDM models, they all aim is to improve
decision-making.\textsuperscript{19} Although, to date, MCDM is not
being used for shoulder injury pathway decision-making, there are many
areas in healthcare where MCDM has been used successfully, such as
prioritising antibiotics, recommending hip tests and classifying
disease.\textsuperscript{20-22}

When considering the basic MCDM, and what makes this a possible
solution, it is helpful to have some history. MCDM has been developing
for over 40 years\textsuperscript{23} and for health care, the use of
MCDM analysis is steadily growing.\textsuperscript{15} It is important
to recognise that in health care, algorithms and point systems have long
been used as a source of assisting decision-making and there is
increasing support for algorithms for more complex decisions, such as
prioritising for elective surgery\textsuperscript{13} With an increasing
prevalence of musculoskeletal conditions as the population ages, this is
an area where MCDM tools can be useful to guide
decision-making.\textsuperscript{24} MCDM tools are used online, and the
process of using internet-based software for health decision-making has
been found acceptable for both health care providers and
patients.\textsuperscript{13} Furthermore, online MCDM software is a
step forward from the earlier mentioned points-based systems.

\textbf{Shoulder injuries}

A model where MCDM analysis could be applied to illustrate the benefit
is shoulder soft tissue injuries and lesions, which are prevalent and
costly.\textsuperscript{12,25-28} Treatment may consist of
physiotherapy, (including manual therapy and exercise), medication, and
for more serious conditions, surgery. Given that the healing of chronic
shoulder problems often seems slow, surgery offers patients a more
immediate solution; however, this is not always the most efficacious
option. Currently, shoulder health care, including outcome reporting, is
highly variable. \textsuperscript{29} Perhaps most importantly, for
clinicians providing such primary health care, judging the appropriate
circumstance and timeframe for imaging and/or surgery is challenging.

When considering shoulder injury treatment pathways, the shoulder
presents some specific challenges. Shoulder pain can be persistent and
reoccurring: while prevalence reporting is variable, 20-50\% of shoulder
presentations were found to be still experiencing pain twelve months
after the initial complaint.\textsuperscript{26,30,31} Furthermore, the
aetiology of shoulder injuries is complex which can sometimes lead to
contradictory clinical opinions. Considering rotator cuff tears, as one
of the most common shoulder injuries, it is known that rotator cuff
tears may develop without injury and can be
asymptomatic.\textsuperscript{32} Therefore, in a health care system
with injury based funding, as in NZ, pre-existing tendon tears
complicate the decision-making for funders. Beyond initial diagnosis and
categorising, the treatment pathway decision-making process is also
complicated by multifactorial clinical criteria, health systems, and
funding. The goal of making the best judgment for the patient is not an
easy one, and interpreting clinical information can vary among
clinicians.\textsuperscript{33}

Accordingly, with the ready availability of imaging as an early
decision-making tool, imaging for shoulder conditions is
overused.\textsuperscript{3} Ideally, the role of imaging is in
identifying pathology that will change the treatment pathway and detect
red flags. Although making a decision is a tangible challenge, gathering
more information in the form of imaging does not necessarily contribute
towards better management of the typical rehabilitation patient. An
identified small soft tissue injury does not always necessitate a change
of care pathway nor surgery. It is known that a small tear caused by
injury can heal,\textsuperscript{34} and a small pathological tear with
no injury can progress to a full tear that will not
heal.\textsuperscript{35} Furthermore, the shoulder can function well
with a full tear\textsuperscript{10} and shoulder pathology can be
present in both symptomatic and asymptomatic
shoulders.\textsuperscript{36}

Decision-making for musculoskeletal shoulder injuries/conditions are not
based on a single factor, and each factor in the process carries a level
of importance; understanding the weighting of each key factor is a step
towards a better understanding of the decision-making process.
Potentially, shoulder injury decision-making is an area where MCDM
analysis could be used to support both the novice and expert
practitioner alike.

\textbf{Conclusion and potential areas for development}

Given the recognised complexity in decision-making for shoulder
conditions, using a MCDM tool offers the potential to support and
simplify this complexity, adding consistency and easing the burden in
decision-making. Furthermore, MCDM tools can lessen the gap between
novice and expert practitioner, while dispelling the uncertainty of
which clinical factor is more important. Likewise, the development of a
musculoskeletal MCDM tool for shoulder injuries can potentially be
adapted and applied to other body sites.

ACKNOWLEDGMENTS

The first author is using this work for a PhD and acknowledges the
support of her supervisors and co-authors.

CONFLICT OF INTEREST

The authors have no conflict of interest.

ORCID

Karen Taylor

https://orcid.org/0000-0002-7183-8033

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