A validated algorithm using current literature to judge the appropriateness of anatomic total shoulder arthroplasty...

Area of Science:

• Orthopedic Surgery
• Health Services Research
• Decision Analysis

Background:

• Lack of established appropriateness criteria for total shoulder arthroplasty (TSA).
• The RAND/University of California, Los Angeles (UCLA) method offers a viable alternative for evaluating appropriateness.
• Increasing TSA utilization necessitates criteria for quality improvement and cost control.

Purpose of the Study:

• To develop explicit criteria for assessing the appropriateness of TSA using the RAND/UCLA method.
• To create a decision-making tool for TSA procedures.
• To enhance clinical decision-making, improve care quality, and manage costs.

Main Methods:

• Literature review on TSA use, effectiveness, and risks by a fellowship-trained physician.
• Development of 186 clinical scenarios based on patient variables (age, rotator cuff, prior surgery, mobility, symptoms, imaging).
• Modified Delphi method with American Shoulder and Elbow Surgeons (ASES) panels to establish appropriateness criteria, followed by reliability testing.

Main Results:

• Agreement reached on 40 (64%) indications; TSA deemed appropriate in 15 (24%) indications.
• For severe symptoms, TSA appropriateness varied by age (<75 years often appropriate, >75 inconclusive/inappropriate).
• Moderate agreement (weighted kappa = 0.56) was achieved between expert panels.

Conclusions:

• The RAND/UCLA method and ASES members developed an appropriateness decision tree for TSA.
• This tool streamlines clinical decision-making for practitioners.
• The decision tree integrates surgeon experience and evidence to inform TSA decisions, improve quality, and control costs.