Saturday, February 24, 2018

Today's shoulder fellowship interviews: clinical significance vs. significantly greater value to the patient

Today we completed our interviews of a second group of outstanding candidates for the fellowship at the University of Washington (after gathering 'round for the traditional home-cooked salmon dinner last night).

This, like our previous interview day in January, was a most stimulating session. Among many other topics, we got into a discussion of two important goals of the fellowship year.

The first is to assure that the fellows become competent and confident in the evaluation and management of the 'big four': shoulder instability, rotator cuff disease, shoulder arthritis, and failed prior surgery (as well as of sternoclavicular, acromioclavicular, clavicular, scapular, biceps and other clinically important shoulder and elbow problems).

The second is for us to learn together to be cautious consumers of new technology. Among many other things, this means that we need to distinguish a new procedure that results in 'clinically significant improvement' from one that provides 'significantly greater' value to the patient than what is in current use. For example, every type of shoulder arthroplasty is likely to result in 'clinically significant improvement' for the patient with arthritis. However, the test for new implant systems should be whether or not they yield better results than those we now use. It is a question of differentiating the value of a new system from its increased value.

This question is critical to our informed consumption of precious health care resources. As this graph shows, there is an ever increasing number of shoulder arthroplasties approved cleared by the FDA each. Each new system carries with it costs of research and development, marketing, and potential unexpected complications.

However, as shown in a recent article (see link) it is unclear that the costs associated with the introduction of these new technologies is offset by increased benefit to the patient. Before adopting a new system, we need to look for this evidence.

We thoroughly enjoyed our day with the applicants. We look forward to the opportunity to partner with them as they master the currently accepted means of treatment on one hand and seek to increase the value of what our field has to offer patients disabled by shoulder and elbow disorders on the other.