The AAOS Board of Directors has approved new appropriate use criteria (AUC) on “Optimizing the Management of Full Thickness Rotator Cuff (RC) Tears.” This is the second AUC released by the AAOS, and it is supported by both a written document and a mobile device app.

“The tremendous effort put forth by the staff and volunteers who developed the rotator cuff AUC will benefit orthopaedic surgeons and their patients by providing a practical, evidence-based tool that will help inform clinical decision making,” said Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality, after the vote. “It is increasingly important for the AAOS to play a leadership role in defining the appropriate indications for the work orthopaedists do.”

Background
RC tears are both common and age-related. Although many may be asymptomatic initially, a substantial proportion becomes symptomatic over time. Because the incidence of full-thickness RC tears increases with age, the prevalence of RC disorders can be expected to increase as “baby boomers” age. The prevalence and potential cost burden of RC tears made this condition an ideal topic for AUC.

The AUC is based on a systematic review of the literature as well as clinician expertise from several specialties. Five treatments—nonsurgical modalities, partial repair and/or débridement, repair, reconstruction, and arthroplasty—are covered, and 432 different patient scenarios help clinicians identify for whom and when the treatments are appropriate.

“We found that, in many patient/treatment combinations, nonsurgical treatments or lesser surgeries treatments (partial repair and/or débridement, or repair) might be appropriate,” said James O. Sanders, MD, who served as section leader and moderator during the AUC’s development. “Major surgery such as reconstruction was an option less frequently, and arthroplasty was rarely appropriate.”

Of the more than 1,100 different patient/treatment combinations, 16 percent were rated as “Appropriate,” 31 percent were rated as “May Be Appropriate,” and 53 percent were rated as “Rarely Appropriate” (Fig. 1). In some situations, more than one treatment was rated as “Appropriate”; in others, all five treatments were rated as “May Be Appropriate.” The inclusion of reconstruction and arthroplasty as potential treatments accounted for the preponderance of “Rarely Appropriate” ratings.

Determining appropriateness
The new AUC is based on the previously developed clinical practice guideline (CPG) on “Optimizing the Management of Rotator Cuff Problems.” Although the CPG covered the range of RC disease, the focus of the AUC is on full-thickness tears. For example, patients with re-tears, a history of RC repair, partial-thickness tears, RC tendinitis, impingement syndrome, RC bursitis, or secondary diagnoses (such as glenohumeral arthritis, calcific tendinitis, or radiculopathy) that might be the actual cause of pain are specifically excluded.

“Unfortunately, we find that many orthopaedic issues have little evidence to support one treatment over another,” said Dr. Sanders. “We believe most people are trying to do appropriate treatments, and the AUC combine the evidence we do have with good clinical judgment, so patients can receive the best treatment possible.”

The model used by the AAOS to determine appropriateness relies on three separate panels, each of which is responsible for a specific task.

The writing panel—a small group of clinicians who are experts in the topic area—develops the list of patient indications, assumptions, and treatments. The RC AUC writing panel included representatives from AAOS, Arthroscopy Association of North America (AANA), American Shoulder and Elbow Surgeons (ASES), American Physical Therapy Association (APTA), American Society of Shoulder and Elbow Therapists (ASSET), and American Orthopaedic Society for Sports Medicine (AOSSM).

The review panel—a larger group of clinicians that ensures that the patient scenarios reflect likely clinical encounters—included representatives from AAOS, AANA, ASES, ASSET, AOSSM, and American Association of Hand Surgery (AAHS).

The voting panel—a multidisciplinary group that uses the literature review and their own clinical judgment to rate the appropriateness of each treatment for each patient scenario—included representatives from AAOS, AANA, ASES, ASSET, APTA, AOSSM, AAHS, American Academy of Physical Medicine and Rehabilitation, American Society for Surgery of the Hand, and Association of Bone and Joint Surgeons.

A complete list of all participants and a full description of the process used can be found in the AUC, available at www.aaos.org/auc

“Putting this together was a months-long process that involved multiple discussions and a full-day face-to-face meeting,” said Dr. Sanders. “Along the way, there were disagreements and several clarifications. Panelists would ask, ‘Why do you think this is appropriate?’ or ‘Where is the evidence to say this is inappropriate?’ Orthopaedic surgeons began to see and appreciate the disorder from the perspective of a physical therapist or rehabilitative professional, and vice versa.”

Establishing a profile
The indication profile outlines the following seven areas that should be taken into account when determining an appropriate treatment:

• symptom severity (mild, moderate, or severe)
• comorbidities (based on the American Society of Anesthesiologists [ASA] scale)
• identifiable factors—such as diabetes, obesity, or osteoporosis—that negatively affect healing
• identifiable factors—such as substance abuse, litigation, or worker’s compensation—that negatively affect outcomes
• tear size and retraction (based on the Snyder classification)
• degree of atrophy and fatty infiltration
• response to previous treatment

“The preamble to the AUC defines and details these areas,” explained Dr. Sanders, “and the mobile app provides immediate access to that information. Hovering over each area brings up a short definition; clicking on it provides a more extensive definition. The app also links to the background, assumptions, and literature review.”

Mobile app available
The web-based mobile app (http://aaos.webauthor.com/go/auc) allows the clinician to select specific patient characteristics to build an indication profile. Clicking the “submit” button generates the list of treatment recommendations. Green circled checkmarks designate an appropriate treatment, yellow caution symbols indicate that the treatment may be appropriate, and red circled Xs warn that the treatment is rarely appropriate (Fig. 2).

The app also provides links to background material, assumptions, the literature review, and the list of contributors. The numbers to the left of the treatment recommendation signify the median rating determined by the voting panel. On a scale of 1 to 9, treatments that received a median score of 1, 2, or 3 are considered rarely appropriate; those with a median score of 4, 5, or 6 may be appropriate, and those with a median score of 7, 8, or 9 are considered appropriate.

For example, a patient who has a massive tear with severe symptoms, ASA status 2, no identifiable factors that would negatively affect healing or outcomes, minimal atrophy and fatty infiltration, and no response to previous conservative treatment would be an appropriate candidate for a repair procedure. Additional conservative treatments, a partial repair and/or débridement, and reconstruction might also be appropriate treatments. Arthroplasty, however, would rarely be appropriate in this situation.

“I would hope that our colleagues take advantage of the mobile app,” said Dr. Sanders. “The AAOS has devoted substantial resources to developing quality tools such as AUC, and we are constantly improving our processes and learning as we go along. Our goal is to continue to release AUC on the heels of clinical practice guidelines, so that we help the front-line clinician make good decisions with the patient and ensure that whatever care is provided to patients is of the highest possible evidence and quality.”

Funding for the rotator cuff AUC was provided by the AAOS. Development of AUC is overseen by the AUC section of the Evidence-Based Quality and Value Committee and the Council on Research and Quality. The full AUC document is available on the AAOS website, at www.aaos.org/auc

Mary Ann Porucznik is managing editor of AAOS Now and can be reached at porucznik@aaos.org; Leeaht Gross is the evidence-based medicine coordinator in the AAOS department of research & scientific affairs and can be reached at gross@aaos.org

Bottom Line

• Appropriate use criteria (AUC) combine evidence-based information with clinical expertise of physicians from multiple medical specialties to address common clinical scenarios and provide guidance in clinical decision making to improve patient care and outcomes.
• AUC are not meant to supersede clinician expertise and experience or patient preference.
• AUC are helpful for conditions, such as rotator cuff tears, where randomized clinical trials are not available or are inadequately detailed for identifying distinct patient types.

Additional Information

• Appropriate Use Criteria
• AUC Development Processes and Procedures
• Get Involved in the AUC Process
• What Are Appropriate Use Criteria?
• AUC Feedback Survey