Shoulder pain is a common cause of lost work days and disability. A majority of the patients are treated in primary health care [1
]. In Sweden, health and medical care are organised in three levels: regional medical care, county medical care, and primary care which is organised by the county councils. Primary care is intended to meet the needs of most patients for medical treatment, care, preventive measures and rehabilitation. When more specialised care is necessary, patients are referred to the county hospitals. The regional hospitals treat rare and complicated cases. There were very few private care providers in the county at the time of this study. Resources are scarce, and the Swedish Health and Medical Services Act states that priority should be given to those who are in the greatest need of health and medical care. Quality of care can be defined as a combination of structure, process, and outcome [4
]. Cost-of-illness studies can provide information about healthcare resources and costs allocated to different groups of patients.
Net costs to healthcare authorities for health and medical care in Sweden in 2005 were 16% for primary care and 52% for specialised physical care [5
], most of which is financed from tax revenues. There is a government-imposed patient's cost ceiling for health care, meaning that no patient needs to pay more than €100 during a 12-month period, and no patient needs to pay more than €200 for prescription drugs covered by the benefits.
About 6,500 shoulders were operatively treated in Sweden in 2004 [6
], and since 1998 the number of shoulder surgeries has increased by about 10% annually. A recent study reported a four-fold increase in the number of acromioplasties for rotator cuff disorders in New York State from 1996 to 2006 [7
]. Multifactorial reasons were suggested for this increase, with patient-based, surgeon-based, and systems-based factors all playing a role. The differential diagnoses for shoulder pain are based on the history, acute or chronic nature of the pain, physical examination, and, if needed, completed with imaging. Tests for diagnostic accuracy [8
] as well as surgical indications, are being discussed [1
]. Although evidence from case series supports the effectiveness of surgical interventions for shoulder pain when used appropriately [1
], the increase in shoulder surgery cannot be explained by the practice of evidence-based medicine. Three randomised clinical trials [11
] comparing supervised exercises for subacromial pain with surgery, have concluded that supervised exercises are equally effective as surgery - and less expensive. One additional study found that only 10% of the patients awaiting surgery were finally operated on after being treated with physiotherapist-supervised exercises in a hospital setting [14
]. This indicates a need for economic evaluations of current treatment strategies in primary health care.
The initial steps taken to diagnose and treat the patient in primary care may be essential for effective treatment, and may contribute to fewer patients being referred to surgery as well as lower costs to society. Kuijpers et al [15
] reported costs of shoulder pain in primary care patients who presented with shoulder pain to their general practitioner (GP) in the Netherlands in 2006. Patients were followed for six months and their shoulder pain related costs were calculated by using patients' cost diaries. The patients reported all expenses relevant to their shoulder complaints; direct costs, such as visits to healthcare centres, and indirect costs, such as sick leave, and paid and unpaid help. In their study, 70% had persistent symptoms after six weeks and 46% after six months. They found that 12% of the patients with shoulder pain were responsible for 74% of the total costs, mostly a result of sick leave from paid work. Our study was performed to investigate the situation in Swedish primary health care, using an alternative design.
In Sweden, electronic patient records (EPR) based on diagnostic codes are used mainly in the clinical care of patients and rarely to evaluate healthcare programmes or cost-effectiveness aspects. Completeness and accuracy of diagnostic codes have been found acceptable [16
], in spite of a coding system poorly adapted to primary health care. Attempts have been made, using EPR, to monitor the burden of illness for patients with low back pain [18
], diabetes [19
], and groups of patients according to their health status [20
]. Linking costs and consequences based on already collected patient data may be useful to monitor the cost of illness in selected groups of patients.
The aim of this study was to assess the costs associated with healthcare use and loss of productivity caused by shoulder pain in Sweden, by auditing data from the EPR.
Questions asked in the study:
- What are the shoulder pain related treatment costs in primary care consulters in Sweden (direct costs)?
- What are the costs of shoulder pain in defined sub-groups of the selected population (highest costs)?
- What are the costs for sick leave (indirect costs)?
- What are the total costs?