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A four fold difference in operating rates has to be very significant and clearly the question is should the lower rates be higher or the higher rates lower?
The fact that PROMs were good in all patients is very good but does NOT indicate that treatment was necessarily the best choice for the patients. Morbidity and mortality associated with surgery might be quite important, as would loss of work time compared to other options.
Basically do we know that all of these patients were offered evidence- based alternatives or are we back to fast track of all patients to surgery which is a worry for the NHS economy and questionably for patient care ( if some of them die with an embolus for example).
Basically we need more and varied data to find the true picture. Perhaps its there and we havent heard.