Barriers and facilitators to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative study

Abstract

ObjectivesThe demand for total knee arthroplasty (TKA) is increasing. Differentiating who will derive a clinically meaningful improvement from TKA from others is a key challenge for orthopaedic surgeons. Decision aids can help surgeons select appropriate candidates for surgery, but their uptake has been low. The aim of this study was to explore the barriers and facilitators to decision aid uptake among orthopaedic surgeons.DesignA qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators.SettingOne tertiary hospital in Australia.ParticipantsTwenty orthopaedic surgeons performing TKA.Outcome measuresBeliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids.ResultsWhile prioritising their clinical acumen, surgeons believed a decision aid could enhance communication and patient informed consent. Barriers identified included the perception that one’s patient outcomes were already optimal; a perceived lack of non-operative alternatives for the management of end-stage osteoarthritis, concerns about mandatory cut-offs for patient-centred care and concerns about the medicolegal implications of using a decision aid.ConclusionsMultifaceted implementation interventions are required to ensure that orthopaedic surgeons are ready, willing and able to use a TKA decision aid. Audit/feedback to address current decision-making biases such as overconfidence may enhance readiness to uptake. Policy changes and/or incentives may enhance willingness to uptake. Finally, the design/implementation of effective non-operative treatments may enhance ability to uptake by ensuring that surgeons have the resources they need to carry out decisions.

Meaningful shared decision‐making: complex process demanding cognitive and emotional skills

“…31 In one study, participants had a high confidence in their SDM skills but had low performance as assessed by an observer using a validated tool. 32 Orthopedic surgeons might be more likely to use a decision aid if they were aware that a substantial proportion of total knee arthroplasties resulted in inadequate outcomes 33 : Clinicians are motivated to improve care but lack intention to change current behavior if they are unaware of their suboptimal performance. 33 Additional barriers exist at the system level, including leadership, culture, resources, priorities, clinical guidelines, and lack of remuneration for the quality of SDM.…”

“…32 Orthopedic surgeons might be more likely to use a decision aid if they were aware that a substantial proportion of total knee arthroplasties resulted in inadequate outcomes 33 : Clinicians are motivated to improve care but lack intention to change current behavior if they are unaware of their suboptimal performance. 33 Additional barriers exist at the system level, including leadership, culture, resources, priorities, clinical guidelines, and lack of remuneration for the quality of SDM. 34 A paper from the Harvard School of Public Health suggests shifting payment power to patients, that is, granting a percentage of the payment to quality of care as perceived by the patient according to his or her own values and expectations.…”

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial

“…Previous reports investigating facilitators and barriers among orthopedic surgeons suggest a number of challenges in the use of non-surgical treatment in patients with knee OA [ 27 , 31 ]. For example, “No effect of physical therapy when there is an obvious loss of cartilage” and “Lack of visibility into physical therapies” were associated with decline in referrals to physical therapy and reported as a barriers [ 27 ].…”

Barriers and Facilitators Affecting Implementation of a Clinical Decision aid for the Diagnosis of Acute Aortic Syndrome: A Qualitative Study

“…[11][12][13] Data generated using this approach can be used to inform implementation strategies in order to maximize uptake of and adherence to guidelines and clinical decision aids, and studies have employed this approach to both established guidelines and prior to clinical trials. 7,14…”

“…Because otherwise, you either don't do the test or you do the test-like the CT-and it's kind of like, well, we have another option now. "(9,14)…”