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

Objectives: The 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. 

Design: A qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators. 

Setting: One tertiary hospital in Australia. 

Participants: Twenty orthopaedic surgeons performing TKA. 

Outcome measures: Beliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids. 

Results: While 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. 

Conclusions: Multifaceted 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.