Evaluating learning and change in orthopaedics: What is the evidence-base?

Learning and change are key elements of clinical governance and are responsible for the progression of our specialty. Although orthopaedics has been slow to embrace quality improvement, recent years have seen global developments in surgical education, quality improvement, and patient outcome research. This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered. Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure. Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data. With various organisations promoting centralisation of care, learning curve analysis is more important than ever before. The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide. Patient outcome research is rapidly changing, with an increased focus on quality of life measures. These are key to patients and their care. Cost-utility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care. Large-scale international, multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread. A global lack of surgeon equipoise will need to be addressed. Quality improvement projects frequently employ interrupted time-series analysis to evaluate change. This technique's limitations must be acknowledged, and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur. Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability, validity, and importance of the conclusions drawn from orthopaedic research.