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Published on: April 30, 2014
Mixed-Methods Evaluation to Identify Factors Influencing High-Value Surgeon Decisions in Orthopedics: An Example in
Meghan M JaKa1, Maren S G Henderson1, Jennifer M Dinh1
1Center for Evaluation & Survey Research, HealthPartners Institute, Bloomington, Minnesota, USA.
Rationale:
Many advances have been made to identify novel, effective orthopedic care practices. For all that is known about the comparative effectiveness of various clinical decisions in anterior cruciate ligament (ACL) injury care, surprisingly little is known about how surgeons approach decision-making in the face of this evidence. Implementation science models such as Capability, Opportunity, Motivation - Behavior (COM-B) offer a way to organize and comprehensively understand how clinicians make decisions.
Aims And Objectives:
This evaluation aimed to understand and quantify the factors that influence orthopedic surgeons' decision-making in ACL injury care according to COM-B.
Methods:
This pragmatic evaluation used a sequential exploratory mixed-methods approach combining orthopedic leader discussions and qualitative semi-structured interviews, followed by four rounds of quantitative census surveys to understand the factors influencing four surgeon decision points related to ACL injury care. First, two authors (BN a practicing surgeon with a clinical and research leadership role and MR the director of the affiliated orthopedic research institute) participated in recurring in-person orthopedic leader discussions; then additional selected surgeons were invited to participate in one-time qualitative semi-structured phone interviews; and, finally all surgeons that perform ACL procedures in the health system were invited to participate in four quantitative web surveys. Results were summarized descriptively according to the COM-B model.
Results:
Two co-authors (BN and MR) participated in the orthopedic leader discussions, five invited surgeons participated in qualitative interviews (100% response rate), and 10-11 surgeons participated in four survey rounds (83%-100% response rate). Factors influencing each of the four selected decision points were identified within each COM-B category. Clinical knowledge (capability) and social influence of patient preferences (opportunity) were identified as highly influential for all decisions. Automatic decision making or habit (motivation) was also highly important for most but not all decisions.
Conclusions:
Interviews and surveys with surgeons from one Midwest U.S. health system demonstrate the complexity of ACL injury care decision-making. Surgeons reported that capability, opportunity, and motivation were important in all four decisions. The most important factors influencing decisions ranged from their technical ability to perform one surgical technique over another (e.g., hamstring autograft) in selecting what type of surgical graft to use to their patients' preferences for having surgery in deciding whether to recommending surgery. Future research to identify and test intervention strategies like shared decision-making training in alignment with the identified factors like technical ability and social influences have the potential to lead to higher-value orthopedic care by supporting decisions like recommending longer pre-operative rehabilitation.
