整形外科医の臨床診療における介入の効果：システマティックレビュー
Nicholas F Banfield1, Rebekah M Kleinsmith, Haley D Puckett
1From the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Banfield and Swiontkowski), the Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN (Kleinsmith, Puckett, Cunningham, and Swiontkowski), the Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN (Kleinsmith, Puckett, Cunningham, and Swiontkowski), and the Department of Orthopaedic Surgery, Campbell Clinic, Memphis, TN (Kleinsmith).
Background:
Orthopaedic surgeons face increasing pressure to align clinical decision making with evidence-based practices. However, the adoption of such practices can be inconsistent because of variability in surgical techniques, patient factors, and entrenched habits. This systematic review evaluates interventions designed to change orthopaedic surgeons' clinical decision making across cost optimization, diagnostic ordering, and prescribing behaviors.
Methods:
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses and MECIR-adherent search was conducted across seven databases (MEDLINE, PsycINFO, EMBASE, Cochrane Library, Business Source Premier, SPORTDiscus, and Scopus) to identify studies from the United States and Canada reporting interventions aimed at modifying orthopaedic surgeons' clinical decision making. Studies were included if they evaluated changes in practice patterns in at least one of the three domains: procedure costs, orders (tests/procedures), or medication prescribing. Two independent reviewers conducted screening, data extraction, and quality assessment using the Effective Public Health Practice Project tool.
Results:
Of 9,065 records identified, 28 studies met inclusion criteria: education (n = 24), physician reminders (n = 3), and incentive systems (n = 1). Most used before-and-after designs (n = 23) and were of moderate quality (n = 21). Three of five studies (60%) on procedure costs demonstrated statistical significance in cost reduction after intervention (P ≤ 0.05), with the largest from a surgeon "scorecard" initiative ($694 per total knee arthroplasty case, P < 0.001). Four of 14 studies (29%) on diagnostic/procedural ordering demonstrated statistical significance in clinical decision-making change. All nine studies on prescribing behaviors, predominantly opioid stewardship, showed statistically significant clinical decision-making change, including reductions in morphine milligram equivalents and improved guideline compliance.
Conclusions:
Evidence-based interventions, particularly education combined with audit and feedback, can meaningfully shift orthopaedic surgeons' clinical decision making. Sustained change is less well studied, highlighting the need for prospective trials with long-term follow-up. This synthesis provides a framework for designing future interventions that improve adherence to best practices.
Level Of Evidence:
Level III.
