WORKPLAN#2 BEHAVIOUR AND SOCIAL SCIENCE
Decision making in total joint replacement
Chief Investigators: Anthony Scott, Michelle Dowsey.
Associate Investigators: Michael Kattan, Darshini Ayton, Ian Incoll.
Patients’ and surgeons’ assessments of the risks and benefits of TJR surgery don’t always align. We will investigate factors which might influence decisions, expectation and why surgeons offer surgery to inappropriate candidates have not been subjected to rigorous evaluation. Research indicates complex influences on clinicians’ decisions but few studies are based on a theoretical understanding of what drives decision-making, therefore interventions have not been carefully designed and consequently are not effective. Previous reviews of feedback interventions have shown that feedback and changes in information provided to doctors can influence their behaviour, but that their effects are variable depending on the context and the characteristics of intervention. This includes the timing and frequency of feedback, who delivers the feedback, the content of the feedback, and planned actions taken following feedback.
We are currently conducting a first of its kind NHMRC funded study (Application 1058438 - MARKA) that examines and compares benefit and risk preferences of patients with end-stage Osteoarthritis (OA) undergoing knee TJR with surgeon preferences. The study uses discrete choice experiments (DCEs) to explore how patients balance risks and benefits, determine the extent these align with surgeons’ expectations, and explores whether guiding patients through a decision making process prior to surgery improves patient expectations, health outcomes and satisfaction. We aim to determine patient and surgeon characteristics that correlate with willingness to undergo (patients) or offer (surgeons) knee TJR through a series of structured questionnaires, administered to patients and orthopaedic surgeons including measures of personality, control, risk attitudes and optimism. The role of individual and institutional knee TJR volume and whether employed at a tertiary, rural or community facility are also being examined. The design of the DCE has been finalised with patient input, pre-tested for understanding and piloted in patients and surgeons.
Results illustrate that despite the risk of poor outcome such as moderate or severe pain at 12 months and complication rates approaching 20% in some scenarios, 95% of patients stated they would undergo knee TJR. In contrast, when surgeons were faced with the same scenarios, the opt-out rate for providing surgery was as high as 80%.
Presenting accurate unbiased information may significantly impact patient and surgeon decision making and alter behavioural biases in surgeons who may be overconfident and believe that these outcomes would not occur for ‘their’ patients.
While the MARKA study includes a patient-level intervention to reduce patients’ expectations, it is clear that an intervention to address surgeon behaviours and beliefs is also required. Given our group’s expertise and current research, as well as our collaboration with the Australian Orthopaedic Association, we are in a unique position to extend this research to develop and test the impact of an intervention directed at surgeons to influence surgeon-patient decision making and informed consent for knee TJR. These approaches are unique and would provide a significant insight into decision-making never before considered in TJR.
Changing surgeon behaviour requires an in-depth understanding of what determines their behaviour in order to develop a theory-based intervention. This will be achieved using participatory action research.
Discrete choices experiments will reveal the extent to which surgeon’s focus on surgical risks or post-operative patient outcomes, and the extent to which these influence their decision to recommend surgery. It will also examine how surgeons’ preferences vary according to the volume of knee TJRs performed, their personality, and locus of control, risk aversion, optimism and overconfidence. Feedback methods will be implemented and data pooled to determine how and at what point final consent is justified. The role of technology and data visualisation will also be explored in designing the feedback intervention.
After determining the design and intervention method(s), we will assess the usefulness of these changed methods with surgeons and registrars through various forums prior to implementation. In addition to the MARKA study, we have recently been awarded a University of Melbourne Faculty of Business & Economics and Medicine, Dentistry & Health Sciences Collaboration Grant to aid in this research program. This will be critical for our proposed cluster RCT to evaluate the effect of a feedback intervention on patient pain and function, alongside other associated evaluations.
Expected Outcomes and significance
Workplan #2 will provide new knowledge of the clinical and economic benefits of this feedback intervention. Ultimately, evidence-based decision-making has the potential to minimise inappropriate surgery with the potential to save millions of dollars in healthcare expenditure.