Orthopaedic Key Review Concepts
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The primary aim of many of the included studies was to identify the influence of a factor or variety of factors on a particular aspect of surgical practice or treatment decision. Studies varied in the factors they assessed over a range of orthopaedic procedures including hip and knee arthroplasty, hip fracture, upper extremity and spine surgery, anterior cruciate ligament surgery and the use of associated procedures such as blood transfusion and drainage, steroid injects and physical therapy. We brought together the studies systematically using summary tables presented in Supplementary file S2.
Two systematic review studies were included in the review. These were undertaken by Barr et al. The first addressed the drivers of transfusion decision-making in orthopaedic surgery and the second aimed to discover the decision-making drivers for degenerative hip, knee and spine surgery. The initial stages of PIP resulted in the identification of 44 prominent codes in the included 26 studies. The PIP central pillar integration process resulted in eight themes Table 2.
An overview diagram of the data structure is presented in Figure 3. Displaying the data structure in this way is recommended by Pratt et al. The boilerplate refers to a standardised language and format for presenting research findings, and this is not something qualitative and mixed methods researchers strive to achieve. This equifinality can make it extremely problematic to portray qualitative and qualitative research [ 35 ]. However, presenting the data using an overview diagram as in Figure 3 , enables us to honor the worldview of the articles that were included in the review, provide sufficient evidence for claims made, and allows us to contributes to extant theory through the conclusions made [ 35 ].
The review identified sources of evidence, or the knowledge types reported as important for orthopaedic decision-making. These sources are influential in determining patient treatment and help to explain how and why there is unwarranted variation in orthopaedic surgical practice. Factors were identified and categorised into eight themes which reflect the micro-level patient and clinical drivers; and meso factors such as characteristics of the organisation or surgeon through to the impact of formal training.
At the macro-level we identified the influence of evidence, policy and guidelines. Each theme is described below and a conceptual model is presented which demonstrates the relationship between these sources of evidence and knowledge types. Formal codified knowledge is explicit, written down and thus available to everyone to use alongside personal judgment [ 34 ].
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In our review, formal codified knowledge represents the macro-level clinical guidelines and scientific literature to which orthopaedic surgeons can and are expected to refer when making evidencebased decisions. This knowledge is hard, factual, spelt out and easy to transfer between individuals. Formal codified knowledge was reported to influence decisionmaking in ten of the 26 studies. It included reference to guidelines [ 36 - 38 ], evidence-based medicine [ 39 - 44 ] and independent peer reviewed literature [ 43 , 45 ]. The included studies reported a low influence of this type of knowledge.
This low influence is in contrast to what would be expected by the advocates of evidence-based medicine and the significance attached to the hierarchy of evidence in the clinical field. Managerial knowledge represents an important component of clinical decision-making within orthopedics as it can underpin the routines and capabilities of practice — i.
In this area, the literature often referred to resource issues such as time, cost and safety or quality of services but without definite or consistent criteria of what is considered acceptable. Managerial knowledge is subjective and experiential and is often not written down for healthcare staff to access. This makes it difficult to transfer between and across organisational, departmental and also across professional boundaries within the same organisation [ 35 ].
In the six studies which mention managerial knowledge, cost [ 36 , 46 - 51 ] and availability of resources [ 47 , 48 ] were most influential in clinical decision-making. The knowledge and skills of individuals who manage healthcare organisations were considered valuable but intangible in the organisations.
This led to uncertainly, for example treatment costs influenced decisions when both expensive options [ 36 ] and cheaper treatment options were available [ 44 ]. The weight assigned to managerial knowledge in orthopaedics is increasingly important due to the rising demand for treatment, and reinforced by pressures to reduce resource use. Organisational knowledge has a wider structural emphasis. It is embedded in the processes of healthcare organisations and influences the behavior of its members. Organisational processes become normative and reflect the common education, training and career structures of particular organisations [ 50 ].
This type of knowledge is ingrained in the routines of the orthopaedic departments and hospitals but not necessarily acknowledged by the individuals themselves [ 47 ]. Organisational constraints such as theatre availability, surgical waiting lists and patient prioritisation acted as forms of organisational knowledge in the included studies [ 8 , 47 , 51 ]. Variation in the practice of patient categorisation or treatment delay resulted from organisational knowledge that does not diffuse but becomes sticky within the organisation.
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Time pressures and staffing influenced clinical decisions when planning surgery [ 36 , 41 ]. These organisational factors develop over time and become entrenched, so that knowledge exists in the processes and clinical pathways themselves not in the individual actors. The likelihood of finding a common ground for collaboration and knowledge sharing within but not across orthopaedic departments to reduce variation in the healthcare organisations is limited. The socialisation of individuals into different clinical professions plays an important role in their decision-making processes.
Orthopaedic surgery represents a highly professionalised area of clinical work as a specialty where an elite community of practice is strongly embedded [ 8 , 9 ]. This community has socialised knowledge that impacts on the way decisions are made by its members.
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The knowledge is treated as a vital source of evidence which is held in the group but not shared with outsiders. Nine papers reported socialised knowledge influenced decisions. There was a distinction between knowledge that came from inside or outside the defined group, in this case the orthopaedic community [ 8 , 52 ].
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This theme demonstrates how the wider orthopaedic profession can influence clinical practice and drive decision-making for patients. For example, the presence of professional societies, such as the British Orthopaedic Association in the UK and the American Academy of Orthopaedic Surgeons in the USA, enabled the members to retain substantial autonomy, authority and control over their work practices and to resist external intervention [ 8 , 51 , 53 ]. This external intervention might be in the form of clinical guidelines and regulation which are codified evidence produced outside the orthopaedic sector.
The use of this type of evidence in decision-making was likely to be complex and fraught with political challenges.
It was to a certain extent linked to how surgeons maintained their elite position in the wider clinical field by privileging their normative professional knowledge over clinical guidelines that can be accessed by anyone [ 51 , 54 ]. Therefore, it can influence decisions at all levels: the micro individual surgeon deciding to operate or not, the meso communities of practice who plan and allocate intervention thresholds, and the macro professional groups who build consensus statements and establish orthopaedic criteria. Medico-legal challenges to practice drove patterns of a- to decision-making to minimise legal action in two papers [ 8 , 35 ].
The power of pharmaceutical and implant manufacturing companies within this sector was also highlighted [ 8 ]. This could be associated with incentives to maintain professional control and power over clinical decisions. Training courses undertaken later in surgical practice were considered more important to surgeons [ 43 ]. This is maybe because these reflect the subspecialist training that the surgeons were most attracted to.
Formal training in evidence-based medicine was reported its to increase its use in clinical decisions, and the perceived importance of evidence to practice [ 42 ]. Training and formal education becomes an important foundation which can be built on over time using elements from all other knowledge types. When considering the tacit — explicit knowledge spectrum, informal experiential knowledge sits in opposition to formal codified knowledge.
It cannot easily be explained, transferred and understood by another person, particularly someone outside the orthopaedic community. Individual knowledge gained from their experience does not exist in the activity alone, but in the knowledge that individuals use to perform the activity [ 56 ]. Hence, a surgeon possesses tacit knowledge of how to perform an operation when they are outside of theatre. The included studies reported several examples of informal experiential knowledge which drive decisions [ 8 , 51 , 53 ].
The final theme clusters all factors that were directly related to the characteristics of the patient or surgeon that influenced clinical practice decisions in the included studies.
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Surgeons with a greater surgical volume in joint replacement would be more inclined to conduct a joint replacement compared to non-surgical management. Patient factors included age, [ 38 , 41 , 51 , 56 ] medical condition, [ 36 , 45 , 35 , 56 ] sex, [ 33 , 56 ] lifestyle, [ 51 , 54 , 55 ] treatment options, medication and symptoms [ 39 , 43 , 49 , 51 , 53 , 55 ]. Surgeon factors included age, [ 39 , 54 ] sex, [ 33 ] personality type [ 8 ] and surgical volume [ 39 ].
Some pragmatic factors were also important, such as time taken to perform surgery where certain procedures were selected because they were shorter than other options [ 8 , 45 , 46 ]. We have identified many sources of evidence which compete for space and prominence in the process of decision-making. The competition may be subconscious as medical professionals may broker various evidence sources and knowledge types within current organisational contingencies.
This element of tacit practice came through strongly in many of the included studies [ 8 , 51 - 58 ] and has been recognised elsewhere in the medical literature [ 14 , 63 ]. It is important that surgeons and orthopaedic departments develop an awareness of this subjective and subconscious brokering process.