Discussion
The present study, according to the authors’ knowledge, is unique of its kind. It aims to investigate and present three perspectives on the treatment decision-making process after an ACL injury, those of patients and their orthopaedic surgeons and physiotherapists. The results show that, in general, patients and caregivers seem to consider that patients’ needs to be informed, heard and involved and to agree on the decision during the treatment process are fulfilled to a high extent. Fewer patients in the non-ACLR decision group gave a high rating for their contact with the orthopaedic surgeon compared to the ACLR group. Orthopaedic surgeons rated generally highly in all categories.
In total, more than two thirds of orthopaedic surgeons and physiotherapists gave high ratings for the questions about information and about being heard. Most patients in the ACLR group gave high ratings to these questions; however, about one patient in every three in the non-ACLR group, compared to one patient in every five in the ACLR group, were less content with the information. The same tendency was found in the questions about patients’ involvement, where fewer patients in the non-ACLR decision group (67%) gave high ratings compared to the ACLR group (97%). These results indicate that, when a treatment decision-making process results in ACLR as treatment, more patients perceive that they have been heard and involved than when a non-ACLR treatment decision is taken.
Concerning decisions on the choice of treatment, 78% of the non-ACLR group and 87% of the ACLR group agreed with the orthopaedic surgeon about the treatment. This result is somewhat surprising, since all treatments require agreement between all the parties involved before they can commence. Overall, more orthopaedic surgeons rated these questions more highly than the patients.
In terms of the caregivers’ rating of patient involvement, 100% of orthopaedic surgeons thought patients were involved “to a very high extent”. It has previously been suggested that a non-surgical treatment decision taken by an orthopaedic surgeon is related to greater experience and a less macho attitude towards surgery [
27], yet the present results show that patients and orthopaedic surgeons seem to have different opinions about the decision-making process, in terms of patient involvement. Orthopaedic surgeons are in general willing to be involved in a shared decision-making process [
28], although it is a barrier that they are concerned that it is more time consuming [
29]. Research shows that both healthcare personnel and patients prefer a SDM management [
30], and when they are provided with information about the injury and treatment options, patients are more likely to be involved in their healthcare decisions [
31]. A treatment decision-making process where SDM and patient involvement is practised is extremely important in order to strive for and improve patient-centred care [
32]. This, in light of the results from the present study, emphasises the importance of putting extra effort into the non-ACLR treatment decision-making process, to enhance patient involvement.
The majority of patients in the ACLR group stated that the treatment decision matched their preferences, but there were more missing data in the non-ACLR group (
n = 11, 37%), and therefore uncertainty as to whether the non-ACLR decision was the preferred treatment. One year after ACLR, seven patients reported that they would not choose ACLR again if they had to make a new treatment choice. A surgical treatment cannot be undone and that can be a reason for giving the patient some time to consider the treatment options and allow for an appropriate share of decision-making. The IKDC-SKF scores show that the patients seem to have acceptable symptoms, function and sports activity level [
25] at twelve months after injury for non-ACLR and twelve months after surgery for ACLR, which indicates that the results of the treatments were successful.
Compared to physiotherapists’ ratings, more of the orthopaedic surgeons rated positively that patients understood the
information they had been given and that they took the patient’s wishes into consideration, as well as that the patient felt
involved in the decision. On the other hand, a greater proportion of patients gave high ratings to the
information given, and the questions about
being heard in the meeting with their physiotherapist, compared to the meeting with their orthopaedic surgeon. This indicates that there is a discrepancy between how patients and caregivers experience these meeting(s) and the process of treatment decision-making. A potential difference in patients’ experience is that a structured rehabilitation might include several meetings between the patient and physiotherapist, while an orthopaedic surgeon only meets the patient once or a few times. Lack of time and concern about interference with workflow are factors that have been shown to be barriers for practising SDM in orthopaedic clinics, although a meeting where the conversation is based on an SDM approach might not be more time consuming [
29].
Orthopaedic surgeons and physiotherapists gave high ratings to the statement that they agreed about the choice of treatment, but this was done by fewer physiotherapists (58–66%) than orthopaedic surgeons (80%). However, there was a high number of responses stating that the physiotherapist or orthopaedic surgeon was not involved in the decision. Previous research has shown that the orthopaedic surgeon might not always be involved in a non-ACLR decision [
8], and perhaps a physiotherapist is not always involved when an early decision for ACLR is taken. In contrast, orthopaedic surgeons and physiotherapists do state that they rate the importance of each other’s assessments highly [
6]. Since it is proposed that a structured rehabilitation should be initiated in most situations before the treatment decision is made [
5], it is likely that the physiotherapist will have had repeated contact with the patient before the treatment decision takes place. The physiotherapist will therefore have had the opportunity to discuss the preferred treatment and expectations with the patient. Our results show that there might be room for improvement in the interprofessional communication between physiotherapists and orthopaedic surgeons. Panesar et al. [
33] found that the causes of adverse events in an orthopaedic setting are often related to poor teamwork and poor communication, which emphasises the importance of interprofessional communication.
The choice of surgical treatment after an ACL injury is an elective surgery with a possible quality-of-life enhancing result, rather than a treatment for a life-threatening situation or condition. In such situations, many factors might affect patients’ preferences and expectations, depending on the state of the diagnosis and patient characteristics [
34]. Discussions of preoperative expectations, as well as postoperative reality, is suggested to be an important part of clinical care [
35]. The results of the present study show that the majority of patients with an ACL injury were satisfied with the information they received from both their orthopaedic surgeon and their physiotherapist. Most patients also experienced that they were given the opportunity to explain what was important to them, and that the healthcare professionals listened. However, fewer patients with a non-ACLR treatment decision seem to have felt that they were involved in the decision to choose treatment. This calls for action to understand what patients need during the decision-making process in order to experience involvement and how healthcare personnel can enhance patient involvement.
There are some limitations to this study. Since healthcare systems might be structured differently in different parts of the world, the results may not be applicable everywhere, but they are probably valid in Scandinavian settings. However, there should be efforts made to enhance an SDM process during treatment decisions in every healthcare encounter, thus the discussion should be brought into the light regardless of the healthcare structure.
The SDMP questionnaire developed for this study was based on litteratur on SDM och inspired by the collaboRATE framework. To address the specific treatment decision situation, and all parties involved, no existing questionnaire was adequate to authors knowledge, but new questions needed to be developed. The SDMP was tested for face validity by healthcare professionals. More test of validity and reliability could have provided more explicit indications of the fit of the questionnaire, in the specific population and to the research questions. One of the questions in the SDMP differ slightly between the health care personnel questionnaire and the patient questionnaire. It was adapted to get more accurate information from each party, it concerns. The question about whether the healthcare personnel took patient’s wishes into consideration in their decision on treatment, was in the patient questionnaire represented by two questions: if they were able to let the personnel know what was important to them and if the personnel understood what was important to them. A direct mirroring of the questions to the patient (i.e., asking the healthcare personnel if they allowed the patient to explain what was important and if they listened to the patient) was considered not to give as much information about the interaction between the three parties; therefore, the question about taking patient’s wishes into consideration was chosen.
The patients in the present study had all suffered an ACL injury, but the inclusion criteria also allowed for associated injuries, as well as a previous ACL injury to the other knee. This allows for greater heterogeneity in the study population, with greater variation in the patients’ preunderstanding of the situation that they bring into the meeting. However, it also reflects the clinical reality, as associated injuries and previous ACL injuries to the other knee are common among ACL injured patients. The analyses show no differences in age, sex and activity levels before injury between the selected group of patients in the NACOX study who fulfilled the inclusion criteria for the current analyses compared to the patients who were excluded. This indicates that the participants in the present study can be considered representative regarding these aspects. The slightly higher proportion of ACLR in the selected group for the current analyses may be due to the fact that sometimes one or more of the parties, especially the orthopaedic surgeon, are not part of a non-surgical treatment.
This study is an explorative descriptive study, and the results are presented as differences in fixed numbers, not statistical differences. A larger study population could provide the opportunity to conduct other statistical analyses and examine statistical differences to a greater extent.
The quantitative approach that was used allows quantification of the data and the possibility to draw conclusions about the population with ACL injuries. A qualitative approach, however, would have given a deeper understanding of how patients, orthopaedic surgeons and physiotherapists experience the treatment decision-making process, and could form a future complement to the results gathered in the present study.