The online version of this article (doi:10.1186/s12891-015-0537-y) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
TB conceived, designed, conducted, analysed, and drafted the manuscript. CG cross referenced the analysis and read and approved the final manuscript. Both authors read and approved the final manuscript.
TB is an orthopaedic registrar and research fellow who completed this work as part of a NICE Scholarship.
Knee arthroscopy has historically been a common treatment for knee osteoarthritis. However, multiple Randomised Controlled Trials along with a Cochrane review has led NICE to recommend that arthroscopy is not used in the vast majority of patients that have knee osteoarthritis. These recommendations have been replicated internationally.
The use of arthroscopy for knee osteoarthritis has decreased; however, it is still prevalent. This study examines the factors that are perceived to influence decision-making using a theoretical framework that was developed for behaviour change research (Theoretical Domains Framework). This study will allow future work to develop and evaluate an intervention specifically targeted to the barriers identified.
A multimodal approach was used including questionnaire research and semi-structured interviews with all grades of physician offering a knee arthroscopy service in a Level One Trauma Centre in the West Midlands, U.K. Focus groups with patients were also conducted. Mixed methods analysis was used, with descriptive statistics for quantitative data, and thematic content analysis for qualitative data.
A total of 26 surgeons responded to questionnaires, with 6 semi-structured interviews taking place. All surgical grades were represented. Two focus groups of six patients were performed. The results identified 13 beliefs across 12 domains (some beliefs were represented across domains). The beliefs that there was a pressure from patients to do something, that there were limited other options available, that surgeons wanted to meet patients expectations, and that there was a time pressure in clinic appeared to be the predominant barriers.
Using the Theoretical Domains Framework, this paper has described the relevant barriers and enablers to the implementation of NICE guidance regarding arthroscopy use in patients with knee osteoarthritis. The next step in this process is the development of a targeted intervention, and we discuss the barriers that are most likely to alter practice if targeted through an intervention, and how such an intervention could look. Such an intervention would require evaluation within the clinical setting.
Campbell MK, Skea ZC, Sutherland AG, Cuthbertson BH, Entwistle VA, McDonald AM, et al. Effectiveness and cost-effectiveness of arthroscopic lavage in the treatment of osteoarthritis of the knee: a mixed methods study of the feasibility of conducting a surgical placebo-controlled trial (the KORAL study). Health Technol Assess. 2010;(5):[1–115 tn: isrctn02328576/isrctn pp.]. Available from: http://www.journalslibrary.nihr.ac.uk/hta/volume-14/issue-5.
Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002; (2):81–8. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa013259.
Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008; Issue 1. Art. No.: CD005118. doi:10.1002/14651858.CD005118.pub2.
NICE. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (IPG230). http://www.nice.org.uk/IPG230: NICE; 2007 [cited 2012].
NICE. Osteoathritis: Care and management in adults. http://www.nice.org.uk/Guidance/CG177: NICE; 2014.
American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. AAOS clinical practice guideline [Internet]. 2nd ed. 2013.
Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006;21 Suppl 2:S14–20. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557130/pdf/jgi0021-0S14.pdf. PubMedPubMedCentral
Francis JJ, O'Connor D, Curran J. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci. 2012;24(7):35. CrossRef
Craig P, Dieppe P, Macintyre S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Brit MedJ. 2008;337:a1655. CrossRef
Survey Monkey [cited 2013 Feb]. Available from: http://www.surveymonkey.com.
NICE. Benefits of implementation. NICE, 20011. Available from https://www.nice.org.uk/about/what-we-do/into-practice.
Saks M, Allsop J. In: Allsop J, editor. Researching Health; Qualitative, Quantitative, and Mixed Methods. 4th ed. London: SAGE Publications; 2013. p. 489.
Baker R. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2010;(3):CD005470. doi:10.1002/14651858.CD005470.pub2.
Smink AJ, van den Ende CH, Vliet Vlieland TP, Swierstra BA, Kortland JH, Bijlsma JW, et al. “Beating osteoARThritis”: development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clin Rheumatol. 2011;30(12):1623–9. CrossRefPubMed
No listed author. Management of Osteoarthritis in Consultations Study: the development of a complex intervention in primary care (MOSAICS) ISRCTN Register2012 [cited 2014 June]. Available from: http://www.controlled-trials.com/ISRCTN06984617.
Hofstede SN, Vliet Vlieland TP, van den Ende CH, Marang-van de Mheen PJ, Nelissen RG, van Bodegom-Vos L. Designing a strategy to implement optimal conservative treatments in patients with knee or hip osteoarthritis in orthopedic practice: a study protocol of the BART-OP study. Implement Sci. 2014;9:22. CrossRefPubMedPubMedCentral
- Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study
Caroline Elizabeth Plant
- BioMed Central
Neu im Fachgebiet Orthopädie und Unfallchirurgie
Mail Icon II