37 Barriers and facilitators for de-implementation of unnecessary MRI’s and arthroscopic surgeries in patients aged 50+ years with degenerative knee complaints among orthopaedic surgeons

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Abstract

Objectives

Approximately 25% of patients aged 50 years and over experience knee pain from degenerative knee disease. Despite the Dutch – evidence based – Choosing Wisely recommendation ‘No arthroscopic surgery and no MRI for patients of 50 years and older with knee degenerative knee complaints’ (in short: CW-recommendation), orthopaedic surgeons still frequently prescribe an MRI and/or arthroscopic surgery to these patients. To de-implement the use of unnecessary MRI’s and arthroscopic surgeries among patients with degenerative knee complaints, more insight is needed in the factors influencing the uptake of the CW-recommendation by orthopaedic surgeons. Therefore, this study aimed to assess the barriers and facilitators associated with the uptake of the CW-recommendation among Dutch orthopaedic surgeons.

Method

We performed an internet-based survey among 421 Dutch orthopaedic surgeons, of whom 243 (58%) responded. This survey included questions about background characteristics, uptake of the CW-recommendation (4-point scale), and 40 factors possibly influencing the uptake of the CW-recommendation (4-point scale). Factors were based on literature and interviews with orthopaedic surgeons, and classified according to the framework of Grol. Spearman rank correlations were used to identify factors associated with the uptake of the CW-recommendation. Next, as individual factors may be related to each other, we included factors significantly associated with the uptake of the CW-recommendation into a multivariable logistic regression model (p<0.05). For this analysis, we dichotomized the answers on the uptake of the CW-recommendation and the individual factors because of few observations in some cells. Factors increasing the uptake of a CW-recommendation were classified as facilitators, factors decreasing the uptake as barriers.

Results

200 (82%) orthopaedic surgeons reported to adhere to the CW-recommendation for arthroscopic surgery and 197 (81%) for MRI. De-implementation of arthroscopic surgery was independently associated with awareness (β=5.00 (95%CI 1.76till8.26), facilitator) and agreement with CW-recommendation (β=4.66 (95%CI 2.30till7.02), facilitator), belief in value of arthroscopic surgery (β=−1.88 (95%CI −3.10till-0.66), barrier) and clinical experience (β=−1.83 (95%CI-2.86till-0.81), barrier), knowledge about latest evidence (β=1.34 (95%CI 0.20till2.49), facilitator) and colleagues following the CW-recommendation (β=1.36 (95%CI 0.22till2.52), facilitator). De-implementation of MRI was independently associated with agreement with CW-recommendation (β=2.69 (95%CI 1.30till4.69), facilitator), belief in value of MRI (β=−0.91 (95%CI −1.76till-0.08), barrier) and clinical experience (β=−0.87 (95%CI −1.67till-0.08), barrier).

Conclusions

Barriers and facilitators were mostly found on the individual professional level, related to the awareness of, belief in and attitude towards the CW-recommendation. For the de-implementation of unnecessary MRI’s and arthroscopies in patients aged 50 years and over with degenerative knee complaints, these barriers and facilitators should at least be included in any strategy to be likely to be effective.

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