Preferences and beliefs of Dutch orthopaedic surgeons and patients reduce the implementation of "Choosing Wisely" recommendations in degenerative knee disease

The impact of a meta-analysis on orthopaedic surgeons' practice with regards to vancomycin graft pre-soaking in anterior cruciate ligament reconstruction: A paper questionnaire survey study

Background and Aims

Understanding the impact of orthopaedic scientific research is vital in identifying facilitators and barriers to its implementation in clinical practice. A meta-analysis was carried out which showed that presoaking hamstring (HT) autografts in vancomycin was associated with a 10-fold reduction in infection rate in anterior cruciate ligament (ACL) reconstruction. Our aim was to determine the practice of orthopaedic surgeons with regards to vancomycin presoaking and explore whether they would adopt the findings of this meta-analysis.

Methods

A paper questionnaire survey was administered to attendees of an annual EFORT podium presentation of the meta-analysis findings. Descriptive statistics were used to summarize the characteristics of respondents and their responses.

Results

A total of 29 senior surgeons/subspecialists performing a median of 40 ACL reconstructions per year completed the survey of whom 7 (24.1%) had encountered an ACL graft infection in the previous 2 years and 14 (48.3%) in the previous 5 years. Only 3 (10.3%) presoaked the ACL graft with an antibiotic. About 1/4 of those who up to then did not pre-soak the graft (6/26, 23.1%) would consider changing their practice to pre-soaking with vancomycin, with similar findings (5/20, 25.0%) in those that used a HT autograft as their first choice.

Conclusions

Orthopaedic surgeons are receptive to the findings of a meta-analysis reporting on the effectiveness of vancomycin graft presoaking in ACL reconstruction, which can thus have a substantial impact upon clinical care. Addressing concerns about vancomycin induced graft toxicity and comparing the pre-soaking effect to that of specific intravenous antibiotic regimens may further enhance the uptake of this practice.

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

Background

Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects.

Methods

We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated.

Results

Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy.

Conclusions

Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.

A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis

PURPOSE

To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group).

METHODS

All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital.

RESULTS

136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (β =  - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (β =  - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (β =  - 0.74, P = 0.228) nor arthroscopy (β = 0.13, P = 0.688).

CONCLUSIONS

The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands.

LEVEL OF EVIDENCE

III.

Performing a knee arthroscopy among patients with degenerative knee disease: one-third is potentially low value care

PURPOSE

The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors.

METHODS

A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis ("Arthrosis" versus "Meniscal lesion"), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy.

RESULTS

Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient-provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984-1.043)], diagnosis [OR 0.998 (95% CI 0.886-1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948-1.032)] were significantly associated with performing a potentially low value knee arthroscopy.

CONCLUSIONS

In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care.

LEVEL OF EVIDENCE

IV.