Surgical innovation and safety: femoroacetabular impingement and the IDEAL collaborative framework

Examining the application of the IDEAL framework in the reporting and evaluation of innovative invasive procedures: secondary qualitative analysis of a systematic review

OBJECTIVES

The development of new surgical procedures is fundamental to advancing patient care. The Idea, Developments, Exploration, Assessment and Long-term (IDEAL) framework describes study designs for stages of innovation. It can be difficult to apply due to challenges in defining and identifying innovative procedures. This study examined how the IDEAL framework is operationalised in real-world settings; specifically, the types of innovations evaluated using the framework and how authors justify their choice of IDEAL study design.

DESIGN

Secondary qualitative analysis of a systematic review.

DATA SOURCES

Citation searches (Web of Science and Scopus) identified studies following the IDEAL framework and citing any of the ten key IDEAL/IDEAL_D papers.

ELIGIBILITY CRITERIA

Studies of invasive procedures/devices of any design citing any of the ten key IDEAL/IDEAL_D papers.

DATA EXTRACTION AND SYNTHESIS

All relevant text was extracted. Three frameworks were developed, namely: (1) type of innovation under evaluation; (2) terminology used to describe stage of innovation and (3) reported rationale for IDEAL stage.

RESULTS

48 articles were included. 19/48 described entirely new procedures, including those used for the first time in a different clinical context (n=15/48), reported as IDEAL stage 2a (n=8, 53%). Terminology describing stage of innovation was varied, inconsistent and ambiguous and was not defined. Authors justified their choice of IDEAL study design based on limitations in published evidence (n=36) and unknown feasibility and safety (n=32) outcomes.

CONCLUSION

Identifying stage of innovation is crucial to inform appropriate study design and governance decisions. Authors' rationale for choice of IDEAL stage related to the existing evidence base or lack of sufficient outcome data for procedures. Stage of innovation was poorly defined with inconsistent descriptions. Further work is needed to develop methods to identify innovation to inform practical application of the IDEAL framework. Defining the concept of innovation in terms of uncertainty, risk and degree of evidence may help to inform decision-making.

Arthroscopic hip surgery offers better early patient-reported outcome measures than targeted physiotherapy programs for the treatment of femoroacetabular impingement syndrome: a systematic review and meta-analysis of randomized controlled trials

Targeted physiotherapy programs (TPP), and surgery, using either open surgical hip dislocation or hip arthroscopy (HA), are the treatment modalities available for femoroacetabular impingement syndrome (FAIS). Randomized controlled trials have recently been performed to compare these treatment options. This review was performed to provide a focused synthesis of the available evidence regarding the relative value of treatment options. A systematic search was performed of Medline, Embase, Cochrane Library and ClinicalTrials.gov databases. Inclusion criteria were randomized controlled trials comparing treatment methods. The Cochrane Risk of Bias assessment tool (RoB2) was used to assess the selected studies. A meta-analysis was performed between homogenous studies. Four trials were identified including 749 patients (392 males). The mean ages of the cohorts ranged between 30.1 and 36.2 years old. Three hundred thirty-five patients underwent HA by 46 surgeons among all trials. Fifty-two patients crossed over from the TPP to the HA group. One of the trials was found to have a high risk of bias, while the other three were between low risk and some concerns. The iHOT-33 was the most commonly used patient-reported outcome measure followed by the HOS ADL and EQ-5D-5L. Others scores were also identified. Scores from two trials could be pooled together for meta-analysis. Apart from SF-12 and GRC, all other scores have shown significantly better outcomes with HA in comparison to TPP at 8- and 12-months follow-up points. HA offers better patient-reported outcomes than TPP for management of FAIS at 8- and 12-months follow-up.

Conceptualising Surgical Innovation: An Eliminativist Proposal

Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas in discussions of (surgical) innovation, that we categorised alliteratively under the themes of "purpose" (about drivers of innovation), "place" (about contexts of innovation), "process" (about differentiating innovation), "product" (about tangible and intangible results of innovation) and "person" (about personal factors and viewpoint). These conceptual areas are used in varying-sometimes contradictory-ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term "innovation" carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term "innovation" from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery.