Health Systems and Policy Research

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Evidence and the Drivers of Variation in Orthopaedic Surgical Work: A Mixed Method Systematic Review

Grove A, Johnson R,Clarke A, Currie G

The increasing demands on orthopaedic services brought about by the aging population and rising incidence of arthritis, together with the financial constraints in the healthcare system mean that orthopaedic departments have to deliver more for less. This is coupled with patterns of variation in current practice and provision of orthopaedic surgery which are not justified by variation in patient needs. Researchers and policymakers set out to develop evidence-based guidelines, interventions, and recommendations to address the balance and ensure that services are both clinically and cost-effective whilst being high quality, safe and equitable. However, it is not clear to what extent these external sources of evidence and guidelines are accepted and implemented in orthopaedic practice. We conducted a systematic review using an interpretative mixed methods synthesis and thematic analysis. We aimed to understand: i) Approaches and techniques to knowledge and evidence use, and ii) Factors influencing decisionmaking and practice variation within orthopaedic surgery. Two systematic reviews and 24 primary studies were included. Evidence sources were grouped into eight themes and presented in a conceptual framework (formal codified and managerial knowledge, medical socialization, cultural, normative and political influence, training and formal education, experiential factors, individual patient and surgeon factors). Formal codified knowledge in the form of clinical guidelines appeared to play a small part in clinical practice decision-making in orthopaedic surgery. More significant drivers of variation include medical socialization, cultural and normative factors and the existence of complex and competing sources of evidence. These drivers need to be incorporated into a new method to implement evidence-based knowledge in practice which takes account of the context in which the decision is made.