Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study

Background: 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. Methods: 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. Results: 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. Conclusions: 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.