Developing a patient decision aid for Achilles tendon rupture management: a mixed methods study

Key points

1. 0118 health professionals and 15 patients user-tested the decision aid through iterative interviews and acceptability questionnaires
2. 02All health professionals and most patients (13 of 13 who completed the questionnaire) rated acceptability as good or excellent
3. 03Broad agreement existed on sections covering treatment options, benefits and harms comparison, questions for clinicians, and formatting
4. 04Health professionals disagreed on specific details: tendon retraction distance as a surgical criterion, factors modifying harm risk, and rehabilitation protocol differences between treatment arms
5. 05The final decision aid met 6 of 6 IPDAS criteria for being classified as a decision aid, 6 of 6 criteria to minimise harmful bias, and 20 of 23 criteria for improving user experience

How it was conducted

Design

Mixed-methods: iterative development with reflexive thematic analysis of semi-structured interviews and descriptive analysis of acceptability questionnaires

Participants

18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 sports medicine physician, 1 chiropractor) and 15 patients who had previously sustained an Achilles tendon rupture

Recruitment

Social media platforms (Twitter, Facebook), Royal Prince Alfred Hospital, Concord Hospital, and local allied health clinics in Sydney, Australia

Data collection

Pre-interview questionnaires, Think-Aloud semi-structured interviews, and post-interview acceptability questionnaires via REDCap

Analysis

Reflexive thematic analysis for qualitative interview data; descriptive statistics (medians, IQR, counts, percentages) for questionnaire data

Decision aid standard

Developed against the International Patient Decision Aid Standards (IPDAS) instrument checklist v4.0 and an 11-item user-centred design measure

What they found

• All 18 health professionals completed acceptability questionnaires; 78% strongly agreed the aid would be easy to use and easy to understand (Likert median 5, IQR 5-5)
• 13 of 15 patients completed the acceptability questionnaire; 100% rated the length as 'just right' and 92% rated the amount of information as 'just right'
• 85% of patients rated the introduction section as excellent or good; 92% rated the questions-to-ask section as excellent or good; 100% agreed they would have found the aid useful when making their decision
• 77% of patients agreed the decision aid would have made their decision easier; 92% agreed there was enough information to help decide on surgery or not
• The final decision aid met 6/6 IPDAS decision aid classification criteria, 6/6 bias-minimisation criteria, and 20/23 user-experience improvement criteria
• 39-56% of health professionals strongly agreed the decision aid would complement usual practice and result in more informed patient decisions; median Likert scores ranged from 4 to 5 across all acceptability items

Limitations

• Small sample sizes for acceptability questionnaires limit statistical precision
• Median age of patient participants was low (30 years, IQR 29-37), so findings may not apply to middle-aged or older adults who are also commonly affected
• Surgeons and certain health professional types (no emergency medicine specialists, only one sports doctor, one chiropractor) were under-represented
• The underlying systematic review used to populate benefits and harms data had its own limitations, including pooled outcomes across heterogeneous surgical approaches and a predominantly observational study base

Why it matters

For patients

Patients facing the surgery-versus-non-surgical choice for a ruptured Achilles tendon can expect this decision aid to present balanced, evidence-based information about re-rupture and complication risks in an accessible format.

For clinicians

Physiotherapists and orthopaedic surgeons found the tool compatible with clinical practice and likely to support shared decision-making, though some controversy remains around presenting tendon retraction distance and rehabilitation protocol details.

For readers

This study demonstrates a rigorous, IPDAS-aligned development process for a musculoskeletal decision aid, but effectiveness on actual decision outcomes (knowledge gain, decisional conflict) must still be tested in an RCT.