Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study

Key points

1. 0126 health professionals and 14 patients across multiple countries were interviewed across iterative design cycles
2. 02Most participants rated all aspects of the decision aid as adequate to excellent, including length, comprehensibility, and presentation
3. 03The decision aid met 6 out of 6 IPDAS criteria to qualify as a decision aid and 6 out of 6 criteria to reduce harmful bias
4. 04Divergent views existed mainly around the causes and symptoms section and the framing of evidence on benefits and harms, with some orthopaedic surgeons perceiving bias against surgery
5. 05A randomised controlled trial to evaluate whether the decision aid reduces intentions to have shoulder surgery and facilitates informed choices was already underway at time of publication

How it was conducted

Design

International mixed-methods study: iterative development and user testing of a patient decision aid using qualitative interviews and quantitative acceptability questionnaires

Participants

26 health professionals (11 physiotherapists, 7 orthopaedic surgeons, 4 GPs, 3 chiropractors, 1 osteopath) and 14 people with shoulder pain recruited via social media, hospitals, and author networks across Australia, USA, Canada, and England

Decision aid basis

Built from 2019 Cochrane reviews on subacromial decompression surgery and rotator cuff repair surgery; designed in accordance with International Patient Decision Aids Standards (IPDAS)

Data collection

One-on-one semistructured video-conference interviews with think-aloud protocol; acceptability questionnaires administered after interviews; over 10 iterative revision cycles

Analysis

Thematic analysis (inductive, grounded theory approach) for qualitative data; descriptive statistics (means, SDs, counts, percentages) for quantitative acceptability data

What they found

• All aspects of decision aid acceptability were rated adequate to excellent by most health professionals (n=15 completed questionnaire) and patients (n=11 completed questionnaire)
• Health professionals: 80% strongly agreed the decision aid was easy to understand (mean 4.8, SD 0.4); 80% strongly agreed it would be easy to experiment with using (mean 4.8, SD 0.4)
• 'It will be easy for me to use': 67% strongly agreed, mean 4.5 (SD 1.1) overall; mean 3.6 (SD 1.5) for orthopaedic surgeons specifically
• 'This decision aid is better than how I usually go about helping patients decide about shoulder surgery': 20% strongly agreed, 27% somewhat agreed, 27% neither agreed nor disagreed, 27% somewhat disagreed; mean 3.4 (SD 1.1)
• 'There is a high probability this decision aid may cause more benefit than harm': 47% strongly agreed, mean 4.0 (SD 1.2) overall; mean 3.4 (SD 1.3) for orthopaedic surgeons
• Patient acceptability: 82% rated 'Causes and symptoms' as excellent or good; 91% rated 'Practical issues' as excellent or good; 100% rated the decision aid as 'Useful when deciding about surgery'; 91% agreed enough information was provided
• The final decision aid met 6/6 IPDAS criteria to be considered a decision aid, 6/6 criteria to reduce risk of harmful bias, and 20 and 23 quality criteria on the IPDASi checklist (V.4.0)
• Nearly three in four patients thought the decision aid was balanced, despite the evidence showing surgery is not superior to non-surgical management

Limitations

• Small quantitative acceptability sample (15 health professionals, 11 patients), limiting the precision of acceptability estimates
• Unable to recruit certain health professional groups such as rheumatologists and sports doctors, reducing breadth of professional perspectives
• Decision aid developed only in English, limiting generalisability to non-English-speaking populations
• Individual patient circumstances (insurance coverage, activity levels, job demands) may limit applicability of the averaged evidence presented in the aid

Why it matters

For patients

Patients with subacromial shoulder pain can use this decision aid to understand that surgery is not clearly better than non-surgical options and to have more informed, structured conversations with their health professional before choosing treatment.

For clinicians

Clinicians, particularly physiotherapists and GPs, found the decision aid broadly acceptable and compatible with practice, though orthopaedic surgeons were more cautious and some felt the evidence presentation was skewed against surgery.

For readers

This study demonstrates a rigorous, IPDAS-compliant process for developing a shoulder surgery decision aid, but its impact on actual treatment choices and patient outcomes awaits results from the registered RCT.