Methods: We contacted 2679 eligible members of the American Academy of Orthopaedic Surgeons in regions with back surgical rates that are, relative to the national average: < 25% below; 25% below to 30% above, and > 30% above (i.e., 54 regions with < 3.4/1000; 186 with 3.5-5.7/1000; and 66 with > 5.8/1000). They read about PtDAs for surgical/non-surgical management of herniated disc/spinal stenosis, then rated: the basic idea of using PtDAs; the most feasible media and practice models for practice settings; and the ways PtDAs could/couldn't be helpful in actual practice.
Results: 577 eligible spine surgeons responded (target sample size: 520), with n = 152, 354, and 71 in the low-, medium-, and high-rate regions, respectively. There were no across-region differences in reports that: a) PtDAs are a good/excellent idea (>85%); b) booklets with/without an audiotape are the most feasible PtDA media (39-53%); c) practices would improve by using PtDAs to: describe management options (>87%), benefits (>88%), and risks (>90%); answer patients' questions and clarify preferences (>80%); match treatment with preferences (>76%); foster doctor–patient communication (>77%); reduce anxiety (>79%) and depression (>47%); raise patients' confidence (>72%), “compliance” (>72%), quality of life (>58%), satisfaction with care (>84%); and d) surgeons' willingness to use PtDAs if they reduced rates for malpractice insurance (>84%) and litigation (>83%), were reimbursed (>81%), and were a quality assurance indicator (>78%). Surgeons in high-rate regions considered easiest the practice model in which the patient receives the PtDA at the first visit, then discusses treatment options at a second visit after reviewing it at home (X2 = 21.748; p = 0.016).
Conclusions: Across high-/low-rate regions, sub-groups of U.S. orthopaedic surgeons strongly support PtDAs for elective back surgery. Dissemination strategies could target these sub-groups, while recognizing that busier practice settings may need particular implementation models. Multi-site longitudinal studies assessing potential system-wide rewards from using PtDAs -- such as reduced litigation and malpractice insurance rates, appropriate reimbursement, and improved quality assurance – are needed.