Purpose: Widespread dissemination of patients' decision aids (PtDAs) that increase comprehension and reveal informed preferences might modify unwarranted geographic variations in rates for elective back surgery. Successful implementation requires insight into the opinions about PtDAs held by orthopaedic surgeons in geographic areas with relatively high and low back surgery rates.

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.