We surveyed 19,574 orthopaedic surgeons in the United States (18,843) and Canada (731). Each surgeon was sent a survey corresponding to only one of the clinical trials, ensuring that physicians were responding solely to the scenarios presented. Receiving only one study prevented surgeons from deducing the intent of the study, improving the integrity of responses. Surveys were sent to members of the American Academy of Orthopaedic Surgeons and the Canadian Orthopaedic Association. Each surgeon was randomly assigned a study, and the results from the surveys were collected via SurveyMonkey (www.surveymonkey.com). After the survey was sent out, two reminder e-mails were sent at 2-week intervals for 6 weeks or until the survey was completed.
A total of 2,674 surveys were returned, with 1,546 responding to the clavicle fracture and 1,128 to the Achilles rupture. The breakdown by country is shown in Table 2.
Clavicle Fracture Management
The responses to the five scenarios are shown in Table 3. Surgery was favored by most of both American and Canadian surgeons in the same three scenarios. However, surgery was not favored in two scenarios, one involving the oldest patient (65 years of age) and the other involving an obese patient (body mass index of 35).
Seventy-one percent of American surgeons and 90% of Canadian surgeons were familiar with the trial. Among American surgeons, 54% indicated that the evidence changed their practice and 64% indicated that they manage more clavicle fractures surgically than they did 5 years ago. Conversely, among Canadian surgeons, 78% indicated that the evidence changed their practice and 68% indicated that they recommend surgical intervention for clavicle fractures more often than they did 5 years ago.
The practice settings of American respondents were 16% academic, 67% nonacademic, and 17% hybrid, whereas those of Canadian respondents were 47% academic, 29% nonacademic, and 24% hybrid (Table 4).
Achilles Tendon Rupture Management
The responses to the five scenarios for the Achilles trial are shown in Table 5. Surgery was favored by most American surgeons in four of five scenarios but favored by Canadian surgeons in only one of five scenarios. American surgeons favored nonsurgical treatment in the scenario involving the oldest patient (65 years of age), and Canadian respondents favored surgery only in the scenario involving the youngest and most active patient (20-year-old collegiate athlete).
Seventy-seven percent of American surgeons and 87% of Canadian surgeons were familiar with the RCT. Thirty-seven percent of American respondents indicated that the evidence changed their practice, with 29% managing more Achilles ruptures nonsurgically than they did 5 years ago. Conversely, 72% of Canadian physicians altered their practice in response to the study, with 67% managing fewer Achilles ruptures surgically.
The practice settings of American respondents were 17% academic, 67% nonacademic, and 16% hybrid, whereas those of Canadian respondents were 37% academic, 38% nonacademic, and 25% hybrid (Table 4).
Both studies presented to American and Canadian physicians were level I clinical evidence and should have similar respective effect on clinical decision making. However, American physicians seemed more willing to adjust their practice for evidence favoring surgical intervention, whereas Canadian physicians were willing to change their practice for evidence favoring both surgical and nonsurgical treatment. Several potential explanations are available for this discrepancy. Historically, wait times for procedures in Canada are longer or assumed to be longer than those in the United States.7 Given the acute nature of clavicle fractures and Achilles ruptures, a shorter delay in surgery may make surgical intervention a more attractive option for American physicians. Although there is notable, often successful, effort in Canada to reduce wait times for surgery and consultation,7 physicians may still tend toward nonsurgical treatment when possible based on established practice.
Furthermore, fee reimbursement in the United States favors surgery over conservative treatment. American physicians receive reimbursement based on relative value units of procedures performed.8 For each unit, American physicians receive additional reimbursement from one of numerous possible private or public insurance providers.8 In Canada, the single-payer provincial system allows for greater bargaining power with physicians to negotiate lower fees and less profitable surgical reimbursement.9 As a result, Medicare and other American insurers have historically reimbursed physicians for surgical procedures at markedly higher rates than the Canadian health system.10 Welch et al10 showed that Medicare reimburses nearly three times more than the Canadian average for orthopaedic surgery, whereas fees for office visits are nearly identical for both state programs. Thus, American physicians may favor surgical intervention in more cases than their Canadian counterparts partially because of financial incentives.
Familiarity with new research may also play a role in physician decision making. Physicians are more likely to review emerging literature when practicing in an academic setting. In this study, Canadian respondents were more frequently from an academic setting than American respondents, and unsurprisingly, they were more likely to have heard of each RCT (Table 4). Here, increased exposure to new clinical evidence appears to correlate with greater willingness to translate that evidence into clinical practice. Additionally, both RCTs in this study were performed by Canadian research groups.2 , 3 Although both were published in international journals based in the United States, the study site location may play a role in physicians adopting clinical evidence. Physicians may be more familiar with the work of their direct colleagues or more trusting of studies performed within their own healthcare system.
This study is partially limited by the difference in acute condition described by each of the example studies. Achilles ruptures and clavicle fractures, though similar in their acute nature, do not necessarily demand the same management plans. However, because of the limited number of high-quality RCTs available, comparisons between the two still have clinical value. Furthermore, we would expect each individual study to weigh equally on decision making regardless of surgeon location. Additionally, we did not inquire about surgeons' subspecialties. Although we expect all respondents are appropriately trained, physicians specializing in foot and ankle or upper extremity care are likely more familiar with emerging research.
Integrating new evidence into surgical decision making helps improve medical practice and advance the standard of care. Although physicians should account for the entire body of available evidence when evaluating surgical indications, we hoped to model responsiveness to emerging literature through two high-quality RCTs. Ideally, both American and Canadian physicians would alter their practice based on high-quality clinical evidence, regardless of the nature of treatment supported by the study.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons
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