Professor of Orthopaedic Surgery, Co-Medical Director, Spine Center Cedars-Sinai Medical Center Los Angeles, California, United States
Introduction: Substantial variation exists in clinical decision making regarding which patients are good candidates for spine surgery and which procedures are best for each patient. To improve decision making, specialty societies have established criteria for the appropriate use of surgery. However, few strategies exist to facilitate uptake and use of appropriateness criteria in surgical practice. Behavioral science nudges are defined as modest adjustments to the environment that influence behavior in a predictable way without limiting autonomy, and are an increasingly evidence-based strategy for enhancing decision making by clinicians. We sought to design “surgical appropriateness nudges” to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis.
Methods: To inform nudge development, we conducted two sets of focus groups of spine surgeons at two regional referral centers. In an iterative process, we developed nudge prototypes by integrating five inputs: (1) previously developed appropriateness criteria, (2) frameworks for behavioral science nudges (based on 9 systematic reviews and 12 other publications), (3) electronic tools for clinical decision making, (4) maps of the surgical workflow at the two sites, and (5) sources of variation in surgeon decision making (Focus Group 1). To produce refined nudges that appeared potentially acceptable, feasible for integration in the workflow, and effective, we incorporated feedback from content experts, site leaders, and spine surgeons (Focus Group 2).
Results: Fifteen surgeons participated in focus groups. Surgeons gave substantive, constructive input and feedback on nudge design and affirmed three nudges as potentially acceptable, feasible, and effective: individualized surgeon score cards (nudge frameworks: descriptive social norms/peer comparison/feedback), online appropriateness calculators (frameworks: decision aid/mapping), a multispecialty case conference and database (frameworks: injunctive norms/social influence).
Conclusion : Spine surgeons found behavioral science nudges to be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow. Ongoing work is pilot testing the surgical appropriateness nudges in preparation for a future pragmatic randomized controlled trial.
