Factors influencing prosthesis selection and variation: a survey of orthopaedic surgeons in Australia.

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Michelle J Allen, David Brain, Ross Crawford, Sameera Senanayake, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3439378/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: There is increasing demand for knee and hip arthroplasties, with considerable health system cost implications. Despite much of the surgical costs relating to the particular prosthesis used, little is known about which factors are most influential for surgeon decision-making, nor is it clear what level of variation may be warranted for clinical reasons. Materials and Methods: A three-stage study was conducted to address the dual objectives of: a) identify factors influencing prosthesis selection for total hip arthroplasty (THA) and total knee arthroplasty (TKA); and b) develop a working definition for what could be considered unwarranted variation in THA and TKA implant selection. A questionnaire was developed and piloted with input from orthopaedic surgeons. This cross-sectional survey was conducted with orthopaedic surgeons across Australia, followed by an expert panel to finalise the working definition. Results: Revision rates, familiarity with implant, and implant quality, were factors considered a priority when choosing a prosthesis, whilst other factors including cost, were reported to have limited influence. Technological advancement and revision rates were influential for past changes of prosthesis, and strong clinical evidence for future changes. Consensus was reached on a working definition of unwarranted variation that focused on implants with revision rates of 20% or higher compared to published benchmarks. Use of multiple cost thresholds was recommended for defining both narrow and broad definitions of unwarranted variation. Conclusion: Findings from this study provide valuable insights into the decision-making process for prosthesis selection, as well as what surgeons believe might constitute unwarranted variation. This information can be used to progress our understanding of the magnitude and impact of this variation through use of the suggested unwarranted variation definitions, as well as inform strategies to address unwarranted variation in prosthesis selection. Level of evidence: Non-randomised cross-sectional survey – Level 3. Trial registration: Not applicable. Orthopedic Surgery Prosthesis Arthroplasty unwarranted variation surgeon selection decision-making cost Figures Figure 1 Figure 2 Figure 3 Introduction The number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries are increasing globally and particularly across OECD countries ( 1 ). High-income countries, including the United States, are currently experiencing very high incidence rates per 100,000 for both THA and TKA, while other high-income countries like Australia are expecting rates to double in the coming decades ( 2 – 4 ). In the Australian context, where the present study was conducted, projected costs are expected to reach $ AUD1.38B for TKA, and $ AUD953M for THA, respectively by the year 2030 ( 5 ), with the cost of the implant itself averaging approximately 60% of the total expenditure ( 6 , 7 ). In high-income countries, prosthesis selection is largely driven by orthopaedic surgeons, but little is known about what factors influence their decision making. A recent systematic review to identify the factors influencing surgeons’ prosthesis selections for knee and hip arthroplasty in high-income countries highlighted a range of factors including patient anatomy, familiarity with implant, implant quality, and even the friendliness of the sales representative are considered by surgeons ( 8 ). However, due to the small number and heterogeneity of studies on this topic, no strong conclusions about the relative importance of these factors were articulated. Better understanding of factors influencing prosthesis selection is needed to support the development and implementation of strategies to improve patient outcomes and reduce unwarranted variation. Unwarranted variation that is unrelated to clinical need, evidence or patient preferences can lead to poorer outcomes for patients, or other detrimental effects, including higher cost or wasted healthcare resources ( 9 , 10 ). The dual objectives for this study were to: a) identify factors influencing prosthesis selection by surgeons for THA and TKA; and b) develop a working definition for what could be considered unwarranted variation in implant selection for THA and TKA. This working definition will be used to inform an economic analysis of unwarranted variation. Materials and Methods Study design Informed by our recently completed scoping review of factors influencing prosthesis selection ( 8 ), we undertook a three-stage mixed methods study to address the objectives. The first stage comprised i) interviews with orthopaedic surgeons to inform the questionnaire design, and ii) piloting the questionnaire. The second stage was conducting a cross-sectional survey with orthopaedic surgeons in Australia. The results of the survey were then reviewed by the expert panel in stage 3, to consolidate a working definition of unwarranted variation for implant selection for THA and TKA. Stage 1: Development and pilot of questionnaire Key informant interviews with three orthopaedic surgeons were used to explore the findings of the systematic review and develop a questionnaire for surgeons within the Australian context. Key informant sampling was used, with participants for the interviews and pilot recruited via email through existing professional networks. A semi-structured interview guide was used to explore factors influencing prosthesis selection and what constitutes unwarranted variation (Supplementary File 1). Online piloting of the questionnaire was undertaken to review question wording and structure to ensure clinical relevance, as well as user-friendliness for participants. Analysis and question development Initial interviews were audio recorded and transcribed. Framework analysis of the interview transcripts were undertaken using the seven-step process of transcription, familiarisation with the data, coding, framework development, applying the framework, charting the data, and interpreting the data for meaning ( 11 ). The initial framework was based on inductive coding and deductive coding relating to the factors derived from the systematic review. Codes were grouped to create themes, then used to formulate the questions. Multiple iterations of the draft questionnaire were shared, both electronically and in-person, with available interview participants and the research team to refine question content, phrasing, and structure of the questionnaire. To pilot the penultimate questionnaire, an orthopaedic surgeon, a health economist, and a healthcare administrator were emailed a link to the questionnaire, with feedback emailed to the study’s Chief Investigator. Final questionnaire The final questionnaire had six sections: respondent characteristics, level of autonomy, factors influencing prosthesis selection, changing prosthesis selection, registry results, and unwarranted variation. It contained between 15 to 28 questions, depending on responses. The questionnaire used branching, whereby the number and type of questions depended on whether participants indicated they were a consultant or a registrar; whether they undertook THA, TKA or ‘both’ surgeries; and whether they worked in a public hospital, private hospital, or both. For example, if a respondent indicated that they only conducted THA, then no subsequent questions relating to TKA would be shown. There were no required fields and respondents could choose to not answer any of the questions. Section 1: Respondent characteristics The questionnaire was built in Qualtrix and included several questions to describe respondent characteristics, including age and number and location of surgeries performed. Section 2: Level of autonomy and knowledge of cost Both the systematic review and the interviews highlighted that there needed to be questions relating to the level of autonomy that surgeons have in relation to prosthesis selection in their context, as well as their awareness of the cost of the prostheses they use, to support the interpretation of results, which were both added to the final survey. Section 3: Factors influencing prostheses selection Twelve factors derived from the systematic review and interviews were included in the questionnaire. Pilot and interview participants suggested selecting the top five factors influencing selection would be sufficient to gain useful insight, without being too onerous. Section 4: Changing prosthesis selection Interview participants discussed the likelihood that surgeons might select prostheses, and their associated suppliers, based on what they had been trained on. Therefore, questions were included around whether surgeons changed prosthesis in the past, the reasons for doing so, and potential reasons for future changes. Section 5: Registry results Australia has a national joint registry which publishes revision rates for implants and combinations of implants, including individual surgeon level data. Questions on the use of registry data were also included. Section 6: Unwarranted variation Three questions about unwarranted variation were included using 5-year and 10-year revision rates and cost thresholds informed by national reporting measures and interview data. Stage 2: Survey of orthopaedic surgeons Participants A cross-sectional survey was conducted with: ( 1 ) Orthopaedic surgeons who undertake hip and/or knee surgery in Australia and are registered on the email mailing list of the Arthroplasty Society of Australia, a subspecialty group of the Australian Orthopaedic Association. ( 2 ) Orthopaedic registrars, both training and non-training. Recruitment Survey participants were contacted via email sent from the Arthroplasty Society of Australia that contained a link to the questionnaire. The Arthroplasty Society of Australia has 121 members on its mailing list. Twenty registrars were emailed a link to the questionnaire through informal clinical networks, with the request to share with other registrars, whether they were training or non-training. The questionnaire remained active for three months to allow time for completion. Analysis The questionnaire responses were analysed using descriptive statistics and use of a numerical score to identify the highest priority factor. For this prioritisation exercise, respondents were asked to select their top five factors from a list of 12 that they consider when selecting an implant. We assigned a numerical score ranging from 5 (highest priority) to 1 (fifth priority), with all other non-prioritised factors receiving a score of 0. We then calculated the mean score for each factor, with higher scores providing an indication of factors that were perceived to have greater importance. All free text comments provided, have been reported. Survey Results Respondent characteristics The survey was completed by 59 participants (50 consultants and 9 registrars) with a response rate of 41% and 45% respectively. Respondent characteristics are outlined in Table 1 , noting respondents from all Australian states and territories, except the Northern Territory, and a 75–25% split between those practicing in metropolitan compared to regional hospitals. Most respondents practiced in both public and private hospitals (56% n = 33), with the remainder split evenly between public only and private only. Over half the respondents noted that they were either 15–20 years (n = 12, 20%) or 20 + years (n = 20, 34%,) post orthopaedic specialisation training. Table 1 Respondent Characteristics Q1: Which state or territory do you primarily work in? State or territory # of responses % of total (n = 59) QLD 20 34% NSW 19 32% VIC 7 12% SA 5 8% TAS 4 7% WA 2 3% ACT 1 2% NT 0 0% Missing 1 2% Q2: What setting do you primarily work in? Setting # of responses % of total (n = 59) Metropolitan 44 75% Regional 15 25% Rural or remote 0 0% Q3: Are you currently a : Professional role # of responses % of total (n = 59) Consultant orthopaedic surgeon 50 85% Fellow 0 0% Non-training registrar 5 9% Training registrar 4 7% Q4: How many years post training? Year range # of responses % of total (n = 59) 0-5years 11 19% 6–10 years 5 9% 11–15 years 2 3% 15-20years 12 20% 20 + years 20 34% Missing 9 15% Q5: What is your age group? Age range # of responses % of total (n = 59) 20–34 9 15% 35–49 19 32% 50–64 26 44% 65+ 4 7% Prefer not to say 1 2% Q6: Do you conduct (select all that apply) : Surgery type # of responses % of total (n = 59) THA only 1 2% TKA only 5 8% Both THA and TKA 53 90% Surgery type # of responses % of total (n = 59) Total knee replacement* 58 98 Total hip replacement** 54 90 *If selected include Q7 and enable Q15-18 ** If selected include Q8, also enable Q19-21 Q7: How many total hip replacements do you carry out per year? THR range # of responses % of total (n = 54) Less than 20 11 20% 20–50 7 13% 50–100 18 33% 100+ 18 33% Q8: How many total knee replacements do you carry out per year? TKR range # of responses % of total (n = 58) Less than 20 8 14% 20–50 10 17% 50–100 20 34% 100+ 20 34% Q9: Do you practice in (select all that apply) : Hospital type # of responses % of total (n = 59) Public only 13 22% Private only 13 22% Both public and private 33 56% Hospital type # of responses % of total (n = 59) Public hospital 46 78% Private hospital 46 78% Table 1 : Respondent characteristics Level of autonomy and knowledge of cost For those practicing in private hospitals, all respondents noted full autonomy over prosthesis selection. Approximately half of the consultants practicing in public hospitals reported full autonomy (51%, n = 19), closely followed by departmental consensus (46%, n = 17), with a single participant noting limited input. When combined with registrar responses, departmental consensus became the most selected response overall (n = 21, 46%) for those practicing in public hospitals. Free text comments highlighted that several consultants with full autonomy in public hospitals noted some hospital processes to minimise variation (that were not enforced), whilst registrar choices were directed. Further, the majority of respondents (n = 51, 88%) either knew the cost of the implant/s they use most often (n = 19, 32%) or knew the approximate price range (+/- $ 1000) (n = 32, 54%). Table 2 : Level of autonomy and cost awareness Table 2 Level of autonomy and knowledge of cost Q10: In the public setting, what level of autonomy over choice of implant do you have? Autonomy level Consultant orthopaedic surgeon (n = 37) Others (n = 9) Total (n = 46) Full autonomy 19 (51%) 0 (0.0%) 19 (41%) Departmental consensus 17 (46%) 4 (44%) 21 (46%) Limited input 1 (3%) 3 (33%) 4 (9%) Other 0 (0.0%) 2 (22%) 2 (4%) Free text responses : Full autonomy “Department attempts to use similar implants to reduce cost… but there is no pressure to use something else” “Full autonomy within [state] tender, which most companies are. Needs to be an implant with some track record, but essentially full autonomy”. “Full autonomy, but free to choose any prosthesis with a threshold price”. “Have not tested the boundaries on my full autonomy”. “Implant contract with one large company is threshold based. Although autonomous in choice as there is no pressure to switch to this company” Departmental consensus “Choice of two determined by departmental consensus”. “Patients over 75 have all cemented implant. Have departmental rules regarding over costs for implant” “[company] agreement in public for hip and knee arthroplasty” “No restrictions for revisions. Two primary THR and two primary TKR choices available for use” “Implant tender tied to robot use!!” Limited input/ Other “Do what I’m told” “Implant selected by consultant” Q11: In the private setting, what level of autonomy over choice of implant do you have? Autonomy level # of responses % of total (n = 46) Full autonomy 46 100 Departmental consensus 0 0 Limited input 0 0 Free text responses: “Required to be in top 10% registry survivorship at minimum 5 years” Q12: Do you know the cost of the implant/s you use most often? Knowledge level # of responses % of total (n = 59) Yes, I know the cost of the implant/s I use 19 32 I know the approximate price range (+/- $ 1000) 32 54 No, I am not really sure of the cost of the implant/s I use 3 5 Missing (none selected) 5 9 Factors influencing prostheses selection The factor selected the most often as surgeons’ first priority was revision rate (n = 20). The most frequently “top 5” factors, regardless of position, were familiarity with implant and revision rates (selected 40 times each). When factor ratings were used to provide a relative indicator of perceived factor importance, the highest ranked factor was revision rate (3.6), followed by familiarity of implant (2.6) and implant quality (2.2). Cost, availability of implant at hospitals, and length of time in surgery were the lowest ranked factors. Prioritisation of factors is outlined in Table 3 . Table 3 Factor Ranking Q13: Please select your top 5 factors you consider when selecting an implant. Click on the item and drag and drop into the boxes 1–5 (1 = top priority, 2 = second priority, etc). Mean score Max = 5, Min = 0 Revision rate 3.6 Familiarity with implant 2.6 Implant quality 2.2 Patient post-op functionality 1.6 Ease of use in theatre 1.2 Education and support provided with implant 1 Patient age 0.9 Reason for replacement (e.g.) osteoarthritis, trauma, inflammatory arthritis 0.7 Relationship with the implant supplier/ company 0.6 Implant cost 0.5 Type/brand of implant available at the hospital where I work 0.2 Length of time in surgery 0.1 Table 3 : Prosthesis selection factor ranking Changes to prostheses selection Questions related to changes in prosthesis selection were split into those who conduct THA (n = 44) and those who conduct TKA (n = 49), with some respondents answering questions in both categories. Factors influencing previous changes to implant selection and expected future reasons are summarised in Figs. 1 and 2, and Supplementary Table 1. Total hip replacement (n = 44) Post training, the number of different THA implants used had a mixed spread, with more than five different implants the most common response (25%, n = 11). Most (61%, n = 30) respondents had changed away from at least one of the implants they used during training. Technological advancement (67%, n = 18), followed by registry data (56%, n = 15) were the most commonly selected reasons, with the least selected being cheaper alternatives providing similar results (11%, n = 3). For future changes, of the 15 out of 53 THA respondents that answered the question, strong clinical evidence for or against (93%, n = 14) was the most commonly selected response. Total knee replacement (n = 49) Post training, the number of different TKA implants used was equally split by one or two implants respectively (22%, n = 11 each), followed by more than five different implants (18%, n = 9). 61% of respondents (n = 27) had changed away from at least one of the implants they used during training. Registry data (67%, n = 20) followed by technological advancement (60%, n = 18) were the most commonly selected, with cheaper alternatives providing similar results (7%, n = 2) the least common. For future changes, of the 17 out of 58 TKA respondents that answered the question, strong clinical evidence for or against (77%, n = 13) was chosen. Figure 1: Factors influencing decision – THA Figure 2: Factors influencing decision – TKA. Registry results Just over half of consultant participants checked their results once a year (54%, n = 27), with another 32% (n = 16) checking their own results multiple times each year. Two consultant respondents (4%) indicated that they had never checked registry results. When asked how important joint registry outcomes were to them, more than 75% of respondents indicated extremely or very important (extremely important 39% n = 23, very important 37.3% n = 22). Table 4 : Joint registry data use Table 4 Joint Registry Use Q24: How often do you check your individual registry results?* Support # of responses % of total (n = 50) Multiple times a year 16 32 Once a year 27 54 Once every 2–3 years 2 4 Once every 3–5 years 1 2 Once every 5 + years 0 0 Never 2 4 Missing 2 4 Q25: How important are joint registry outcomes to you? Importance level Consultant orthopaedic surgeon (n = 50) Others (n = 9) Total (n = 59) Extremely important 19 (38%) 4 (44%) 23 (39%) Very important 20 (40%) 2 (22%) 22 (37%) Moderately 7 (14%) 0 (0%) 7 (12%) Slightly important 2 (4%) 0 (0%) 2 (3%) Not at all important 2 (4%) 0 (0%) 0 (0%) Missing 19 (38%) 3 (33) 5 (9%) * NB: Q24 was answered by those who selected consultant only. Unwarranted variation Cost of prostheses Participants were asked about unwarranted variation in relation to prosthesis cost (Unwarranted variation summarised in Fig. 3 and supplementary Table 2). Answers were mixed, with 27% (n = 16) indicating that a prosthesis costing 20% more than an equivalent was unwarranted variation, but this was closely followed by 24% (n = 14) indicating that a prosthesis costing 10% more than an equivalent was unwarranted variation. This question was not answered by 14% (n = 8) of participants. The distribution of responses was broadly consistent between consultants and registrars. Five-year revisions Fifty-eight percent of respondents (n = 34) indicated that a ‘more than 20%’ increase in five-year revision rates compared to equivalent prostheses constitutes unwarranted variation. This option was selected by 62% (n = 31) of consultants and a third (33%) of registrars. However, nearly a third (29%, n = 17) of respondents selected a lower threshold. Of note, 13.6% of surgeons (n = 8) did not answer this question. 10-year revisions More than 20% increase in 10-year revision rates was also the most commonly selected response for 10-year revision rates, with 59% (n = 35) selecting this overall, comprising 62% (n = 31) and 44% (n = 4) of consultants and registrars, respectively. Similar to the five-year revision rates, 27% (n = 16) of respondents selected a lower threshold, with the same number of respondents (n = 8) not selecting a threshold at all. Figure 3: Unwarranted variation Stage 3: Panel discussion to define unwarranted variation Survey results were reviewed by a panel of two orthopaedic surgeons and a health economist with expertise in unwarranted variation to consolidate a working definition of unwarranted clinical variation. This definition will be used as part of an economic evaluation using current prosthesis use data. Key outcomes from the panel meeting are summarised below. 1. Revision rates are a key indicator, which should form part of the working definition. 2. Revision rates of 20% or higher than an agreed benchmark rate at 5-year and 10-year intervals were suitable for a working definition. It was noted by participants 20% is similar to international benchmarking. 3. Uncertainty would always be present in estimates of unwarranted variation, for example, if derived from registry data revision rates, confidence intervals could be used for defining conservative narrow and broad definitions of unwarranted variation. 4. Cost is a useful indicator of unwarranted variation. However, given the mixed response in the survey, the panel suggested that multiple cost thresholds, along with revision rates, should be used within the working definition. 5. There was some discussion about other potentially confounding factors, including cemented vs uncemented, or age of implant recipients, and how this ought to be accounted for in future studies investigating unwarranted variation in this field. Discussion This study demonstrates that the most influential factors for surgeon decision making in relation to prosthesis selection include revision rate, familiarity with implant, and implant quality, while factors including cost have limited influence. Similarly, technological advancement and revision rates were influential for past changes of prosthesis, and strong clinical evidence was reported to be influential for future changes. A working definition of unwarranted variation was agreed upon, which focused on implants with revision rates of at least 20% higher than published benchmarks with multiple cost thresholds. National registries in Australia and internationally provide comprehensive data on revision rates for both THA and TKA implants, yet there is continued use of implants with no long term data, or with considerably higher revision rates ( 12 ). Previous research has also demonstrated a large disparity in revision rates between public and private hospital rates in Australia ( 13 ). Higher revision rates in private hospitals were shown to be largely related to differences in implant selection, with revision rates equalising where data was restricted to high performing implants only ( 13 ). Given that revision rates were demonstrated in this study as the key deciding factor when selecting an implant, providing a working definition on what constitutes potential unwarranted variation that includes a threshold for revision rates is a key outcome that can be applied in future research. Cost was not highlighted in this study as a major deciding factor for most surgeons. Given the majority of respondents perceived that they knew the cost or approximate cost of the implants they use most often, the minimal role played by cost in decision making does not appear to be related to cost awareness. This high level of cost awareness is similar to that found by Sharkey et al.( 14 ), with the majority of respondents in both studies having a high level of control over their implant selection. The authors of that study also noted that surgeons are likely to continue selecting the same implant, even if there is a more affordable implant with acceptable clinical outcomes ( 14 ). Given our results and that of previous studies, future strategies to address unwarranted variation must move beyond mere awareness raising. Our finding regarding familiarity with implant being a key driver of prosthesis selection warrants further investigation. Studies have demonstrated that surgical experience and familiarity with other members of the operating team can lead to reduction in theatre time ( 15 , 16 ), length of stay and 30 day readmission rates ( 16 ). One study suggests that surgeons perceived that changing implants and the associated learning curve would adversely affect patients in the short term ( 14 ). Conversely, another study found that firm preferences for specific implants was a barrier to acquiring competency in a broader range of implants that would better align to the needs of patients ( 17 ). Our results further resonate with other research on unwarranted variation which have highlighted the influence of capacity (individual and organisational) and individual preferences (both patient and clinician), as potential reasons for underlying variation, both warranted and unwarranted ( 9 , 18 ), and the need for further consideration of these factors. Several considerations that have been reported in previous research, including surgeon’s relationships with implant companies ( 19 , 20 ), technological aspects ( 14 , 17 , 19 , 20 ), or patient fit ( 14 , 17 , 19 , 20 ), did not feature as prominently in our study. This may be due to factors being described in more detail in the questionnaire, for example, patient age and reason for replacement are both aspects of patient fit, which may have ranked higher if they were combined. Technological advancement on the other hand was reported in this study as a factor that influenced past changes in prosthesis selection, but not in relation to current decision making. This may align with the perception that surgeons believe there are minimal differences among common prostheses, so improvements would need to be significant before change to an alternate prosthesis would be considered ( 17 ). A strength of this study is the relatively representative sample of consultant orthopaedic surgeons across Australia. However, we did not have a large number of registrars in the sample, and their responses must be interpreted with caution. Despite piloting the questionnaire and aligning the top threshold with current reporting standards, some limitations remained, including a potential ceiling effect of using ‘20% and over’ as the top increment for the unwarranted variation questions (both cost and revision rate). This may have led to the missing data with several participants not selecting a threshold for unwarranted variation based on revision rates (n = 8), or this may be due to the lack of importance placed on this data by some, despite revision rates being the highest ranked factor for prosthesis selection in this study. Furthermore, we did not explicitly define departmental consensus or implant quality within the questionnaire tool itself, which may have resulted in variable interpretation among participants. Reasons for future changes to implant also had missing data for 66% and 65% for THR and TKR respondents respectively. It is unclear as to whether this related to a lack of willingness to consider changing implants in the future, or difficulty making a selection for future decisions. Directly observing revealed preferences for implant selection may provide different outcomes from this survey study, presenting a useful area for future research. Conclusion This study highlights several factors that are influential in surgeon decision making in relation to implant choice for THA and TKA. Further, it provides a working definition for unwarranted variation that can be applied in future research and health system strategies to improve patient outcomes and provide better value care. Abbreviations AUD Australian dollars OECD Organisation for Economic Co-operation and Development THA total hip arthroplasty TKA total knee arthroplasty Declarations Competing interests The authors have no relevant financial or non-financial interests to disclose. Acknowledgements We would like to thank all those who piloted or completed the survey for your time and expertise. Ethics approval and consent to participate Ethical approval for this study was granted by the Queensland University of Technology Human Research Ethics Committee, reference number UHREC-2022-4255. Participant consent for participation in the interviews was obtained in writing. For the survey, consent was provided electronically by selecting ‘agree to consent’ prior to being given access to complete the questions. Consent for the expert panel was provided verbally and recorded with the audio recorder as part of the meeting. Consent to Publication Consent to publish was included in all the above consent procedures. All participants that consented to participate, also consented to publish. Data and materials The survey data used and/ or analysed during the current study are either provided within the manuscript or supplementary materials, or are available from the corresponding author on reasonable request that has ethical clearance. The transcripts and audio-recordings of the interviews and expert panel are not available in their raw form due to potential re-identifiability given the small sample size, however a summary of the data and further detail on coding is available on reasonable request. Funding This work was funded by an unencumbered gift to the Queensland University of Technology from the Medibank Foundation. There was no contribution by the funders to data analysis, interpretation, writing or publication of results. Author contributions All authors conceived and designed the study. MJA undertook the interviews and undertook initial coding of the transcripts. Consolidation of themes and development of survey questions was done by MJA, RC, and DB, with the online questionnaire created by SS. Survey data was analysed by SS with results reviewed by all authors. Initial draft was written by MJA and LE. Subsequent drafts were reviewed by all authors and significant intellectual contribution was provided by all. All authors reviewed and agreed on the final manuscript. Author information RC and IH are orthopaedic surgeons with extensive experience in hip and knee arthroscopy. DB, SS, VM, SMM are health economists with an interest in value-based care. 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Surgeon's Preference in Total Knee Replacement: A Quantitative Examination of Attributes, Reasons for Alteration, and Barriers to Change. J Arthroplasty. 2017;32(10):2980–9. Supplementary Files 6SuppTables1220230817.docx Supplementary Files 1 and 2 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3439378","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":239795814,"identity":"050e13ef-8e90-48d9-9e07-b2e74c3b2d5f","order_by":0,"name":"Michelle J Allen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDAC9v4PDAwFFkBGA5jP2EBQC88BAwYGAwkQg4HhAFFaJBKgWiQSiNSi25CQwPDDQELOXPLxNukPDDayGw4wP5PAp8XswIEDjD0GEsaWs9PKJA4wpBlvOMBmhl/LwcYGBh4DicQNt3PMgFoOJ244wEBAy2FmBsY/BhL1G26eAWn5D9TC/g2/lmNsDMxAWxIMbvCAtBwAauEhYMsZHobDMgYShhvOpBVbnDFINp55mKfYAq+W+28YH76psJE3OH54442KCjvZvuPtG2/g0wICB6C0ARgxMBNSjwQMSFA7CkbBKBgFIwkAAF+lSf9L2zgKAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-2178-4054","institution":"Queensland University of Technology Australian Centre for Health Service Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"J","lastName":"Allen","suffix":""},{"id":239795815,"identity":"1abb0ce0-ba54-4ddd-99a3-b766f4c50fd2","order_by":1,"name":"David Brain","email":"","orcid":"https://orcid.org/0000-0002-6612-348X","institution":"Queensland University of Technology Australian Centre for Health Service Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Brain","suffix":""},{"id":239795816,"identity":"3182286f-fb30-4824-83aa-328dd0dd7efa","order_by":2,"name":"Ross Crawford","email":"","orcid":"https://orcid.org/0000-0001-6079-1316","institution":"Queensland University of Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ross","middleName":"","lastName":"Crawford","suffix":""},{"id":239795817,"identity":"3596199d-0d53-463d-8c10-6da57ebe59c5","order_by":3,"name":"Sameera Senanayake","email":"","orcid":"https://orcid.org/0000-0002-5606-2046","institution":"Duke NUS Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sameera","middleName":"","lastName":"Senanayake","suffix":""},{"id":239795818,"identity":"d63fba1b-963e-48fb-8111-489c538d480d","order_by":4,"name":"Ian A Harris","email":"","orcid":"https://orcid.org/0000-0003-0887-7627","institution":"University of New South Wales","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ian","middleName":"A","lastName":"Harris","suffix":""},{"id":239795819,"identity":"87396c4f-ff68-4097-9db7-4d29281a4779","order_by":5,"name":"Lana Elliott","email":"","orcid":"https://orcid.org/0000-0003-0228-6957","institution":"Queensland University of Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lana","middleName":"","lastName":"Elliott","suffix":""},{"id":239795820,"identity":"ca097542-7ccd-449e-b7d2-c3432831c45f","order_by":6,"name":"Reece Hinchcliff","email":"","orcid":"https://orcid.org/0000-0001-9920-4211","institution":"Griffith University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Reece","middleName":"","lastName":"Hinchcliff","suffix":""},{"id":239795821,"identity":"d357fdaa-b1d5-43da-be8b-b1f4ad05a12c","order_by":7,"name":"Victoria McCreanor","email":"","orcid":"https://orcid.org/0000-0002-0589-8521","institution":"University of Newcastle Hunter Medical Research Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"McCreanor","suffix":""},{"id":239795822,"identity":"7fb251b5-b911-4766-8492-9fc14449e44a","order_by":8,"name":"Steven M McPhail","email":"","orcid":"https://orcid.org/0000-0002-1463-662X","institution":"Queensland University of Technology Australian Centre for Health Service Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Steven","middleName":"M","lastName":"McPhail","suffix":""}],"badges":[],"createdAt":"2023-10-13 00:57:47","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-3439378/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3439378/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44712406,"identity":"747ea813-e8be-4e8a-be7d-06eb60974e7d","added_by":"auto","created_at":"2023-10-16 17:42:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53329,"visible":true,"origin":"","legend":"\u003cp\u003eFactors influencing decisions for total hip arthroscopy (THA)\u003c/p\u003e","description":"","filename":"4Figure1FactorsPreviousExpectedTHA.png","url":"https://assets-eu.researchsquare.com/files/rs-3439378/v1/3de7f5941b34661b875ebec3.png"},{"id":44711503,"identity":"41e2d1a5-6a51-495b-b8a3-6db180fccbb6","added_by":"auto","created_at":"2023-10-16 17:34:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54434,"visible":true,"origin":"","legend":"\u003cp\u003eFactors influencing decisions for TKA\u003c/p\u003e","description":"","filename":"5Figure2FactorsPreviousExpectedTKA.png","url":"https://assets-eu.researchsquare.com/files/rs-3439378/v1/24e8b1422aaee0150ddca4a4.png"},{"id":44713236,"identity":"08840bce-0a8c-43fb-b23f-d7302de693b4","added_by":"auto","created_at":"2023-10-16 17:50:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eUnwarranted variation\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-3439378/v1/4be503156669f738c334a876.png"},{"id":44714137,"identity":"babd9d84-ec5a-4203-9f31-774b6a06579d","added_by":"auto","created_at":"2023-10-16 17:58:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":989106,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3439378/v1/cee20062-4766-4d74-93ba-d437563af155.pdf"},{"id":44711500,"identity":"e65fa8b8-a326-4ed6-a07a-ba65393a5fb6","added_by":"auto","created_at":"2023-10-16 17:34:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27196,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Files 1 and 2\u003c/p\u003e","description":"","filename":"6SuppTables1220230817.docx","url":"https://assets-eu.researchsquare.com/files/rs-3439378/v1/1e0c3b9f6321e2188dc0f68a.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003e\u003cstrong\u003eFactors influencing prosthesis selection and variation: a survey of orthopaedic surgeons in Australia.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries are increasing globally and particularly across OECD countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). High-income countries, including the United States, are currently experiencing very high incidence rates per 100,000 for both THA and TKA, while other high-income countries like Australia are expecting rates to double in the coming decades (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In the Australian context, where the present study was conducted, projected costs are expected to reach \u003cspan\u003e$\u003c/span\u003eAUD1.38B for TKA, and \u003cspan\u003e$\u003c/span\u003eAUD953M for THA, respectively by the year 2030 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), with the cost of the implant itself averaging approximately 60% of the total expenditure (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn high-income countries, prosthesis selection is largely driven by orthopaedic surgeons, but little is known about what factors influence their decision making. A recent systematic review to identify the factors influencing surgeons\u0026rsquo; prosthesis selections for knee and hip arthroplasty in high-income countries highlighted a range of factors including patient anatomy, familiarity with implant, implant quality, and even the friendliness of the sales representative are considered by surgeons (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, due to the small number and heterogeneity of studies on this topic, no strong conclusions about the relative importance of these factors were articulated.\u003c/p\u003e \u003cp\u003eBetter understanding of factors influencing prosthesis selection is needed to support the development and implementation of strategies to improve patient outcomes and reduce unwarranted variation. Unwarranted variation that is unrelated to clinical need, evidence or patient preferences can lead to poorer outcomes for patients, or other detrimental effects, including higher cost or wasted healthcare resources (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The dual objectives for this study were to: a) identify factors influencing prosthesis selection by surgeons for THA and TKA; and b) develop a working definition for what could be considered unwarranted variation in implant selection for THA and TKA. This working definition will be used to inform an economic analysis of unwarranted variation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eInformed by our recently completed scoping review of factors influencing prosthesis selection (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e), we undertook a three-stage mixed methods study to address the objectives. The first stage comprised i) interviews with orthopaedic surgeons to inform the questionnaire design, and ii) piloting the questionnaire. The second stage was conducting a cross-sectional survey with orthopaedic surgeons in Australia. The results of the survey were then reviewed by the expert panel in stage 3, to consolidate a working definition of unwarranted variation for implant selection for THA and TKA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eStage 1: Development and pilot of questionnaire\u003c/h2\u003e\n \u003cp\u003eKey informant interviews with three orthopaedic surgeons were used to explore the findings of the systematic review and develop a questionnaire for surgeons within the Australian context. Key informant sampling was used, with participants for the interviews and pilot recruited via email through existing professional networks. A semi-structured interview guide was used to explore factors influencing prosthesis selection and what constitutes unwarranted variation (Supplementary File 1). Online piloting of the questionnaire was undertaken to review question wording and structure to ensure clinical relevance, as well as user-friendliness for participants.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eAnalysis and question development\u003c/h2\u003e\n \u003cp\u003eInitial interviews were audio recorded and transcribed. Framework analysis of the interview transcripts were undertaken using the seven-step process of transcription, familiarisation with the data, coding, framework development, applying the framework, charting the data, and interpreting the data for meaning (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). The initial framework was based on inductive coding and deductive coding relating to the factors derived from the systematic review. Codes were grouped to create themes, then used to formulate the questions. Multiple iterations of the draft questionnaire were shared, both electronically and in-person, with available interview participants and the research team to refine question content, phrasing, and structure of the questionnaire. To pilot the penultimate questionnaire, an orthopaedic surgeon, a health economist, and a healthcare administrator were emailed a link to the questionnaire, with feedback emailed to the study\u0026rsquo;s Chief Investigator.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eFinal questionnaire\u003c/h2\u003e\n \u003cp\u003eThe final questionnaire had six sections: respondent characteristics, level of autonomy, factors influencing prosthesis selection, changing prosthesis selection, registry results, and unwarranted variation. It contained between 15 to 28 questions, depending on responses. The questionnaire used branching, whereby the number and type of questions depended on whether participants indicated they were a consultant or a registrar; whether they undertook THA, TKA or \u0026lsquo;both\u0026rsquo; surgeries; and whether they worked in a public hospital, private hospital, or both. For example, if a respondent indicated that they only conducted THA, then no subsequent questions relating to TKA would be shown. There were no required fields and respondents could choose to not answer any of the questions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 1: Respondent characteristics\u003c/h2\u003e\n \u003cp\u003eThe questionnaire was built in Qualtrix and included several questions to describe respondent characteristics, including age and number and location of surgeries performed.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 2: Level of autonomy and knowledge of cost\u003c/h2\u003e\n \u003cp\u003eBoth the systematic review and the interviews highlighted that there needed to be questions relating to the level of autonomy that surgeons have in relation to prosthesis selection in their context, as well as their awareness of the cost of the prostheses they use, to support the interpretation of results, which were both added to the final survey.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 3: Factors influencing prostheses selection\u003c/h2\u003e\n \u003cp\u003eTwelve factors derived from the systematic review and interviews were included in the questionnaire. Pilot and interview participants suggested selecting the top five factors influencing selection would be sufficient to gain useful insight, without being too onerous.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 4: Changing prosthesis selection\u003c/h2\u003e\n \u003cp\u003eInterview participants discussed the likelihood that surgeons might select prostheses, and their associated suppliers, based on what they had been trained on. Therefore, questions were included around whether surgeons changed prosthesis in the past, the reasons for doing so, and potential reasons for future changes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 5: Registry results\u003c/h2\u003e\n \u003cp\u003eAustralia has a national joint registry which publishes revision rates for implants and combinations of implants, including individual surgeon level data. Questions on the use of registry data were also included.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSection 6: Unwarranted variation\u003c/h2\u003e\n \u003cp\u003eThree questions about unwarranted variation were included using 5-year and 10-year revision rates and cost thresholds informed by national reporting measures and interview data.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eStage 2: Survey of orthopaedic surgeons\u003c/h2\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eA cross-sectional survey was conducted with:\u003c/p\u003e\n \u003cp\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) Orthopaedic surgeons who undertake hip and/or knee surgery in Australia and are registered on the email mailing list of the Arthroplasty Society of Australia, a subspecialty group of the Australian Orthopaedic Association.\u003c/p\u003e\n \u003cp\u003e(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) Orthopaedic registrars, both training and non-training.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eRecruitment\u003c/h2\u003e\n \u003cp\u003eSurvey participants were contacted via email sent from the Arthroplasty Society of Australia that contained a link to the questionnaire. The Arthroplasty Society of Australia has 121 members on its mailing list. Twenty registrars were emailed a link to the questionnaire through informal clinical networks, with the request to share with other registrars, whether they were training or non-training. The questionnaire remained active for three months to allow time for completion.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eAnalysis\u003c/h2\u003e\n \u003cp\u003eThe questionnaire responses were analysed using descriptive statistics and use of a numerical score to identify the highest priority factor. For this prioritisation exercise, respondents were asked to select their top five factors from a list of 12 that they consider when selecting an implant. We assigned a numerical score ranging from 5 (highest priority) to 1 (fifth priority), with all other non-prioritised factors receiving a score of 0. We then calculated the mean score for each factor, with higher scores providing an indication of factors that were perceived to have greater importance. All free text comments provided, have been reported.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eSurvey Results\u003c/h2\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003eRespondent characteristics\u003c/h2\u003e\n \u003cp\u003eThe survey was completed by 59 participants (50 consultants and 9 registrars) with a response rate of 41% and 45% respectively. Respondent characteristics are outlined in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, noting respondents from all Australian states and territories, except the Northern Territory, and a 75\u0026ndash;25% split between those practicing in metropolitan compared to regional hospitals. Most respondents practiced in both public and private hospitals (56% n\u0026thinsp;=\u0026thinsp;33), with the remainder split evenly between public only and private only. Over half the respondents noted that they were either 15\u0026ndash;20 years (n\u0026thinsp;=\u0026thinsp;12, 20%) or 20\u0026thinsp;+\u0026thinsp;years (n\u0026thinsp;=\u0026thinsp;20, 34%,) post orthopaedic specialisation training.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRespondent Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eQ1: Which state or territory do you primarily work in?\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eState or territory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNSW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVIC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ2: What setting do you primarily work in?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetropolitan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural or remote\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ3: Are you currently a\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsultant orthopaedic surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFellow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-training registrar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraining registrar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ4: How many years post training?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0-5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u0026ndash;15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15-20years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ5: What is your age group?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ6: Do you conduct (select all that apply)\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTHA only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTKA only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth THA and TKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal knee replacement*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal hip replacement**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003e*If selected include Q7 and enable Q15-18\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e**\u003cem\u003eIf selected include Q8, also enable Q19-21\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ7: How many total hip replacements do you carry out per year?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTHR range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ8: How many total knee replacements do you carry out per year?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTKR range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ9: Do you practice in (select all that apply)\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth public and private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cem\u003eRespondent characteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eLevel of autonomy and knowledge of cost\u003c/h2\u003e\n \u003cp\u003eFor those practicing in private hospitals, all respondents noted full autonomy over prosthesis selection. Approximately half of the consultants practicing in public hospitals reported full autonomy (51%, n\u0026thinsp;=\u0026thinsp;19), closely followed by departmental consensus (46%, n\u0026thinsp;=\u0026thinsp;17), with a single participant noting limited input. When combined with registrar responses, departmental consensus became the most selected response overall (n\u0026thinsp;=\u0026thinsp;21, 46%) for those practicing in public hospitals. Free text comments highlighted that several consultants with full autonomy in public hospitals noted some hospital processes to minimise variation (that were not enforced), whilst registrar choices were directed. Further, the majority of respondents (n\u0026thinsp;=\u0026thinsp;51, 88%) either knew the cost of the implant/s they use most often (n\u0026thinsp;=\u0026thinsp;19, 32%) or knew the approximate price range (+/- \u003cspan\u003e$\u003c/span\u003e1000) (n\u0026thinsp;=\u0026thinsp;32, 54%).\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cem\u003eLevel of autonomy and cost awareness\u003c/em\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLevel of autonomy and knowledge of cost\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cem\u003eQ10: In the public setting, what level of autonomy over choice of implant do you have?\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAutonomy level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsultant orthopaedic surgeon (n\u0026thinsp;=\u0026thinsp;37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers (n\u0026thinsp;=\u0026thinsp;9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n\u0026thinsp;=\u0026thinsp;46)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFull autonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepartmental consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited input\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eFree text responses\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eFull autonomy\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Department attempts to use similar implants to reduce cost\u0026hellip; but there is no pressure to use something else\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Full autonomy within [state] tender, which most companies are. Needs to be an implant with some track record, but essentially full autonomy\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Full autonomy, but free to choose any prosthesis with a threshold price\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Have not tested the boundaries on my full autonomy\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Implant contract with one large company is threshold based. Although autonomous in choice as there is no pressure to switch to this company\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDepartmental consensus\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Choice of two determined by departmental consensus\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Patients over 75 have all cemented implant. Have departmental rules regarding over costs for implant\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[company] agreement in public for hip and knee arthroplasty\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;No restrictions for revisions. Two primary THR and two primary TKR choices available for use\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Implant tender tied to robot use!!\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eLimited input/ Other\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Do what I\u0026rsquo;m told\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Implant selected by consultant\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ11: In the private setting, what level of autonomy over choice of implant do you have?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAutonomy level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;46)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFull autonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepartmental consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited input\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eFree text responses:\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Required to be in top 10% registry survivorship at minimum 5 years\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ12: Do you know the cost of the implant/s you use most often?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eYes, I know the cost of the implant/s I use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI know the approximate price range (+/- \u003cspan\u003e$\u003c/span\u003e1000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo, I am not really sure of the cost of the implant/s I use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMissing (none selected)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors influencing prostheses selection\u003c/h2\u003e\n \u003cp\u003eThe factor selected the most often as surgeons\u0026rsquo; first priority was revision rate (n\u0026thinsp;=\u0026thinsp;20). The most frequently \u0026ldquo;top 5\u0026rdquo; factors, regardless of position, were familiarity with implant and revision rates (selected 40 times each). When factor ratings were used to provide a relative indicator of perceived factor importance, the highest ranked factor was revision rate (3.6), followed by familiarity of implant (2.6) and implant quality (2.2). Cost, availability of implant at hospitals, and length of time in surgery were the lowest ranked factors. Prioritisation of factors is outlined in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactor Ranking\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ13: Please select your top 5 factors you consider when selecting an implant. Click on the item and drag and drop into the boxes 1\u0026ndash;5 (1\u0026thinsp;=\u0026thinsp;top priority, 2\u0026thinsp;=\u0026thinsp;second priority, etc).\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean score\u003c/p\u003e\n \u003cp\u003eMax\u0026thinsp;=\u0026thinsp;5, Min\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRevision rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamiliarity with implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImplant quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient post-op functionality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEase of use in theatre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation and support provided with implant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReason for replacement (e.g.) osteoarthritis, trauma, inflammatory arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship with the implant supplier/ company\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImplant cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType/brand of implant available at the hospital where I work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of time in surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cem\u003eProsthesis selection factor ranking\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eChanges to prostheses selection\u003c/p\u003e\n \u003cp\u003eQuestions related to changes in prosthesis selection were split into those who conduct THA (n\u0026thinsp;=\u0026thinsp;44) and those who conduct TKA (n\u0026thinsp;=\u0026thinsp;49), with some respondents answering questions in both categories. Factors influencing previous changes to implant selection and expected future reasons are summarised in Figs.\u0026nbsp;1 and 2, and Supplementary Table\u0026nbsp;1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eTotal hip replacement (n\u0026thinsp;=\u0026thinsp;44)\u003c/h2\u003e\n \u003cp\u003ePost training, the number of different THA implants used had a mixed spread, with more than five different implants the most common response (25%, n\u0026thinsp;=\u0026thinsp;11). Most (61%, n\u0026thinsp;=\u0026thinsp;30) respondents had changed away from at least one of the implants they used during training. Technological advancement (67%, n\u0026thinsp;=\u0026thinsp;18), followed by registry data (56%, n\u0026thinsp;=\u0026thinsp;15) were the most commonly selected reasons, with the least selected being cheaper alternatives providing similar results (11%, n\u0026thinsp;=\u0026thinsp;3). For future changes, of the 15 out of 53 THA respondents that answered the question, strong clinical evidence for or against (93%, n\u0026thinsp;=\u0026thinsp;14) was the most commonly selected response.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eTotal knee replacement (n\u0026thinsp;=\u0026thinsp;49)\u003c/h2\u003e\n \u003cp\u003ePost training, the number of different TKA implants used was equally split by one or two implants respectively (22%, n\u0026thinsp;=\u0026thinsp;11 each), followed by more than five different implants (18%, n\u0026thinsp;=\u0026thinsp;9). 61% of respondents (n\u0026thinsp;=\u0026thinsp;27) had changed away from at least one of the implants they used during training. Registry data (67%, n\u0026thinsp;=\u0026thinsp;20) followed by technological advancement (60%, n\u0026thinsp;=\u0026thinsp;18) were the most commonly selected, with cheaper alternatives providing similar results (7%, n\u0026thinsp;=\u0026thinsp;2) the least common. For future changes, of the 17 out of 58 TKA respondents that answered the question, strong clinical evidence for or against (77%, n\u0026thinsp;=\u0026thinsp;13) was chosen.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFigure 1: Factors influencing decision \u0026ndash; THA\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFigure 2: Factors influencing decision \u0026ndash; TKA.\u003c/em\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eRegistry results\u003c/h2\u003e\n \u003cp\u003eJust over half of consultant participants checked their results once a year (54%, n\u0026thinsp;=\u0026thinsp;27), with another 32% (n\u0026thinsp;=\u0026thinsp;16) checking their own results multiple times each year. Two consultant respondents (4%) indicated that they had never checked registry results. When asked how important joint registry outcomes were to them, more than 75% of respondents indicated extremely or very important (extremely important 39% n\u0026thinsp;=\u0026thinsp;23, very important 37.3% n\u0026thinsp;=\u0026thinsp;22).\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cem\u003eJoint registry data use\u003c/em\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eJoint Registry Use\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cem\u003eQ24: How often do you check your individual registry results?*\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupport\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total (n\u0026thinsp;=\u0026thinsp;50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMultiple times a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOnce a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOnce every 2\u0026ndash;3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOnce every 3\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOnce every 5\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ25: How important are joint registry outcomes to you?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eImportance level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsultant orthopaedic surgeon (n\u0026thinsp;=\u0026thinsp;50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers (n\u0026thinsp;=\u0026thinsp;9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n\u0026thinsp;=\u0026thinsp;59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtremely important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e20 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerately\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSlightly important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot at all important\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*\u003cem\u003eNB: Q24 was answered by those who selected consultant only.\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eUnwarranted variation\u003c/h2\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eCost of prostheses\u003c/h2\u003e\n \u003cp\u003eParticipants were asked about unwarranted variation in relation to prosthesis cost (Unwarranted variation summarised in Fig.\u0026nbsp;3 and supplementary Table\u0026nbsp;2). Answers were mixed, with 27% (n\u0026thinsp;=\u0026thinsp;16) indicating that a prosthesis costing 20% more than an equivalent was unwarranted variation, but this was closely followed by 24% (n\u0026thinsp;=\u0026thinsp;14) indicating that a prosthesis costing 10% more than an equivalent was unwarranted variation. This question was not answered by 14% (n\u0026thinsp;=\u0026thinsp;8) of participants. The distribution of responses was broadly consistent between consultants and registrars.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003eFive-year revisions\u003c/h2\u003e\n \u003cp\u003eFifty-eight percent of respondents (n\u0026thinsp;=\u0026thinsp;34) indicated that a \u0026lsquo;more than 20%\u0026rsquo; increase in five-year revision rates compared to equivalent prostheses constitutes unwarranted variation. This option was selected by 62% (n\u0026thinsp;=\u0026thinsp;31) of consultants and a third (33%) of registrars. However, nearly a third (29%, n\u0026thinsp;=\u0026thinsp;17) of respondents selected a lower threshold. Of note, 13.6% of surgeons (n\u0026thinsp;=\u0026thinsp;8) did not answer this question.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003e10-year revisions\u003c/h2\u003e\n \u003cp\u003eMore than 20% increase in 10-year revision rates was also the most commonly selected response for 10-year revision rates, with 59% (n\u0026thinsp;=\u0026thinsp;35) selecting this overall, comprising 62% (n\u0026thinsp;=\u0026thinsp;31) and 44% (n\u0026thinsp;=\u0026thinsp;4) of consultants and registrars, respectively. Similar to the five-year revision rates, 27% (n\u0026thinsp;=\u0026thinsp;16) of respondents selected a lower threshold, with the same number of respondents (n\u0026thinsp;=\u0026thinsp;8) not selecting a threshold at all.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFigure 3: Unwarranted variation\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003eStage 3: Panel discussion to define unwarranted variation\u003c/h2\u003e\n \u003cp\u003eSurvey results were reviewed by a panel of two orthopaedic surgeons and a health economist with expertise in unwarranted variation to consolidate a working definition of unwarranted clinical variation. This definition will be used as part of an economic evaluation using current prosthesis use data. Key outcomes from the panel meeting are summarised below.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e1. Revision rates are a key indicator, which should form part of the working definition.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e2. Revision rates of 20% or higher than an agreed benchmark rate at 5-year and 10-year intervals were suitable for a working definition. It was noted by participants 20% is similar to international benchmarking.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e3. Uncertainty would always be present in estimates of unwarranted variation, for example, if derived from registry data revision rates, confidence intervals could be used for defining conservative narrow and broad definitions of unwarranted variation.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e4. Cost is a useful indicator of unwarranted variation. However, given the mixed response in the survey, the panel suggested that multiple cost thresholds, along with revision rates, should be used within the working definition.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e5. There was some discussion about other potentially confounding factors, including cemented vs uncemented, or age of implant recipients, and how this ought to be accounted for in future studies investigating unwarranted variation in this field.\u003c/p\u003e\n \u003c/span\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that the most influential factors for surgeon decision making in relation to prosthesis selection include revision rate, familiarity with implant, and implant quality, while factors including cost have limited influence. Similarly, technological advancement and revision rates were influential for past changes of prosthesis, and strong clinical evidence was reported to be influential for future changes. A working definition of unwarranted variation was agreed upon, which focused on implants with revision rates of at least 20% higher than published benchmarks with multiple cost thresholds.\u003c/p\u003e \u003cp\u003eNational registries in Australia and internationally provide comprehensive data on revision rates for both THA and TKA implants, yet there is continued use of implants with no long term data, or with considerably higher revision rates (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Previous research has also demonstrated a large disparity in revision rates between public and private hospital rates in Australia (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Higher revision rates in private hospitals were shown to be largely related to differences in implant selection, with revision rates equalising where data was restricted to high performing implants only (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Given that revision rates were demonstrated in this study as the key deciding factor when selecting an implant, providing a working definition on what constitutes potential unwarranted variation that includes a threshold for revision rates is a key outcome that can be applied in future research.\u003c/p\u003e \u003cp\u003eCost was not highlighted in this study as a major deciding factor for most surgeons. Given the majority of respondents perceived that they knew the cost or approximate cost of the implants they use most often, the minimal role played by cost in decision making does not appear to be related to cost awareness. This high level of cost awareness is similar to that found by Sharkey et al.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), with the majority of respondents in both studies having a high level of control over their implant selection. The authors of that study also noted that surgeons are likely to continue selecting the same implant, even if there is a more affordable implant with acceptable clinical outcomes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Given our results and that of previous studies, future strategies to address unwarranted variation must move beyond mere awareness raising.\u003c/p\u003e \u003cp\u003eOur finding regarding familiarity with implant being a key driver of prosthesis selection warrants further investigation. Studies have demonstrated that surgical experience and familiarity with other members of the operating team can lead to reduction in theatre time (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), length of stay and 30 day readmission rates (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). One study suggests that surgeons perceived that changing implants and the associated learning curve would adversely affect patients in the short term (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Conversely, another study found that firm preferences for specific implants was a barrier to acquiring competency in a broader range of implants that would better align to the needs of patients (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Our results further resonate with other research on unwarranted variation which have highlighted the influence of capacity (individual and organisational) and individual preferences (both patient and clinician), as potential reasons for underlying variation, both warranted and unwarranted (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and the need for further consideration of these factors.\u003c/p\u003e \u003cp\u003eSeveral considerations that have been reported in previous research, including surgeon\u0026rsquo;s relationships with implant companies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), technological aspects (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), or patient fit (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), did not feature as prominently in our study. This may be due to factors being described in more detail in the questionnaire, for example, patient age and reason for replacement are both aspects of patient fit, which may have ranked higher if they were combined. Technological advancement on the other hand was reported in this study as a factor that influenced past changes in prosthesis selection, but not in relation to current decision making. This may align with the perception that surgeons believe there are minimal differences among common prostheses, so improvements would need to be significant before change to an alternate prosthesis would be considered (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA strength of this study is the relatively representative sample of consultant orthopaedic surgeons across Australia. However, we did not have a large number of registrars in the sample, and their responses must be interpreted with caution. Despite piloting the questionnaire and aligning the top threshold with current reporting standards, some limitations remained, including a potential ceiling effect of using \u0026lsquo;20% and over\u0026rsquo; as the top increment for the unwarranted variation questions (both cost and revision rate). This may have led to the missing data with several participants not selecting a threshold for unwarranted variation based on revision rates (n\u0026thinsp;=\u0026thinsp;8), or this may be due to the lack of importance placed on this data by some, despite revision rates being the highest ranked factor for prosthesis selection in this study. Furthermore, we did not explicitly define departmental consensus or implant quality within the questionnaire tool itself, which may have resulted in variable interpretation among participants. Reasons for future changes to implant also had missing data for 66% and 65% for THR and TKR respondents respectively. It is unclear as to whether this related to a lack of willingness to consider changing implants in the future, or difficulty making a selection for future decisions. Directly observing revealed preferences for implant selection may provide different outcomes from this survey study, presenting a useful area for future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights several factors that are influential in surgeon decision making in relation to implant choice for THA and TKA. Further, it provides a working definition for unwarranted variation that can be applied in future research and health system strategies to improve patient outcomes and provide better value care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" valign=\"top\"\u003e\n \u003cp\u003eAUD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"82.6955074875208%\" valign=\"top\"\u003e\n \u003cp\u003eAustralian dollars\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" valign=\"top\"\u003e\n \u003cp\u003eOECD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"82.6955074875208%\" valign=\"top\"\u003e\n \u003cp\u003eOrganisation for Economic Co-operation and Development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" valign=\"top\"\u003e\n \u003cp\u003eTHA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"82.6955074875208%\" valign=\"top\"\u003e\n \u003cp\u003etotal hip arthroplasty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.3044925124792%\" valign=\"top\"\u003e\n \u003cp\u003eTKA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"82.6955074875208%\" valign=\"top\"\u003e\n \u003cp\u003etotal knee arthroplasty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all those who piloted or completed the survey for your time and expertise. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by the Queensland University of Technology Human Research Ethics Committee, reference number UHREC-2022-4255. Participant consent for participation in the interviews was obtained in writing. \u0026nbsp;For the survey, consent was provided electronically by selecting \u0026lsquo;agree to consent\u0026rsquo; prior to being given access to complete the questions. \u0026nbsp;Consent for the expert panel was provided verbally and recorded with the audio recorder as part of the meeting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish was included in all the above consent procedures. All participants that consented to participate, also consented to publish. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey data used and/ or analysed during the current study are either provided within the manuscript or supplementary materials, or are available from the corresponding author on reasonable request that has ethical clearance. The transcripts and audio-recordings of the interviews and expert panel are not available in their raw form due to potential re-identifiability given the small sample size, however a summary of the data and further detail on coding is available on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by an unencumbered gift to the Queensland University of Technology from the Medibank Foundation. There was no contribution by the funders to data analysis, interpretation, writing or publication of results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors conceived and designed the study. MJA undertook the interviews and undertook initial coding of the transcripts. Consolidation of themes and development of survey questions was done by MJA, RC, and DB, with the online questionnaire created by SS. Survey data was analysed by SS with results reviewed by all authors. Initial draft was written by MJA and LE. \u0026nbsp;Subsequent drafts were reviewed by all authors and significant intellectual contribution was provided by all. \u0026nbsp;All authors reviewed and agreed on the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRC and IH are orthopaedic surgeons with extensive experience in hip and knee arthroscopy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDB, SS, VM, SMM are health economists with an interest in value-based care.\u003c/p\u003e\n\u003cp\u003eMJA, LE, RH are health services researchers with implementation science, public health and health management background\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eOECD. Health at a Glance 20212021.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePabinger C, Geissler A. Utilization rates of hip arthroplasty in OECD countries. Osteoarthritis Cartilage. 2014;22(6):734\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage. 2015;23(10):1664\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eInacio MCS, Graves SE, Pratt NL, Roughead EE, Nemes S. Increase in Total Joint Arthroplasty Projected from 2014 to 2046 in Australia: A Conservative Local Model With International Implications. Clin Orthop Relat Res. 2017;475(8):2130\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAckerman IN, Bohensky MA, Zomer E, Tacey M, Gorelik A, Brand CA, et al. The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030. BMC Musculoskeletal Disorders. 2019;20(1):90.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePalsis JA, Brehmer TS, Pellegrini VD, Drew JM, Sachs BL. The Cost of Joint Replacement: Comparing Two Approaches to Evaluating Costs of Total Hip and Knee Arthroplasty. J Bone Joint Surg Am. 2018;100(4):326\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStargardt T. Health service costs in Europe: cost and reimbursement of primary hip replacement in nine countries. Health Econ. 2008;17(1 Suppl):S9-20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAllen M, Mohammed-Selim, S, Senanayake, S, Blythe, R, Hinchcliff, R, McCreanor, V, Elliot, L, Kularanatna, S, Brain, D, McPhail, S. A scoping review of factors influencing prosthesis selection for knee and hip arthroplasties: perspectives of surgeons in high income countries. PREPRINT (Version 1) available at Research Square [https://doiorg/1021203/rs3rs-3435294/v1]. 2023.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSutherland K, Levesque J-F. Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework. Journal of Evaluation in Clinical Practice. 2020;26(3):687\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWennberg JE. Time to tackle unwarranted variations in practice. BMJ. 2011;342:d1513.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13(1):117.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNg Man Sun S, Gillott E, Bhamra J, Briggs T. Implant Use for Primary Hip and Knee Arthroplasty: Are We Getting It Right First Time? The Journal of Arthroplasty. 2013;28(6):908\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHarris I, Cuthbert A, Lorimer M, de Steiger R, Lewis P, Graves SE. Outcomes of hip and knee replacement surgery in private and public hospitals in Australia. ANZ Journal of Surgery. 2019;89(11):1417\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSharkey PF, Sethuraman V, Hozack WJ, Rothman RH, Stiehl JB. Factors influencing choice of implants in total hip arthroplasty and total knee arthroplasty: perspectives of surgeons and patients. J Arthroplasty. 1999;14(3):281\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaruthappu M, Duclos A, Zhou CD, Lipsitz SR, Wright J, Orgill D, et al. The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis. J R Soc Med. 2016;109(4):147\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXiao Y, Jones A, Zhang BB, Bennett M, Mears SC, Mabrey JD, et al. Team consistency and occurrences of prolonged operative time, prolonged hospital stay, and hospital readmission: a retrospective analysis. World J Surg. 2015;39(4):890\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGagliardi AR, Ducey A, Lehoux P, Turgeon T, Kolbunik J, Ross S, et al. Multiple constraints compromise decision-making about implantable medical devices for individual patients: qualitative interviews with physicians. BMC Med Inform Decis Mak. 2017;17(1):178.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAtsma F, Elwyn G, Westert G. Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems. International Journal for Quality in Health Care. 2020;32(4):271\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBurns LR, Housman MG, Booth RE, Koenig AM. Physician preference items: what factors matter to surgeons? Does the vendor matter? Med Devices (Auckl). 2018;11:39\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVertullo CJ, Grimbeek PM, Graves SE, Lewis PL. Surgeon\u0026apos;s Preference in Total Knee Replacement: A Quantitative Examination of Attributes, Reasons for Alteration, and Barriers to Change. J Arthroplasty. 2017;32(10):2980\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Queensland University of Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prosthesis, Arthroplasty, unwarranted variation, surgeon, selection, decision-making, cost","lastPublishedDoi":"10.21203/rs.3.rs-3439378/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3439378/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere is increasing demand for knee and hip arthroplasties, with considerable health system cost implications. Despite much of the surgical costs relating to the particular prosthesis used, little is known about which factors are most influential for surgeon decision-making, nor is it clear what level of variation may be warranted for clinical reasons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003eA three-stage study was conducted to address the dual objectives of: a) identify factors influencing prosthesis selection for total hip arthroplasty (THA) and total knee arthroplasty (TKA); and b) develop a working definition for what could be considered unwarranted variation in THA and TKA implant selection. A questionnaire was developed and piloted with input from orthopaedic surgeons. This cross-sectional survey was conducted with orthopaedic surgeons across Australia, followed by an expert panel to finalise the working definition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eRevision rates, familiarity with implant, and implant quality, were factors considered a priority when choosing a prosthesis, whilst other factors including cost, were reported to have limited influence. Technological advancement and revision rates were influential for past changes of prosthesis, and strong clinical evidence for future changes. Consensus was reached on a working definition of unwarranted variation that focused on implants with revision rates of 20% or higher compared to published benchmarks. Use of multiple cost thresholds was recommended for defining both narrow and broad definitions of unwarranted variation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFindings from this study provide valuable insights into the decision-making process for prosthesis selection, as well as what surgeons believe might constitute unwarranted variation. This information can be used to progress our understanding of the magnitude and impact of this variation through use of the suggested unwarranted variation definitions, as well as inform strategies to address unwarranted variation in prosthesis selection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence:\u003c/strong\u003e Non-randomised cross-sectional survey – Level 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Not applicable.\u003c/p\u003e","manuscriptTitle":"Factors influencing prosthesis selection and variation: a survey of orthopaedic surgeons in Australia.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-16 17:34:30","doi":"10.21203/rs.3.rs-3439378/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d4daa67-a63c-4f31-b9d7-140efd78051c","owner":[],"postedDate":"October 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":25351494,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2023-10-16T17:34:30+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-16 17:34:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3439378","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3439378","identity":"rs-3439378","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}