JAAOS - 2026-07-01 - Journal Article; Systematic Review
The Effectiveness of Interventions in Orthopaedic Surgeons' Clinical Practice: A Systematic Review.
Banfield NF, Kleinsmith RM, Puckett HD, Cunningham BP, Swiontkowski M
Topics
Key Takeaway
Opioid stewardship interventions achieved 100% statistical significance across all 9 prescribing studies, while cost-reduction interventions succeeded in only 60% of studies and diagnostic ordering interventions in only 29%.
Summary Depth
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Summary
This systematic review evaluated interventions designed to change orthopaedic surgeons' clinical decision making across cost optimization, diagnostic ordering, and opioid/medication prescribing domains. Of 9,065 records screened, 28 studies met inclusion criteria; 24 used educational interventions, 3 used physician reminders, and 1 used an incentive system. Prescribing behavior interventions (n=9, all opioid stewardship) showed 100% statistical significance, cost interventions showed 60% significance including a $694/TKA reduction via surgeon scorecard, and diagnostic ordering interventions showed only 29% significance.
Key Limitation
The predominance of before-and-after designs without control groups across 82% of included studies precludes causal attribution of behavior change to the interventions rather than concurrent external forces such as opioid legislation or payer policy shifts.
Original Abstract
BACKGROUND
Orthopaedic surgeons face increasing pressure to align clinical decision making with evidence-based practices. However, the adoption of such practices can be inconsistent because of variability in surgical techniques, patient factors, and entrenched habits. This systematic review evaluates interventions designed to change orthopaedic surgeons' clinical decision making across cost optimization, diagnostic ordering, and prescribing behaviors.
METHODS
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses and MECIR-adherent search was conducted across seven databases (MEDLINE, PsycINFO, EMBASE, Cochrane Library, Business Source Premier, SPORTDiscus, and Scopus) to identify studies from the United States and Canada reporting interventions aimed at modifying orthopaedic surgeons' clinical decision making. Studies were included if they evaluated changes in practice patterns in at least one of the three domains: procedure costs, orders (tests/procedures), or medication prescribing. Two independent reviewers conducted screening, data extraction, and quality assessment using the Effective Public Health Practice Project tool.
RESULTS
Of 9,065 records identified, 28 studies met inclusion criteria: education (n = 24), physician reminders (n = 3), and incentive systems (n = 1). Most used before-and-after designs (n = 23) and were of moderate quality (n = 21). Three of five studies (60%) on procedure costs demonstrated statistical significance in cost reduction after intervention ( P ≤ 0.05), with the largest from a surgeon "scorecard" initiative ($694 per total knee arthroplasty case, P < 0.001). Four of 14 studies (29%) on diagnostic/procedural ordering demonstrated statistical significance in clinical decision-making change. All nine studies on prescribing behaviors, predominantly opioid stewardship, showed statistically significant clinical decision-making change, including reductions in morphine milligram equivalents and improved guideline compliance.
CONCLUSIONS
Evidence-based interventions, particularly education combined with audit and feedback, can meaningfully shift orthopaedic surgeons' clinical decision making. Sustained change is less well studied, highlighting the need for prospective trials with long-term follow-up. This synthesis provides a framework for designing future interventions that improve adherence to best practices.
LEVEL OF EVIDENCE
Level III.