Patient and surgeon perspectives on shared decision-making in hip and knee osteoarthritis treatment: a qualitative exploratory study.

Patient and surgeon perspectives on shared decision-making in hip and knee osteoarthritis treatment: a qualitative exploratory study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMC Med Inform Decis Mak . 2026 Apr 20;26:203. doi: 10.1186/s12911-026-03503-3 Patient and surgeon perspectives on shared decision-making in hip and knee osteoarthritis treatment: a qualitative exploratory study Trine A Pedersen 1, 2, 7, ✉ , Karina D Steffensen 2, 3, 4 , Martin Lindberg-Larsen 5, 6 , Claus Varnum 1, 2 , Charlotte M Jensen 5, 6 Author information Article notes Copyright and License information 1 Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark 2 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark 3 Center for Shared Decision Making, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark 4 Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Gistrup, Denmark 5 Department of Clinical Research, Clinical Institute, University of Southern Denmark, Odense, Denmark 6 Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark 7 Lillebaelt Hospital, University Hospital of Southern Denmark, Beriderbakken 4, Vejle, 7100 Denmark ✉ Corresponding author. Received 2024 Nov 3; Accepted 2026 Apr 13; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13231628  PMID: 42010654 Abstract Background Navigating the various surgical and non-surgical options for treating osteoarthritis (OA) presents a significant challenge for patients. Determining the optimal treatment involves carefully weighing each option’s benefits, risks, and consequences. What constitutes the “best treatment”—whether surgical or non-surgical—is often subjective and shaped by individual circumstances and personal preferences. While shared decision-making, supported by in-consult patient decision aids, has proven valuable in helping patients and clinicians clarify values and choose the most suitable treatment, its integration into orthopaedic consultations remains limited. This study aims to identify the key decision-making factors relevant to patients and surgeons in the context of hip or knee OA. Methods This qualitative exploratory study involved 15 field observations guided by the five-item Observing Patient Involvement instrument and two focus group discussions (FGs) with patients ( n = 14) and their relatives ( n = 4) and two (FGs) with orthopaedic surgeons ( n = 12). The data were analysed using thematic analysis. Results Field observations revealed variations in consultation practices, particularly in duration, information sharing, and patient-surgeon dynamics. FGs identified six main themes influencing treatment decisions. Patient-derived themes emphasized the critical role of the patient-surgeon relationship in building confidence, the importance of weighing treatment options, and the long decision-making process that often led patients to delay their appointment with the surgeon until they felt surgery was their only option. Surgeon-derived themes highlighted the need for more standardised information, scepticism about the shared decision-making approach, and concerns that patients with predefined treatment decisions might hinder the shared decision-making process. Conclusions This study underscores the complexity of decision-making for patients with severe hip or knee OA, highlighting factors such as symptom severity and trust in healthcare providers. Its findings suggest a need for a more standardised approach to information delivery and the implementation of shared decision-making to improve patient satisfaction with joint replacement outcomes. Introducing in-consult patient decision aids earlier in the decision-making process could help prepare and inform patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-026-03503-3. Keywords: Shared decision-making, Patient decision aid, Hip osteoarthritis, Knee osteoarthritis, Total joint replacement, Qualitative research, Focus group discussion, Field observations Background Shared decision-making (SDM) is an established approach recommended for preference-sensitive clinical decisions, facilitating patient engagement in the decision-making process [ 1 ]. It involves a collaborative partnership between patients and clinicians, where patients express their goals, concerns, and preferences while clinicians provide evidence-based information on available treatment options [ 2 ]. Osteoarthritis (OA) of the hip or knee is a common condition, particularly among older adults, significantly impacting daily life through pain, disability, and reduced quality of life (QoL) [ 3 , 4 ]. Current clinical guidelines recommend non-surgical treatments as primary options, including patient education, exercise, and painkillers [ 4 ]. However, when these prove insufficient, surgical interventions, such as total hip replacement, total knee replacement, or unicompartmental knee replacement, are advised [ 5 ]. The decision-making process in OA management is complex, involving various factors such as patient and surgeon preferences, symptom severity, X-ray results, age, comorbidities, and QoL [ 6 ]. Dissatisfaction often arises from a mismatch between healthcare providers’ recommendations and patients’ unrealistic expectations regarding surgical outcomes [ 7 , 8 ]. Engaging patients in their treatment decisions can enhance their sense of empowerment, foster ownership of their choices, and improve adherence to treatment plans, ultimately leading to better treatment alignment with individual needs. For this to occur, patients must actively seek relevant information, value being consulted on treatment options, and appreciate the opportunity to participate in decision-making [ 9 – 11 ]. A recent Cochrane review analysing data from 209 randomised controlled trials demonstrated that patient decision aids (PtDAs) significantly enhance the quality of patients’ decisions and decision-making processes [ 8 ]. Despite the benefits of SDM, several barriers to its implementation persist. Khatri et al. [ 12 ] found that while surgeons value informed patients, concerns about overwhelming them with information often lead to omitting critical details. Conversely, patients believing themselves well-informed before their consultation preferred to avoid additional information. This dynamic perpetuates misconceptions among both parties, leading to suboptimal decision-making based on incomplete knowledge. While the role of SDM in OA treatment decisions is acknowledged, there is a lack of research specifically examining the factors influencing decision-making in patients with hip or knee OA [ 13 , 14 ]. In order to address this gap, this study explores the key decision-making factors from the perspectives of patients, their relatives, and surgeons. Methods Design This qualitative exploratory study [ 15 , 16 ] reports on the initial phase towards developing and testing two in-consult PtDAs in a following study [ 16 ]. It was conducted through structured field observations [ 17 ] and Focus group (FGs) discussions [ 18 ] to create an in-depth and comprehensive understanding of the factors influencing treatment decisions from several perspectives. In order to avoid the potential consequences of a hierarchical power imbalance [ 18 ], the FGs were divided into two categories: patients and their relatives and surgeons (Fig. 1 ). The primary author (TAP), a PhD student with prior experience in qualitative research and conducting interviews, conducted the observations and led the FGs in close collaboration with one of the supervisors CMJ with extensive experience within qualitative research. This study is reported according to the Consolidated criteria for Reporting Qualitative Research (COREQ) checklist [ 19 ]. Fig. 1. Open in a new tab Illustration of data generation and analyses Setting Participants were recruited from two orthopaedic departments specialising in hip and knee replacements at two university hospitals in the Region of Southern Denmark [ 20 ]. Denmark’s healthcare system provides universal services funded primarily through general taxation [ 20 ]. General practitioners (GPs) act as gatekeepers, with patients typically requiring a GP referral to access hospital care. The pathway for patients in this study generally begins with an assessment by a GP. If OA is diagnosed, the GP follows international guidelines [ 21 ], recommending initial non-surgical treatments such as pain medication, structured physical training, weight loss, or cortisone injections. If symptoms persist or worsen, indicating severe OA, patients are referred to an orthopaedic outpatient clinic [ 20 ]. Participants and recruitment The participating surgeons specialized in hip and knee replacements and were included according to a planned future randomised controlled trial www.ClinicalTrials.gov ( NCT05972525 ), Date of registration: 06.08.2023 [ 16 ]. Patients and relatives were purposefully sampled to ensure broad demographic representation in the various treatment stages (surgical, non-surgical, and pre- and post-operative) and affected joints (hip or knee). This approach provided variation in perspectives and allowed us to capture a wide range of experiences and factors influencing the decision-making process. After consultation with an orthopaedic surgeon at the outpatient clinics, project nurses invited patients and their relatives to participate in the FGs [ 17 ]. Data collection Structured field observations Field observations with moderate participation, as described by Spradley [ 17 ], were conducted between October and December 2022 until data saturation was reached at 15 consultations. The observations were conducted in two departments using a pre-structured guide based on the validated five-item Observing Patient Involvement instrument (OPTION 5), which was developed to assess SDM between clinicians and patients [ 22 ]. This instrument provides a structured framework for evaluating SDM behaviours, thereby minimising observer bias and distinguishing SDM from general patient-centred communication. The guide was supplemented with an open, descriptive section for detailed observation notes. The results from the field observations informed the development of a semi-structured interview guide for the FGs (see Additional file 1 for details). Focus group discussions Four FGs were conducted across the two departments between November 2022 and February 2023 to ensure broad representation across sites and participant groups, including geographical variation. We found no need for additional FGs, as no new overarching themes emerged in the final two sessions. The FGs were conducted using the semi-structured interview guides; one for patients and their relatives and one for surgeons. The development of these guides was informed by preliminary field observations in the outpatient clinics, which helped identify relevant themes and practical issues to explore further. TAP drafted the guides in close collaboration with CMJ, drawing on both clinical expertise and insights from the literature. In addition, the topic guides were theoretically informed by the Shared Decision-Making (SDM) three-talk model [ 23 ], providing a structured yet flexible framework to support discussions on decision-making processes. Each FG for patients and their relatives began with a brief PowerPoint presentation, during which the concept of SDM was introduced. This introduction was followed by a general opening question to initiate the discussion, supported by additional specific and open-ended questions. The guide included questions about making a treatment decision, the timing of this decision, key topics they felt were important to discuss during the decision-making process, and participants’ perceptions of their involvement in the decision-making process (see Additional file 2 for details). Each FG session with the surgeons began with an introduction to the concept of SDM and a generic PtDA template [ 24 ]. Surgeons were then asked to outline relevant treatment options, discuss the advantages and disadvantages of each, describe their current practices in sharing information, and identify critical information needed during treatment decision-making consultations. Additionally, preliminary findings and topics from the FGs with patients and their relatives were shared to stimulate discussion and reflection among the surgeons and explore their perspectives on factors influencing patients’ treatment decisions (see Additional file 3 for details). All FGs emphasized active listening, allowing periods of silence to encourage participants to express unconscious or repressed thoughts and highlight important factors influencing the SDM [ 25 ]. The FGs were audio-recorded. In addition, CMJ wrote down key points throughout the discussions. Data analysis The audio recordings were transcribed, and all identifiable information was removed to ensure anonymity. The transcripts were organized using NVivo (version 11.4; QSR International Pty Ltd., Warrington, UK). A thematic analysis was conducted in two stages: first on the data from the field observations and then on the data from the FGs. The data from the FGs discussions were analysed separately for patients and their relatives and surgeons. The analysis was led by TAP throughout all phases, with ongoing discussions with CMJ. The analysis followed the reflexive approach outlined by Braun and Clarke [ 26 ] and included the following phases: Each dataset was read line by line to familiarize oneself with the data. Initial codes were created for text fragments in each dataset. These codes summarized or described the content of each fragment, and a comprehensive list of codes was compiled across each dataset. The codes were organised into potential subcategories and categories presenting the themes within each dataset. Themes were generated inductively from the data through an iterative process of coding and categorisation, rather than being predefined. The themes were reviewed and refined by revisiting the coded text fragments associated with each theme to ensure they accurately represented the data. The entire dataset was re-examined in collaboration with CMJ to confirm that the themes reflected the core aspects of each dataset. The identified themes were presented, refined, and discussed with all co-authors. Finally, the results were documented, including descriptive quotes from patients (P#) and surgeons (S#). An example of the analysis process is illustrated in Table 1 . Table 1. Examples of the analysis procedures on patient data Key phrases Code Subcategory Category Theme “I don’t have a life; it’s passing by on the horizon , and I can’t keep up.” “Yes , I have been through the whole process , and there is indeed no medication that helps; there simply isn’t any.” “So I have no choice; it’s been done for me.” “Well , it can’t get worse than it is now… I guess I’ll have to take the chance… that’s just how it is.” Feeling checkmate When the limitations and pain force you to choose Checkmate: you can only win when it can’t get any worse. Patients’ internal evaluation process “A lot of information about the risks of surgery didn’t affect me at all because I was so certain that I needed surgery. I was in so much pain , and I was taking all those pills , but they didn’t help at all , so I just didn’t want to keep doing that. I was sure I needed to have the surgery.” “Well , it wouldn’t make any sense to me to hear a lot about the risks because once you’ve made the decision , it doesn’t really matter…” No need to hear about risks and alternatives; they have already made up their mind. I have made up my mind no matter what. No need for a lot of information; it won’t change my mind. “I really don’t think that people at my age can afford to be walking around in so much pain… all the things I’d like to do , I simply can’t because of a couple of bad knees—NO! I honestly think it’s affecting me mentally , and I think you miss out on a lot of things you could do if you had a pair of decent knees.” “What was really decisive for me was that my quality of life has become so poor , I can no longer do what I used to… and then you have to ask yourself , what’s it worth? To not go through with the operation… I have nothing to lose… I’ve reached a point where I can only gain by going through with the surgery.” Decreasing quality of life forces you to make a decision. Decreasing quality of life pushes the realization that surgery is perhaps the only option to regain some level of functionality. The quality of life decides when you are ready for surgery. Open in a new tab Results Field observations A total of 18 field observations were conducted, including 3 pilot observations and 15 that were included in the analysis. In total, 12 of 16 eligible surgeons were observed. The field observations revealed variability in consultation practices, patient-surgeon interactions, and consultation durations, which ranged from 10 to 45 min, regardless of the treatment chosen. Four main themes emerged from the analysis: I. A lack of standardized information guidelines for treatment options: This led to variability in the level of information provided, which depended on the surgeon and the daily consultation schedule. II. Passive roles of patients during consultations: Some patients played a passive role in the decision process, primarily responding to questions from the surgeon rather than actively participating and being involved. III. Decisions made pre-consultation by the patients: Many patients had already decided on their treatment before consulting with a surgeon, limiting the impact of the consultation on their decision. IV. Disagreement with surgeons’ treatment decisions: Some patients appeared to disagree with or did not comprehend the treatment decision made by the surgeons, especially when the decision involved non-surgical options. Focus group discussions Twelve orthopaedic surgeons participated in the FGs, equally divided between hip and knee surgeons. The FGs were arranged at each of their respective departments to facilitate participation. Thirty patients and their relatives were invited, and 22 accepted the invitation (Fig. 2 ). However, four failed to participate, resulting in 18 participants: 14 patients and 4 relatives (Table 2 ). They were divided into two groups, following recommendations that FGs should consist of 6–10 participants to provide a context conducive to exploring and generating nuanced discussions [ 27 ]. Each FG lasted approximately 90 min and they were conducted in meeting facilities at the hospital. All participants attended in person. Fig. 2. Open in a new tab Flowchart of the inclusion of patients and their relatives Table 2. Participants’ characteristics Patients n = 14 Relatives n = 4 Surgeons n = 12 Gender , n Male Female 7 7 2 2 10 2 Age , n < 50 51–60 61–70 71–80 > 80 - 4 4 6 - - 1 3 - 7 2 3 - - Joint specialty , n Knee Hip 8 6 2 2 6 6 Income status , n Working Pension, etc. Other 6 8 - 2 2 - 12 - - Education , n ≥ College graduate Some college High school or less Vocational education Other - 2 6 6 - 1 2 1 12 - - - - Treatment scheduled , n Operated Waiting on an operation Other treatment 6 5 3 1 2 1 Working position , n Specialty doctor Consultant Professor 3 8 1 Open in a new tab Participants included in the four FGs Relatives who participated in the FGs primarily supported and expanded on patients’ statements, for example by providing additional details or personal perspectives. However, they did not introduce new overarching themes beyond those raised by patients. Three main themes emerged from the FGs with patients and their relatives: I. Influence of the surgeon-patient relationship. II. Reluctance and delay in decision-making. III. Patients’ internal evaluation process. Three main themes emerged from the FGs with surgeons: I. Pre-consultation decision-making. II. The surgeon’s perspective of tailored vs. standardized approaches. III. The surgeon’s conditional engagement in SDM. Themes emerging from the patients and their relatives Influence of the surgeon-patient relationship Several patients emphasised the importance of having a positive relationship with their surgeon when making treatment decisions. They felt that good chemistry with their surgeon enhanced their confidence in the decision-making process since they needed to feel secure and confident when choosing a treatment, as elaborated by one patient: He [the surgeon] tried to understand what was important to me , what I wanted , and then together , I felt that we made a decision… Feeling listened to made me feel safe in the decision. (P3) In addition, several patients emphasized the importance of meeting the surgeon who would be performing the joint replacement (JR), as this contributed to the sense of security in the decision-making process, as expressed by one patient: It was comforting to meet the doctor who was going to perform the surgery; it gave me a sense of reassurance. (P12) Reluctance and delay in decision-making Nearly all patients mentioned that they chose to delay their appointment with an orthopaedic surgeon until they believed surgery was the only option. This decision was driven mainly by persistent pain and physical limitations, leading many patients to be resolute in their decision before consulting a surgeon. Several patients shared similar experiences, such as: I didn’t want surgery , but when your quality of life is so low , it forces you to make a decision. (P11) As their resilience and determination to avoid surgery diminished, patients reached a point where they felt they no longer needed extensive information from the surgeon. This shift highlighted a stage where they felt compelled to proceed with surgery based on their assessments rather than wait for further professional input. Some even described their decision as follows: Putting the decision off until the pain interferes too much with your life… Nothing can change my mind , and the surgeon can tell me whatever he wants , nothing will change my decision. (P3) Patients’ internal evaluation process Patients described a long internal process of weighing the advantages and disadvantages of various treatment options. The decision to undergo JR was often seen as overwhelming and challenging, prompting patients to seek guidance and reassurance from the experiences of relatives or by researching online for information. Various patients even documented the advantages and disadvantages in writing before their consultation. Several patients described how they had been grappling with the internal decision-making process for years, as one patient explained: I have weighed the options against each other , and advantages and disadvantages… I’ve been doing that for several years , you know. (P8) Despite being considered eligible for JR by their surgeon, some patients chose alternative treatments or no treatment due to concerns about the surgery’s outcomes and the fear of potential complications. They expressed how they tried to seek confidence in their decision by consulting with their (friends and relatives), or until their pain became intolerable, as one patient expressed: Although I know that experiences vary greatly from person to person , it is still helpful to gain some perspective. It helped me make the decision. (P1) However, nearly all patients described delaying their JR decision because they needed additional information or reassurance about the expected outcomes. This observation underscored the importance of surgeons tailoring communication to provide patients with the necessary comfort and confidence to make informed decisions. As one patient expressed: I went through the whole process… I tried everything because I couldn’t make up my mind. Yes , it was a big decision for me , I think. It was difficult. (P13) Themes emerging from the surgeons Pre-consultation decision-making The surgeons discussed the challenges when patient preferences diverged from their professional recommendations. They all had experiences where patients believed they needed JR because of their GP’s recommendation, but the clinical assessment suggested otherwise. They found it quite challenging to balance these situations since they aimed to ensure patient satisfaction and alignment with the treatment decision, as one surgeon expressed: When the patients are mentally prepared for a JR , it’s difficult to explain to them that an operation is not the right choice. (S8) They all stressed the importance of discussing risks and complications to ensure mutual understanding before scheduling JR. However, they noted that in cases where patients were determined, none of them changed their decision: I have never experienced one single patient who decided against surgery after I told them about the risk of infection. I always inform them , but I have never encountered someone who then says they don’t want the operation. (S10) Several surgeons noted that many patients who visited the outpatient clinic typically aimed to discuss JR, with their primary focus on arranging the surgery. This situation is reflected in the following statement: You could say that most patients , when they first come to see you , are mentally decided that they want surgery. However , they won’t come to the outpatient clinic if they are afraid of infection and hospitals. The consequence is clear: when they come to the outpatient clinic , it’s to discuss surgery. (S3) However, they emphasized that not all patients want surgery. Several patients were only seeking an expert opinion, even if their X-rays and clinical tests suggested severe OA. Some expressed that if a patient is not prepared for surgery, it is crucial to align mutual expectations early in the consultation: Not all patients want surgery; they just want an expert opinion , even though they are candidates for a prosthesis. (S1) The surgeon’s perspective of tailored vs. standardized approaches The surgeons explained that they had developed their methods for consultations and information delivery. Without standardized guidelines or checklists, they had the flexibility to tailor their approach to conveying information to the individual patients as they deemed appropriate, as one surgeon expressed: We have all developed our methods and information presentations. (S7) Awareness of this issue during the FGs led surgeons to express concern about altering their approach to patient information and developing more generic communication. However, several surgeons emphasized the importance of a consistent approach to information sharing, noting that it could enhance reliability and build trust, both among colleagues and between surgeons and patients. As one surgeon explained: I find it unsettling how we communicate without any standardized guidelines , what they [my colleagues] have said and not said to the patient. I see this as a problem if I am the one performing the surgery while my colleague has provided the information. It’s also about trust. (S9) The surgeon’s conditional engagement in SDM Patients in consultations were often firm in their treatment decisions for OA, usually due to having delayed the decision for an extended period or having heard positive outcomes from relatives. Consequently, many patients arrived with pre-determined treatment decisions, making it essential for surgeons to manage their expectations about the anticipated outcomes effectively, as illustrated by one surgeon: Many patients have already decided before they are talking with me [orthopaedic surgeon]; it is therefore important to inform them about what to expect when they get a prosthesis. (S1) However, the surgeons stated that, unlike more straightforward medical requests, JR is planned according to symptom severity, radiological findings, age, comorbidities, and QoL and is not something patients can order or demand. Instead, they emphasized that the decision involves a complex evaluation process, with the final decision resting with the healthcare professionals. As one surgeon stated: When patients have already decided on a treatment , before seeing me , I need to be sure they know all their options that I am recommending. (S5) Several surgeons expressed concerns about introducing the SDM concept, stating that SDM depends on their agreement. If they did not agree with their patient’s treatment choice or wishes, SDM would not be applicable. As one expressed: No shared decision-making if we don’t approve that surgery is needed… (S9) The surgeons highlighted numerous instances where patients were convinced that surgery was necessary, but clinical assessments did not support this belief, emphasizing the critical role of clinical criteria in surgical decision-making. While patients may feel that surgery is essential, this is not always the case, as illustrated by the following quote: You cannot order surgery (S2) Discussion Various factors influence patients’ decision-making when choosing between surgical and non-surgical treatments for hip or knee OA. By combining field observations and FGs, we gained insights into the patient decision-making process, along with perspectives from their relatives and orthopaedic surgeons. Our study highlighted considerable variability in consultation practices, particularly in surgeons’ consultation styles and the amount of information provided, underscoring the complexity of implementing SDM in this context. Many patients had already progressed substantially in their decision-making before their consultations in the orthopaedic outpatient clinic, which both observations and FG accounts confirmed, raising questions about the effectiveness of in-consult PtDAs. The field observations and FG data thus demonstrated convergence and complemented each other, with no findings in contrast. In our study, patients generally expressed a high level of trust in their orthopaedic surgeons, acknowledging this trust as an important factor in managing their uncertainty about treatment options. Field observations, however, indicated that patients often assumed a relatively passive role during consultations, focusing primarily on the surgeon’s explanations and recommendations while seldom posing questions themselves. This dynamic aligns with Berry et al. [ 28 ], who describe how patients in decision-making contexts may hesitate to voice concerns and instead defer to clinicians as authority figures. While our findings suggest that trust was the predominant driver of this pattern—particularly among patients who had already reached a decision in favour of surgery—such dynamics could also contribute to limited patient engagement in some cases. However, by building the consultations explicitly around the three steps of SDM (1) choice talk – making patients aware that a decision needs to be made, (2) option talk – presenting the different treatment options with their pros and cons, and (3) decision talk – supporting patients in deliberating and expressing their preferences, could potentially change this dynamic [ 29 ]. By following these steps, patients are invited – or even required – to participate more actively in the conversation, which may help balance the interaction and strengthen their role in the decision-making process., Similarly, Frongillo et al. [ 30 ] examined the influence of provider recommendations on patient involvement. They suggested that discussions about alternative options and patient preferences tend to decrease once a healthcare provider offers a recommendation. This tendency often leads patients to rely heavily on the surgeon’s opinion, following recommendations without fully exploring other treatment options. Furthermore, in a qualitative study exploring patients’ motives for choosing surgery, Traumer et al. [ 31 ] found, similar to our study, that patients’ decisions regarding OA treatment were strongly influenced by their social networks, with positive experiences raising expectations and negative ones causing hesitation. Our study highlights the complexity of decision-making for patients with hip or knee OA, as they often struggle to determine the most appropriate treatment or timing for JR. As noted by Barker et al. [ 14 ], who synthesized qualitative research to understand the complexities of treatment decision-making for OA, some patients view surgery as the only viable solution, while others hesitate due to perceived risks or hold unrealistic expectations. Our study observed a similar pattern, with many patients arriving at consultations seeking confirmation for JR, having already made up their minds. Similarly, in a qualitative study exploring patients’ experiences with TKA, Smith et al. [ 32 ] described how patients ultimately reached a state of “readiness for surgery.” This pivotal moment arises when their condition leads to a perceived necessity for surgery, motivated by hopes of improved QoL. Our study found that this mind-set significantly impacted patients, making them less open to discussing non-surgical alternatives, regardless of how many treatments they had previously attempted. Their strong confidence in the benefits of JR overshadowed perceived need for further information. The observed dynamics pose a challenge highlighted by the surgeons in our study, who emphasized that JR is not a procedure that can simply be requested or demanded; it must be clinically justified. Furthermore, the disconnect between patient expectations and the clinical criteria for surgery further underscores the complexities of implementing SDM alongside an in-consult PtDA. In preference-sensitive situations, such as treatment decisions for severe OA in the hip or knee, careful consideration of both surgical and non-surgical options is crucial [ 9 ]. While surgeons determine when JR is clinically appropriate, patient-centred recommendations can only be made after thorough discussions, ensuring that expectations are aligned and that patients achieve satisfaction with their treatment outcomes. Given these complexities, the timing of introducing PtDAs seems crucial. Currently, Danish healthcare practice integrates PtDAs during in-hospital consultations [ 33 ]. However, our findings suggest that these tools may be more effective if introduced earlier—either before consultations or during the early stages of OA treatment—in collaboration with the patient’s GP. This proactive approach could encourage patients to explore non-surgical options more thoroughly before considering surgery, potentially reducing their resistance to non-surgical alternatives and fostering more detailed discussions as facilitated by PtDAs. Our findings underscore the multifaceted nature of the decision to undergo JR, shaped by prior treatments, information gaps, social influences, and the need to manage patient expectations. Addressing these factors through early SDM and timely introduction of PtDAs may improve patient satisfaction and alignment between patient expectations and clinical recommendations. Strengths and limitations One strength of our study is its methodological approach, which combines field observations with FGs. By integrating these approaches, we were able to capture both real-time dynamics and retrospective reflections, providing a more exploratory understanding of the decision-making process and offering a nuanced perspective on the factors influencing both patient and surgeon views. While our study was well suited to explore the decision process during the consultation, broader research including primary care perspectives would be valuable to capture the full decision-making trajectory. Another strength of our study is its inclusion of patients and surgeons from two hospitals in the Region of Southern Denmark, allowing for a broader perspective on the decision-making processes across different healthcare settings. A limitation of our study is that its participants may not fully represent the general population of patients with severe OA in the hip or knee, since those who chose to participate in the FGs are likely more motivated and empowered than those who declined. Therefore, the risk of selection bias exists. In addition, many patients with OA have been raised in a hierarchical society, which fosters a strong trust in the healthcare system and the authority of surgeons. This cultural context may have influenced their responses, and some perspectives might have been elicited more effectively through one-to-one interviews conducted in patients’ homes, where accessibility and privacy could encourage more personal reflection. However, this would have come at the expense of the group interaction and collective sense-making that are key strengths of FGs in exploring SDM. Conclusions Our study identified key decision-making factors for patients and surgeons dealing with hip or knee OA, such as symptom severity, trust in surgeons, exclusion of non-surgical options, and the influence of social networks. Many patients tend to postpone JR decisions about JR until they think that no alternatives remain, often arriving with pre-determined choices at the outpatient clinic. Our findings indicate a need for standardised information from surgeons and earlier implementation of PtDAs to improve patient understanding and satisfaction, foster trust, and support SDM before orthopaedic consultations. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (38.2KB, docx) Acknowledgements We thank the participating patients, their relatives, and the orthopaedic surgeons who contributed to the FGs at the Department of Orthopaedic Surgery, Lillebaelt Hospital – Vejle, Denmark, and the Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense and Svendborg, Denmark. We also thank the local project nurses in the outpatient clinics for their role in patient enrolment and the Open Patient Data Explorative Network (OPEN) for their support in data management and providing access to NVivo and OPEN storage. Abbreviations FGs Focus group discussions GP General practitioner OA Osteoarthritis PtDA Patient decision aid SDM Shared decision-making JR Joint replacement QoL Quality of life Author contributions TAP, KDS, MLL, CV, and CMJ supervised the study and contributed to its design. TAP conducted the study and performed all observations, interviews, and analyses. CMJ contributed as a qualitative expert in the FGs, analysis, and theme selection. During the fifth phase of the analysis, themes were presented, refined, and discussed among all authors. TAP wrote the initial draft of the manuscript, and KDS, MLL, CV, and CMJ revised and approved the final version. Funding Open access funding provided by University of Southern Denmark. External funding for this study was provided by the Region of Southern Denmark (grant number 22/26219) and the Research Council at Lillebaelt Hospital. The funders had no involvement in the design, execution, analysis, or interpretation of the study. Data availability The datasets used and/or analysed during this study are available from the corresponding author upon reasonable request. Declarations Ethical approval This study was conducted according to the ethical standards of the institutional and national research committees, as well as the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written consent was obtained from all participants. Data collection and processing were approved by the Region of Southern Denmark (Journal No. 22/9955). According to the Danish Health Research Ethics Committee, this study did not require further approval (project ID: S-20200137). The data were stored in the Open Patient Explorative Network, following the European General Data Protection Regulation. Consent for publication Not applicable. Competing interests CV received travel expenses from Stryker paid to the institution that were unrelated to this study. All other authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Zikmund-Fisher BJ, Couper MP, Singer E, Levin CA, Fowler FJ Jr., Ziniel S, et al. The DECISIONS study: A nationwide survey of United States adults regarding 9 common medical decisions. Med Decis Mak. 2010;30:20–34. 10.1177/0272989x09353792. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Dawn S, Légaré F. Engaging patients using an interprofessional approach to shared decision making. Can Oncol Nurs J. 2015;25(4):455–69. [ PubMed ] [ Google Scholar ] 3. 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Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1 (38.2KB, docx) Data Availability Statement The datasets used and/or analysed during this study are available from the corresponding author upon reasonable request. Articles from BMC Medical Informatics and Decision Making are provided here courtesy of BMC ACTIONS View on publisher site PDF (1.6 MB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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