# Facilitators and barriers to the use of a personalised digital decision aid in total knee replacement consultations: insights from patients and orthopaedic surgeons – an interview study

## TL;DR

This study explores how a digital tool helps patients and surgeons make better decisions about knee replacement surgery by improving communication and shared decision-making.

## Contribution

The study provides new insights into the use of a personalized digital decision aid in total knee replacement consultations through patient and surgeon interviews.

## Key findings

- Both patients and surgeons found the EKIT tool improved shared decision-making and communication.
- Patients who were already decided felt more confident, while undecided patients became more informed.
- Barriers included time constraints and varying patient needs, but these can be addressed.

## Abstract

A substantial proportion of patients remain dissatisfied following total knee replacement (TKR), possibly due to a lack of standardised indication criteria and inadequate incorporation of patients’ preoperative expectations. Therefore, a practice guideline for TKR indication was developed to ensure the careful selection of patients suitable for this procedure. Based on this guideline, we developed a personalised digital decision aid (EKIT tool) to support implementing its recommendations and to improve shared decision-making (SDM) in routine care. This study explored patients’ and orthopaedic surgeons’ perceptions of the EKIT tool’s facilitators and barriers.

This descriptive qualitative study was nested in a randomised controlled trial that assessed the effectiveness of the EKIT tool. We conducted semi-structured telephone interviews with patients considering TKR and orthopaedic surgeons, focusing on themes such as usability, comprehensibility, and perceived usefulness, which we used to identify facilitators and barriers of the EKIT tool. The interviews were transcribed verbatim and analysed using qualitative content analysis.

Seventeen participants were interviewed: nine patients and eight orthopaedic surgeons. Both groups highlighted the EKIT tool’s positive impact on SDM as a major facilitator. The orthopaedic surgeons emphasised that the EKIT tool enhanced the implementation of a structured, patient-centred and guideline-based consultation, facilitated clearer communication regarding patients’ expectations and included a thorough consideration of their possible achievement by TKR. The patients also emphasised the importance of addressing individual expectations during consultations. Those patients who had already made their decision before the consultation reported lower perceived usefulness of the EKIT tool but felt validated and more confident in their decisions. Main barriers reported by the orthopaedic surgeons were the time required and patient-related factors such as heterogeneous information needs and moderate health literacy. Some patients felt overwhelmed by the amount of health information provided.

The EKIT tool has great potential for patients and orthopaedic surgeons to improve SDM in TKR consultations, appears to increase an informed decision for patients who are undecided, and increases confidence for patients who have already decided. All barriers can be addressed, leading to an optimised EKIT tool.

The online version contains supplementary material available at 10.1186/s12913-025-13351-y.