Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

Key Points

1. No existing patient decision aid is available for Achilles tendon ruptures that adheres to the international standards.
2. This tool would likely be useful to spark discussions openly with your patients about their options.

BACKGROUND & OBJECTIVE

Patient decision aids and their development have been a burgeoning area of research and development. There are international guidelines (International Patient Decision Aids Standards – IPDAS) around the development and testing of patient decision aids, but not one for Achilles tendon Ruptures that adheres to these guidelines.

Achilles tendon ruptures are a significant problem with between 2-35 per 100,000 per annum (1,2). Care commonly splits between Surgery or Conservative care and there is much debate around which is best, leaving patients unsure which to choose – assuming they have an option.

The objective of this study was to develop and user-test a patient decision aid which portrays the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures.

Achilles tendon ruptures are a significant problem with between 2-35 per 100,000 per annum.

This tool could be given to patients whilst in the waiting room for their post rupture follow up and then be used as a basis for discussion.

METHODS

• The study used a mixed methods approach to develop and user test the Patient decision aid.

• The decision aid can be seen here: https://bmjopen.bmj.com/content/bmjopen/suppl/2023/06/14/bmjopen-2023-072553.DC1/bmjopen-2023-072553supp001_data_supplement.pdf

• The draft decision aid was developed by a steering group using their knowledge and existing patient decision aids before being testing on/with clinicians working with people with Achilles tendon ruptures or people who had sustained an Achilles tendon rupture.

• This used semi-structured interviews and questionnaires, the interview schedules and questionnaires are available in the supplementary material.

• The feedback from assessors was used to redraft the decision aid and assess acceptability.

• Analysis used iterative cycles to allow redrafting of the decision aid and reflexive thematic analysis using an inductive approach for the interviews.

RESULTS

• 18 health professionals were interviewed (13 Physiotherapists, 3 Orthopaedic surgeons, 1 chiropractor and 1 sports medicine physician).

• 15 patients were recruited who had suffered an Achilles tendon rupture. Interestingly the average patient age was 30 (29-37) and had 33% females with 80% born in the USA.

• Most health professionals ‘strongly agreed’ or ‘somewhat agreed’ with statements on the utility, comprehensibility, ease of use and potential clinical benefit of the decision aid.

• Most patients rated each aspect of the decision aid as ‘excellent’ or ‘good’ and agreed with the amount of information and length of the decision aid.

• The decision aid covers core domains:

  • Who it is for
  • What treatment options are considered
  • Comparison between surgery and non-surgical management – outcome and risks
  • Summary of benefits and harms
  • Questions to consider when talking with your health professional

LIMITATIONS

• Whilst the tool has been developed with key stakeholders, we do not know how it influences patient decisions in the real world and research needs to test this. However, there are implications for this, especially in countries with national health schemes where the cost of patients opting for surgery may quickly start to spiral and cause issues.

• The study recruited through social media and having done this numerous times myself, you tend to get the more health literate individuals which may influence the direction of the decision aid development and feedback along with the level of reading ability.

• The age for Achilles ruptures included in this study was 30 years old, whereas the typical age we would see Achilles ruptures would be 47 years old (based on over 1000 patients). This again may influence the tools development and information contained.

CLINICAL IMPLICATIONS

The tool could be used in clinical practice relatively quickly and I would encourage this, it should be given to patients whilst in the waiting room for their post rupture follow up and then be used as a basis for discussion.

Where possible, local re-rupture rates should be discussed openly with patients as this may be very different from those contained in the decision aid. For example, in our local hospital based on over 1000 people’s data, re-rupture appears to be around 2.8% and normally occurs in younger patients not following protocol. However, it appears to be relatively equal across surgery and conservative care.

It is also important to discuss the financial implications of their decision in healthcare environments where the patient needs to pay.

I personally would add to the tool about the ability of the tendon to heal well with conservative care. Many patients and clinicians struggle to understand how the tendon could heal without surgery. In my experience if surgery is an option, they take it. Therefore, there needs to be something about education of healing in your clinical discussion/interaction and ideally on this tool.

+STUDY REFERENCE

Gan J, McKay M, Jones C, Harris I, McCaffery K, Thompson R, Hoffmann T, Adie S, Maher C, Zadro J (2023) Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study. BMJ open, 13(6).

SUPPORTING REFERENCE

1. Lemme, N.J., Li, N.Y., DeFroda, S.F., Kleiner, J. and Owens, B.D., 2018. Epidemiology of Achilles tendon ruptures in the United States: athletic and nonathletic injuries from 2012 to 2016. Orthopaedic journal of sports medicine, 6(11), p.2325967118808238.
2. Huttunen, T.T., Kannus, P., Rolf, C., Felländer-Tsai, L. and Mattila, V.M., 2014. Acute Achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. The American journal of sports medicine, 42(10), pp.2419-2423.