Exploration of Surgeon Motivations in Management of Abdominal Wall Hernias: A Qualitative Study

IMPORTANCE: Although evidence-based guidelines designed to minimize health care variation and promote effective care are widely accepted, creating guidelines alone does not often lead to the desired practice change. Such knowledge-to-practice gaps are well-recognized in the management of patients with abdominal wall hernia, where wide variation in patient selection and operative approach likely contributes to suboptimal patient outcomes. To create sustainable, scalable, and widespread adherence to evidence-based guidelines, it is imperative to better understand individual surgeon motivations and behaviors associated with surgical decision-making. OBJECTIVE: To evaluate the systematic application of the Theoretical Domains Framework (TDF) to explore motivations and behaviors associated with surgical decision-making in abdominal wall hernia practice to help inform the future design of theory-based interventions for desired practice and behavior change. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study used purposive sampling to recruit 21 practicing surgeons at community and academic hospitals from 5 health regions across Michigan. It used interviews consisting of clinical vignettes for highly controversial situations in abdominal wall hernia repair, followed by semistructured interview questions based on the domains of the TDF to gain nuance into motivating factors associated with surgical practice. Patterns within the data were located, analyzed, and identified through thematic analysis using software. All data were collected between May and July 2018, and data analysis was performed from August 2018 to July 2019. MAIN OUTCOMES AND MEASURES: Factors associated with decisions on the surgical approach to abdominal wall hernia repair were assessed using TDF. RESULTS: Seventeen (81%) of the 21 participants were men, with a median (interquartile range) age of 47 (45-54) years. Of the 14 TDF domains, 5 were found to be most associated with decisions on the surgical approach to abdominal wall hernia repair for surgeons in Michigan: knowledge, beliefs about consequences, social or professional role and identity, environmental context and resources, and social influences. Mapping of the findings to the sources of behavior identified the potential intervention functions and policy categories that could be targeted for intervention. The intervention functions found to be most relevant included education, persuasion, modeling, incentivization, and environmental restructuring. CONCLUSIONS AND RELEVANCE: Using the TDF, this study found that the primary factors associated with individual practice were opinion leaders, practice conformity, and reputational concerns. These findings are important because they challenge traditional dogma, which relies mainly on dissemination of published evidence, education, and technical skills acquisition to achieve evidence-based practice. Such knowledge allows for the development of sustainable, theory-based interventions for adherence to evidence-based guidelines.