ABSTRACT
Keywords: Shoulder;Instability;Diagnostic Decision Support System Purpose: Diagnosis of shoulder instability in children, is difficult and recurrent rates of instability are high (70–90%). Time to a formal diagnosis is normally two years diagnostic delays can lead to poorer outcome and long-term complications e.g. shoulder arthritis (odds ratio 19.3). There is a need to improve diagnostic accuracy and prevent the development of long-term complications. Healthcare services are increasingly drawing upon technological solutions to improve diagnostic accuracy and efficiency, particularly within the context of the COVID-19 pandemic and subsequent ‘Rebuilding of the NHS’ strategy. A Diagnostic Decision Support System (DDSS) has the potential to reduce time to diagnosis and improve outcomes for patients. The aim of this study was to elicit physiotherapists clinical decision-making processes and develop a concept map for a future DDSS in shoulder instability. Methods: A qualitative study, using modified nominal focus group technique, involving three clinical vignettes, was used to elicit physiotherapists decision-making processes. Participants from across four separate clinical sites were recruited within their capacity as physiotherapists with a specialist interest in paediatric shoulder instability. All focus group sessions were audio recorded and transcribed verbatim. Thematic analysis was conducted according to the stages of Braune and Clarke. Results: Twenty-five physiotherapists, (18F:7M) from four separate clinical sites participated. The themes identified related to • Variability in diagnostic processes and lack of standardised practice 1. Differences in diagnoses and diagnostic processes 2. Differences in diagnoses and diagnostic processes 3. Diagnostic process occurs over a long period of time 4. Diagnostic test choices influenced by factors beyond objective markers associated with the patient injury 5. Planning for prognosis influenced by factors beyond assessment findings 6. Trust in staff relationships • General distrust in individuals or modes of medicine used outside of the department • Unity within the department • Knowledge and attitudes towards novel technologies for facilitating assessment and clinical decision making and 1. Lack of knowledge and rejection of 3D motion capture. Conclusion(s): No common structured approach towards assessment and diagnosis was identified. Decision-making processes were not explicit, therefore, limiting the ability to develop a DDSS around current practice. Several systematic biases were identified in the assessment of paediatric shoulder instability, most notably regarding gender. Lack of knowledge, perceived usefulness, access, and cost were identified as barriers to adoption of new technology. Impact: Based on the information elicited a conceptual design of a future DDSS has been developed. Implementation of a DDSS may act as a vehicle for establishing wider consensus in practice and alert clinical end users of potential bias in order to mitigate against it. These findings have wider implications for the training and education of physiotherapists regarding assessment and clinical decision-making. Use of more objective measures, derived from technology, and used alongside an appropriate DDSS may reduce bias and the negative effects on patient outcomes. Development of any subsequent DDSS and software will need to address the barriers identified which are likely to limit the use of novel technology in practice. There is a risk that even if additional information and technology was available to clinicians, they would not use it. Funding acknowledgements: This work was supported by the Keele University, Faculty of Natural Sciences Research Development Fund under Grant C3700-0958.