Objectives Dutch ‘Choosing Wisely’ recommendations were developed to reduce routine use of MRI and arthroscopy in degenerative knee disease. An active de-implementation strategy was developed to effectuate these CW-recommendations in orthopaedic practice. This study evaluated the feasibility and effectiveness of this de-implementation strategy to reduce the use of MR’s and knee arthroscopies in orthopaedic practice using an interruptive time series design.

Methods Based on previously assessed barriers and facilitators among both patients and orthopaedic surgeons, we developed a de-implementation strategy to reduce MRI and arthroscopy use. The strategy included five components: local clinical leaders, education about guidelines and corresponding literature, hospital-specific feedback on MRI and knee arthroscopy use, video about expectation management, and a patient brochure. The feasibility and effectiveness of this strategy is evaluated in 13 orthopaedic centers distributed across the Netherlands. Hospital data from March 2016 till December 2018 were analysed using an interrupted-time series design. The primary outcomes were MRI and knee arthroscopy use in degenerative knee disease among patients aged 50 years and over. In addition, a process evaluation was performed among all local clinical leaders, orthopaedic surgeons and residents who participated in this study to determine the feasibility and effectiveness of the de-implementation strategy.

Results Preliminary results show a downward trend for MRI use among patients with degenerative knee disease (13.6% before versus 5.7% after execution of the de-implementation strategy). Use of knee arthroscopy also decreased for this patient group (before: 9.4%, after: 3.8%). From the process evaluation it appeared that orthopaedic surgeons and residents felt that the education about guidelines and corresponding literature, and the patient brochure had the most added value for enable implementation of the ‘Choosing Wisely’ guidelines in practice. Data collection will be completed in June 2018 and are needed to assess the full effect.

Conclusion From the preliminary data both MRI and arthroscopy use have been reduced. However, it is not yet known whether this was part of general downward trend in MRI and arthroscopy use in degenerative knee disease or that the de-implementation strategy significantly changed this trend, for which we have to await the final data.

Authors in the Smart study group: P. Pander, K.L.M. Koenraadt, R.C.I. van Geenen, J.P.A.H. Onderwater, Y.V. Kleinlugtenbelt, T. Gosens, T.V.S. KLOS, P.C. Rijk, A.V.C.M. Zeegers, R.A.G. Hoogeslag, R. Huis in ‘t Veld, A.A. Polak, N.R.P. Pereira