{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T13:58:07Z","timestamp":1785592687354,"version":"3.56.0"},"reference-count":26,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T00:00:00Z","timestamp":1782172800000},"content-version":"vor","delay-in-days":22,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T00:00:00Z","timestamp":1780272000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Evaluation Clinical Practice"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Rationale<\/jats:title>\n                    <jats:p>Many advances have been made to identify novel, effective orthopedic care practices. For all that is known about the comparative effectiveness of various clinical decisions in anterior cruciate ligament (ACL) injury care, surprisingly little is known about how surgeons approach decision\u2010making in the face of this evidence. Implementation science models such as Capability, Opportunity, Motivation \u2013 Behavior (COM\u2010B) offer a way to organize and comprehensively understand how clinicians make decisions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims and Objectives<\/jats:title>\n                    <jats:p>This evaluation aimed to understand and quantify the factors that influence orthopedic surgeons' decision\u2010making in ACL injury care according to COM\u2010B.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This pragmatic evaluation used a sequential exploratory mixed\u2010methods approach combining orthopedic leader discussions and qualitative semi\u2010structured interviews, followed by four rounds of quantitative census surveys to understand the factors influencing four surgeon decision points related to ACL injury care. First, two authors (BN a practicing surgeon with a clinical and research leadership role and MR the director of the affiliated orthopedic research institute) participated in recurring in\u2010person orthopedic leader discussions; then additional selected surgeons were invited to participate in one\u2010time qualitative semi\u2010structured phone interviews; and, finally all surgeons that perform ACL procedures in the health system were invited to participate in four quantitative web surveys. Results were summarized descriptively according to the COM\u2010B model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Two co\u2010authors (BN and MR) participated in the orthopedic leader discussions, five invited surgeons participated in qualitative interviews (100% response rate), and 10\u201311 surgeons participated in four survey rounds (83%\u2013100% response rate). Factors influencing each of the four selected decision points were identified within each COM\u2010B category. Clinical knowledge (capability) and social influence of patient preferences (opportunity) were identified as highly influential for all decisions. Automatic decision making or habit (motivation) was also highly important for most but not all decisions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Interviews and surveys with surgeons from one Midwest U.S. health system demonstrate the complexity of ACL injury care decision\u2010making. Surgeons reported that capability, opportunity, and motivation were important in all four decisions. The most important factors influencing decisions ranged from their technical ability to perform one surgical technique over another (e.g., hamstring autograft) in selecting what type of surgical graft to use to their patients' preferences for having surgery in deciding whether to recommending surgery. Future research to identify and test intervention strategies like shared decision\u2010making training in alignment with the identified factors like technical ability and social influences have the potential to lead to higher\u2010value orthopedic care by supporting decisions like recommending longer pre\u2010operative rehabilitation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jep.70502","type":"journal-article","created":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T18:35:05Z","timestamp":1782239705000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mixed\u2010Methods Evaluation to Identify Factors Influencing High\u2010Value Surgeon Decisions in Orthopedics: An Example in Anterior Cruciate Ligament Reconstruction"],"prefix":"10.1111","volume":"32","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5744-7215","authenticated-orcid":false,"given":"Meghan M.","family":"JaKa","sequence":"first","affiliation":[{"name":"Center for Evaluation &amp; Survey Research HealthPartners Institute Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6976-2738","authenticated-orcid":false,"given":"Maren S. G.","family":"Henderson","sequence":"additional","affiliation":[{"name":"Center for Evaluation &amp; Survey Research HealthPartners Institute Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3154-824X","authenticated-orcid":false,"given":"Jennifer M.","family":"Dinh","sequence":"additional","affiliation":[{"name":"Center for Evaluation &amp; Survey Research HealthPartners Institute Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Reams","sequence":"additional","affiliation":[{"name":"HealthPartners Institute Bloomington Minnesota USA"},{"name":"TRIA Orthopedics Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradly","family":"Nelson","sequence":"additional","affiliation":[{"name":"TRIA Orthopedics Bloomington Minnesota USA"},{"name":"University of Minnesota Minneapolis Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven P.","family":"Dehmer","sequence":"additional","affiliation":[{"name":"HealthPartners Institute Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeanette Y.","family":"Ziegenfuss","sequence":"additional","affiliation":[{"name":"Center for Evaluation &amp; Survey Research HealthPartners Institute Bloomington Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,6,23]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-022-07087-z"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1177\/0363546511426088"},{"key":"e_1_2_9_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jisako.2024.04.004"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.OA.22.00069"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1177\/0363546506286866"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamapediatrics.2017.0740"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa0907797"},{"key":"e_1_2_9_9_1","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD001356.pub3"},{"key":"e_1_2_9_10_1","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzaa119"},{"key":"e_1_2_9_11_1","doi-asserted-by":"publisher","DOI":"10.1002\/hec.3933"},{"key":"e_1_2_9_12_1","doi-asserted-by":"publisher","DOI":"10.5435\/JAAOS-D-20-00556"},{"key":"e_1_2_9_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.zefq.2015.02.014"},{"key":"e_1_2_9_14_1","doi-asserted-by":"publisher","DOI":"10.1176\/ps.2007.58.3.342"},{"key":"e_1_2_9_15_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13643-022-02030-2"},{"key":"e_1_2_9_16_1","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-6-42"},{"key":"e_1_2_9_17_1","doi-asserted-by":"publisher","DOI":"10.1089\/sur.2020.181"},{"key":"e_1_2_9_18_1","unstructured":"HealthPartners About: Our Mission and Vision October2025 https:\/\/www.healthpartners.com\/about\/."},{"key":"e_1_2_9_19_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.27.3.759"},{"key":"e_1_2_9_20_1","volume-title":"The Basics of Process Mapping","author":"Damelio R.","year":"2011"},{"key":"e_1_2_9_21_1","doi-asserted-by":"publisher","DOI":"10.1108\/QRJ-D-18-00035"},{"key":"e_1_2_9_22_1","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-9-11"},{"key":"e_1_2_9_23_1","volume-title":"Improving Survey Questions: Design and Evaluation","author":"Fowler F. 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