Online surveys have been successfully used in orthopaedics in recent times either to interview surgeons [21–24] or patients . The response rate of just 13.6% illustrated that it is not easy to persuade a large proportion of surgeons to participate in an online survey. Nevertheless, more than a thousand participants did respond, assuring a good dataset. Furthermore, a low response rate does not necessarily mean low validity .
The main aim of our study was to assess the impact of different forms of information in the decision-making process of surgeons. Orthopaedic surgeons are provided with vast amounts of information . Sources like the internet and manufacturers’ leaflets are easy to access and free of charge. Training courses require time and the surgeon incurs costs, a factor that might explain their relatively low usage by junior surgeons . Journal articles also require time to find and study the relevant articles. As scientific literature is often written in English, we cannot exclude a certain language bias.
Nevertheless we clearly found that the sources of information that are preferred by surgeons remain peer-reviewed research articles, presentations at congresses and training courses by independent organisations. Ninety-four percent of respondents judged peer-reviewed scientific sources as a good or very good way of gaining important knowledge in order to identify novel treatment methods. Eighty-seven percent thought the same about independent courses and workshops. Meetings and congresses, as a source of information, were seen as important by 86%. In contrast, manufacturer-initiated publications were only seen by 20% to be a good or very good source. This is in accordance with studies that found evidence-based medicine to be of increasing importance for surgeons. Their impact in terms of changing knowledge, attitudes and uptake in clinical practice has been researched in the past with the aim of improving the use of research findings by individual healthcare professionals . The role of the internet and material provided by manufacturers as a source for decision-making and implementation of new techniques on the other hand has rarely been studied, and even then with suboptimal methodology .
One of the limitations of this study is that we did not enquire about which organisations are seen as independent by orthopaedic surgeons. It would be interesting to determine whether organisations that are officially independent but are directly funded by manufacturers are accepted as “independent”. In addition, we did not specify exactly what respondents judged as “information from the internet”.
Statistical evaluation of the three largest participating nations showed small but significant differences that we cannot fully explain. A possible explanation for the relatively high rate of acceptance of “manufacturers’ newsletters and white papers” in the United Kingdom might be attributed to the term “white papers”, which is the name often given to governmental publications or announcements by the national health service [30–33]. This result should be interpreted with caution, as bias cannot therefore be excluded. The language bias is another restriction of our study, we can not be sure that number of participants and results would have been different if the survey would have been multilingual [34, 35]. Knobloch described a general tendency to publish positive results in English , resulting in a selection bias. The potential limitation of response bias has been widely described [37–42]. In a recent German trial, internet based data sampling showed an additional response bias but had no direct effect on outcome scales . We cannot exclude response bias for our study.