Patient preferences and decision ‐ making when considering surgery for musculoskeletal disorders: A mixed methods systematic review

Introduction: The burden of Musculoskeletal disorders (MSD) is large. Surgery is an important management option but the factors that shape patients' surgical decisions are not well understood. As prior reviews have explored only single data types or conditions, a mixed methods appraisal across the musculoskeletal spectrum was undertaken. Methods: A mixed ‐ methods systematic, convergent segregated approach was used, with PubMed, Cumulated Index to Nursing and Allied Health Literature (CINHAL), Embase and PsycINFO searched to identify studies of adult patients' decisions about whether to undergo surgery. A narrative synthesis was conducted, with identified themes integrated across quantitative, qualitative and mixed ‐ methods studies. Results: Forty ‐ six studies were included (24 quantitative, 19 qualitative and three mixed methods), with four decision ‐ making themes identified (symptoms, socio-demographic and health factors, information and perceptions). Decision ‐ making involves a complex interaction of individual sociodemographic, health and symptom information, integrated with individual perceptions of candidacy and surgical expectations. While most studies investigated hip and knee surgery,


| INTRODUCTION
Musculoskeletal disorders (MSD) are the leading cause of disability worldwide (WHO, 2021).As demand for musculoskeletal care increases, surgical waiting lists grow (Curtis et al., 2010) and costs increase (March et al., 2014).Factors reported to influence patient preference (or patients' decisions) to have surgery for MSD known to be multifactorial (Lam & Loke, 2017;O'Neill et al., 2007) and include a variety of physical, sociodemographic, psychosocial factors and other factors related to the clinical encounter, such as decision aids (Chung et al., 2006;Clark et al., 2004;Figaro et al., 2004;Modi et al., 2014).However, potential commonality and contribution of factors across different MSD is unclear.A better understanding of these factors across the spectrum of MSD could aid communication and care efficiency.
Current understanding of factors impacting patients' decisions to have surgery is greatly limited to single methodological approaches (qualitative or quantitative) or a single surgery.This hinders discovery of common factors across condition-types and integration of qualitative and quantitative findings, which can yield greatly different outcomes; a quantitative systematic review of spinal surgery found pain and function to most influence patient decisions (Lam & Loke, 2017), yet in contrast, a meta-synthesis of qualitative data related to knee arthroplasty found the role of health professional communication, coping strategies, and perceptions of ageing to be most influential (O'Neill et al., 2007).Furthermore, as reviews to date have investigated single conditions, it is unclear whether preferences are unique to specific conditions, or whether there is commonality across MSD that could aid patient communication and shared decision-making.
A mixed methods synthesis seeks provide a richer understanding (Stern et al., 2020) of the factors that influence the decision to undergo surgery for MSD.This review aims were to identify factors reported to be associated with or influence patients' decisions to choose surgery and where possible determine which factors have the greatest association or influence in specific or varied MSDs.Joanna Briggs Institute Critical Appraisal Tools (JBI, 2021) matched to the relevant study type and design (mixed method with both) (Stern et al., 2020) were applied independently by two reviewers (ED and SH), with disagreements resolved by a third reviewer (DM).A percentage score was calculated for each included study by dividing the amount of agree 'yes' criteria by the total number of criteria minus the number of 'NA'.

| General description
Figure 1 shows electronic searches yielded 2169 articles, of which 66 were read in full and 46 studies were included.Twenty four quantitative, included randomised controlled trial, cross-sectional, case control and cohort designs, with conditions predominantly related to hip and knee but including spinal deformity, back pain, shoulder, (Liberati et al., 2009) LITERATURE REVIEW -3 elbow and hand conditions.Nineteen qualitative studies used individual semi-structured interviews or focus groups and all but one reported on people experiencing hip and or knee osteoarthritis (OA).
There were also three mixed methods studies.The majority (16/24 quantitative, 17/19 qualitative and 3/3 mixed methods) involved presurgery data (perceived willingness to undergo surgery).Findings did not differ greatly between pre and post-surgical (Tables 1-4).

| Study quality
Quality appraisal scores are recorded in the corresponding table according to study type (Tables 1, 3 and 4).Overall quality was moderate to good.In the 24 quantitative studies, scores ranged from 44%-100% with a mean of 80%.In the 19 qualitative studies, scores ranged from 30%-100% with a mean of 73%.In the three mixed methods studies, appraisal means were 73% for qualitative and 85% for quantitative.

| Phase 1: Quantitative synthesis
Twenty four quantitative and three mixed methods studies (Tables 1   and 4) revealed 4 themes (symptoms, sociodemographic and health factors, information and perceptions).Heterogeneity of statistical approaches and outcome measures precluded meta-analysis or meaningful comparison of effect sizes.Where available, the size of association has been reported (Table 1).Commonly investigated factors are displayed with a tally of reported significant associations with preference for surgery in Table 2.

Summary
Sixteen studies revealed subthemes of quality of life, pain, function.
Increased pain and decreased function were almost always associated with a preference for surgery across the range of spinal, knee, hip, hand and shoulder conditions (Tables 1 and 2).

Health related quality of life
Six studies found that worse scores in knee and hip osteoarthritis in quantitative (Cronström, Nero, et al., 2019) and mixed methods studies (Nelson et al., 2020), thumb-base osteoarthritis (Wouters et al., 2019), scoliosis (Glassman et al., 2007;Pizones et al., 2017) and shoulder pain (Somerson et al., 2018), were significantly associated with a preference for surgery.Furthermore, hip and knee OA patients (Cronström, Nero, et al., 2019) with improvement in Health related quality of life (HRQoL) following rehabilitation, shifted from willing to unwilling, while those with poor improvements shifted from unwilling to willing to undergo surgery.One study reported that nonsurgical patients had worse HRQoL on subscales of general health (Glassman et al., 2007).

Summary
Sixteen studies found mixed associations with factors including health, employment, gender, race, and age (Table 2).

Health
Seven studies reported an association between general health and decision-making.Co-morbidities (heart disease, circulatory disorders, and diabetes) were significantly associated with deciding against spinal (Glassman et al., 2007) and mixed orthopaedic surgery (Kinghorn et al., 2021).Furthermore, in three studies better general health was significantly associated with choosing spinal surgery or knee arthroplasty (Glassman et al., 2007;Gillian A. Hawker et al., 2004;Somerson et al., 2018).Conversely, two studies found no significant association between health factors and surgical preference (Pizones et al., 2017;Zeni et al., 2010), and one study found higher body mass index significantly associated with surgery (Cronström, Nero, et al., 2019).

Employment
Four studies reported a mixed associations with employment status.It was significantly associated with choosing shoulder arthroplasty (Somerson et al., 2018) and knee arthroplasty (Kwoh et al., 2015) but not associated with choosing knee or hip arthroplasty (Cronström, Nero, et al., 2019;Gillian A. Hawker et al., 2002).

Quality
Appraisal (%) Lurie, et al., 2011 Low back pain (198) Pre-surgery Participants provided with a video-based educational decision aid on lumbar surgery specific to their condition.Preference for surgery was measured before and after.Surgical preference measured on a 5-point likert scale.
Chi square and ANOVA analysis of preference and use of the video 86% of patients watched the video.
Overall, no significant shift towards or away from surgery with the use of this video, although some significant findings reported in post-hoc subgroup analyses.

Gender
Five studies suggest gender does not influence decision-making.While one found males were more likely to choose surgery (Cronström, Nero, et al., 2019), four found gender to be non-significant (G. A. Hawker et al., 2001;Modi et al., 2014;Wouters et al., 2019;Zeni et al., 2010).

Race
Three studies indicate mixed association between race and decisionmaking.In two, minority (non-white) patients were significantly less likely to choose surgery (Hurley et al., 2020;Kwoh et al., 2015), another found race was not significantly associated in shoulder and elbow conditions (Modi et al., 2014).

Summary
Eight studies included decision aids (videos, displays or information packages), or the presentation of information in different formats, such as visual versus numerical.The overall impact upon the decision to prefer or not prefer surgery was inconsistent (Table 2).

Decision aids
Six studies investigated decision aids, with only one reporting a significant associated with preference for surgery (knee and hip osteoarthritis) (Hurley et al., 2020).Four reported no overall significant association in low back pain (LBP) (Deyo et al., 2000;Lurie et al., 2011;Phelan et al., 2001) and in hip and knee OA (Bozic et al., 2013).One LBP study reported only descriptive statistics (Spunt et al., 1996).Two studies investigated different methods of information presentation.Patients who lacked information were less likely to undergo surgery (Riffin et al., 2018) and in one lower quality study patients were more likely to prefer surgery when presented with images rather than numerical data (Fraenkel et al., 2019).

Summary
Nine quantitative and mixed methods studies contributed quantitative data to this theme.Expectations and concerns were defined heterogeneously across studies with a variety of outcome-related surgical expectations or concerns, psychological measures and perceptions about the pathology or disability (Table 1).More consistent significant associations were present between higher expectations and higher psychological distress and the preference for surgery (Table 2).

Surgical expectations and candidacy
While there was variation in definitions and measurement processes (Table 1), five studies were consistent in finding an association between positive expectations (or a positive perception of personal candidacy) and a preference for surgery Two reported positive perceptions about surgery, such as expectations of a good outcome, minimal inconvenience and lower complication fears, to be significantly associated with a preference for surgery (Kwoh et al., 2015;Wouters et al., 2019).One reported fear of poor outcome to be significantly associated with not choosing surgery (Modi et al., 2014).
In two mixed methods studies, patients who perceived they were good candidates were significantly more likely to choose surgery (Fraenkel et al., 2019;Matthies et al., 2020).

Psychological
Three studies acknowledged that increased psychological distress was significantly associated with the decision to have surgery for patients with hip, knee or thumb OA and spinal scoliosis (Hurley et al., 2020;Pizones et al., 2017;Wouters et al., 2019).Two reported low aesthetic or body image was significantly associated with surgery among patients considering hand and scoliosis surgery (Chung et al., 2006;Glassman et al., 2007).

| Phase 2: Qualitative synthesis
18/19 qualitative studies investigated knee and/or hip arthritis and surgical decisions about arthroplasty, one involved hand patients (Table 3).Three mixed methods studies contributed qualitative data (Table 4), one each for hip, knee and spine pathology.Factors that influence patients' surgical decisions fell within four inter-related themes: symptoms, sociodemographic and health factors, information and perceptions, with sub-themes listed for each.

Summary
Seventeen studies revealed three sub themes: pain behaviour, function, and psychological factors.Ongoing intense pain and/or decreased function increased propensity for surgery, while coping-strategies and accommodation of symptoms allowed some patients to avoid surgery.
The pain was getting to where it was [too much].I mean it still hurts [after receiving surgery], … but it's a liveable hurt (Mathews et al., 2016) Frequency of pain was discussed in six studies.A lack of constant pain made patients feel they did not warrant surgery, even if the pain was severe at time (Hudak et al., 2002), while patients in constant pain often more inclined to choose surgery (Al-Taiar et al., 2013;Clark et al., 2004;Hudak et al., 2002;Karlson et al., 1997;McHugh & Luker, 2009;Nelson et al., 2020).
In two studies, reduction in pain prompted a decision to not have surgery and an increase in symptoms was often the catalyst for surgery (Clark et al., 2004;McHugh & Luker, 2009).In three studies longer duration of symptoms was related to increased willingness to have surgery (Clark et al., 2004;Cronström, Dahlberg, Nero, & Hammarlund, 2019;McHugh & Luker, 2009).

Function
Twelve studies reported inability to perform essential and meaningful activities motivated patients to choose surgery (Al-Taiar et al., 2013;Dosanjh et al., 2009;Frankel et al., 2012;Karlson et al., 1997;Kroll et al., 2007;Mathews et al., 2016;McHugh & Luker, 2009;Nelson et al., 2020;Parks et al., 2014;Suarez-Almazor et al., 2010;Toye et al., 2006;Traumer et al., 2018).Many patients viewed surgery as a means of freedom, expecting to re-engage in meaningful function post-operatively: We have about 300 m to our supermarket, but in the end, I could not even go to the supermarket because of the pain (Traumer et al., 2018)

Psychological factors
Distress tended to increase willingness for surgery via anxiety (Mathews et al., 2016;Parks et al., 2014), depression (T.Barlow et al., 2018), feelings of suffering (Karlson et al., 1997), vulnerability (Barlow et al., 2018;Nelson et al., 2020;Toye et al., 2006), or fear of further injury and loss of function (Toye et al., 2006).In eight studies non-surgical patients adjusted to their reduced function, focussed on self-managing symptoms and avoiding surgery (Barlow et al., 2018;Clark et al., 2004;Dosanjh et al., 2009;Frankel et al., 2012;Hudak et al., 2002;Karlson et al., 1997;Kroll et al., 2007;Toye et al., 2006): My office is two floors up, so I have to do the stairs … they brought my laptop down and said work from down here (Barlow et al., 2018) 3.4.2| Theme: Sociodemographic and health factors Summary Sub-themes of personal situation, gender, race, religion, and age had a mixed influence upon patient-decision-making. Caucasian patients were regularly more likely to choose surgery across a variety of MSD, also being younger and in good health often influenced patients towards choosing surgery.

Gender
Females were often more process-orientated, with concerns related to recovery process, post-operative limitations and pain control, while males focussed on factual knowledge in the decision-making process for knee arthroplasty (Chang et al., 2004).Female primary caregivers sometimes delayed surgery, knowingly dealing with functional decline for longer (Karlson et al., 1997).

Race
While surgical timing, impact on employment and medications featured strongly in decision making for Caucasian patients, African American concerns trended more towards finances and trust (in the surgeon and the healthcare system) (Chang et al., 2004).
Caucasians' fears were related to surgical risks, complications, and outcomes, while the influence of faith was not race-specific (Figaro et al., 2004;Parks et al., 2014).Several studies observed Caucasian patients were more likely open to surgical intervention while African American, Hispanic, or Latino patients were more hesitant (Chang et al., 2004;Figaro et al., 2004;Kroll et al., 2007;Parks et al., 2014).

Age
Older age hip and knee osteoarthritis patients were often less inclined to opt for surgery, many considering functional decline a natural consequence of ageing (Hudak et al., 2002;Parks et al., 2014;Selten et al., 2016;Yeh et al., 2017).
When you're this age and you have an ache, well so what?You expect to have aches when you're this age (Hudak et al., 2002) 3.4.3| Theme: Information

Medical sources of information
Patients desire a range of clinical, social, administrative and financial information (Chang et al., 2004).A perceived lack of information, commonly makes surgery less likely (Al-Taiar et al., 2013;Clark et al., 2004;Kroll et al., 2007;Suarez-Almazor et al., 2010;Yeh et al., 2017).Nine studies reported positive doctor-patient relationships influence how information is perceived and shapes decisionmaking (Barlow et al., 2018;Figaro et al., 2004;Frankel et al., 2012;Hudak et al., 2002;Mathews et al., 2016;McHugh & Luker, 2009;Selten et al., 2016;Toye et al., 2006;Traumer et al., 2018).Positive information from the doctor often had the most influential effect: I knew that I needed somebody that was really going to do the best for me, and I felt that he was going to do that… (Barlow et al., 2018)

Medical imaging
Three studies reported that medical imaging played a large role in confirming a diagnosis, justifying symptoms, and influencing patients to undergo surgery (McHugh & Luker, 2009;Toye et al., 2006;Traumer et al., 2018): There was no cartilage between my bones.That's why I had to undergo surgery (Traumer et al., 2018) Yet suboptimal communication can override the influence of medical imaging results.
Well, he did an x-ray, and I didn't actually see the
I have friends who have had the replacements.It's like "new bones."Well, it's just marvellous (Clark et al., 2004) Surgeries for me, I am really cautious, because there was an incident that happened with my husband … And that just did something to me (Parks et al., 2014) The opinion of friends and family often influenced surgical decision-making (Al-Taiar et al., 2013;Mathews et al., 2016;McHugh & Luker, 2009;Parks et al., 2014;Selten et al., 2016;Suarez-Almazor et al., 2010;Toye et al., 2006).The Internet was another common source of information about conditions and surgical process, often easing the psychological burden of the unknown (Dosanjh et al., 2009;McHugh & Luker, 2009;Parks et al., 2014;Suarez-Almazor et al., 2010), specific surgical techniques (Dosanjh et al., 2009) and the credentials of the surgeons (Parks et al., 2014).

Conflicting information
Conflicting information from health professionals, friends and family often hindered decision-making (Ballantyne et al., 2007a;Karlson et al., 1997;Suarez-Almazor et al., 2010).Often, negative experiences of others conflicted with doctors' recommendations and strongly influenced decision-making.
Well, he (doc) was recommending that operation on my spine.Well, my sister in Barrie, she had an operation on her back … and it never worked out.I don't want to take a chance and end up worse (Ballantyne et al., 2007a) 3.4.4| Theme: Perceptions (of surgery)

Summary
From eleven studies, it emerged that positive expectations about surgery and its outcomes influence decision-making towards surgery, while negative expectations had the opposite impact.Many interacting subthemes include concerns of fear, risk and racial disparity within the healthcare system, which consistently reduced the tendency to choose surgery.

Surgery-related concerns and expectations
The hope of restoration of quality of life (decreased pain and improved function) influenced the choice of surgery among osteoarthritis patients (Al-Taiar et al., 2013;Parks et al., 2014;Suarez-Almazor et al., 2010).Furthermore, negative surgical expectations, sometimes from lack of knowledge reduced surgical preference for knee osteoarthritis (Al-Taiar et al., 2013;Figaro et al., 2004).
Furthermore, the longer a patient spends deliberating the factors which present as pros and cons, the more stress surrounding their decision, making it more complicated (Barlow et al., 2018).

Summary
Thirteen studies addressed candidacy (perceived surgical appropriateness), with subthemes related to patient's personal situation, experience, expectations and assessment of whether their situation was bad enough to choose surgery Negative previous experiences and the perception of not being bad enough for surgery made patients more inclined to not undergo surgery.

Personal situation
The cost of surgery was a concern that influenced many patients (Barlow et al., 2018), often overriding other considerations (Selten et al., 2016;Suarez-Almazor et al., 2010).
I would borrow, if I didn't have the money and the pain was bad enough, I would have it done, I'd get the money.(Kroll et al., 2007) Three studies reported that having support for post-surgical recovery contributed to decisions to undergo surgery (Riffin et al., 2018;Selten et al., 2016;Yeh et al., 2017).

Previous experience
Two studies reported that the relationship between perceived candidacy and previous experience with the healthcare system influenced decision-making (Ballantyne et al., 2007b;Hudak et al., 2002).
Negative personal experiences and/or mistrust of a doctor's advice established resistance to surgery in knee OA (Ballantyne et al., 2007b;Hudak et al., 2002).

Being 'bad' enough
Two studies examined the perception of being bad enough to warrant surgery for hip or knee osteoarthritis (Frankel et al., 2012;Hudak et al., 2002).Some noted others had greater need for surgery, thus consolidating their decision against surgery (Hudak et al., 2002).Older osteoarthritis patients stated that they had tried 'everything' before accepting surgery (Cronström, Dahlberg, et al., 2019).
It would have to be at the point where life is just plain bloody miserable or … where I had no options of improving any other way.(Frankel et al., 2012) The concept of appropriate surgical candidacy included acknowledgement of a hierarchy of health concerns, age-related comorbidities, pain levels and other priorities which may take precedence over surgery (Ballantyne et al., 2007b;Nelson et al., 2020;Parks et al., 2014;Yeh et al., 2017).

| Phase 3: Aggregation of quantitative and qualitative synthesis
Key findings reported across the four themes overlap across quantitative and qualitative studies, are summarised in Table 5 and represented in a proposed decision-making model (Figure 2).
The level of symptoms and dysfunction often influence decisionmaking in a consistent direction; more pain, reduced function and/or poorer quality of life increases preference for surgery.
Although most included studies related to hip and knee conditions, these findings are consistent across the range of MSD represented and across both quantitative (hip, knee, shoulder, spine, hand, elbow) and qualitative (hip, knee, hand, spine) data.A variety of sociodemographic and information sources also underpin perceptions of personal candidacy (suitability, sufficient symptoms) and perception of surgery (expectations about outcomes, inconvenience and risk).Favourable perceptions in both these domains consistently increase preference for surgery in the range of MSD represented.
Qualitative studies often identified factors that patients consider important to surgical decision-making and quantitative data provided further clarification by demonstrating the direction (increase or decrease preference for surgery) and the consistency of a factor's influence.For example, reduced function and general health concerns feature qualitatively as important considerations for patients (Table 3) and quantitative data adds to this insight by showing that reduced function is highly consistent in its association with a preference for surgery, while better general health is less consistently associated with a preference for surgery (Table 2).While this is not the first review to report that patient surgical decision-making is individual and complex, it is the first to demonstrate commonality in the factors that influence surgical decisions across a spectrum of MSD.The strong link between being highly symptomatic

Perceptions of surgery
Positive expectations and lower fears, also psychological and/or body image distress consistently associated with a preference for surgery Hip knee spine shoulder elbow hand Positive expectations influence for surgery.Surgical concerns, or fear of risks influence against surgery.

Perceptions of candidacy
Limited data indicates a positive perception of candidacy is associated with a preference for surgery.
Hip knee Uncertainty about being 'bad' enough influence decisions against surgery a Limited data for spine and hand (one study for each).and surgery, also the lack of a consistent relationship between patient characteristics and surgical preference, have both previously been reported in a review of patient decisions in spinal surgery (Lam & Loke, 2017).Two prior qualitative reviews conducted in patients undergoing knee arthroplasty reported decision-making themes relating to age, professional support, symptoms, expectations and concerns (Timothy Barlow et al., 2016;O'Neill et al., 2007).Our qualitative evaluation supports these findings, and our mixed-methods approach reveals how consistently these themes are associated with surgical preference (Tables 2 and 5).Conversely, quantitative investigations of associations between a set of patient characteristics and surgical willingness, gain added impact when considered alongside qualitative data.Several overlapping themes were identified (Table 5), indicating that patients consciously consider the factors (such as pain and candidacy) that are also associated with surgical preference.This link could be explored further with primary mixed-methods research into patient decision making.
The process by which patients' reach the point of surgical opinion, has been the subject of criticism; with inefficiencies reported in primary and secondary care interfaces (Briggs et al., 2012), low surgical conversion rates from General Practitioner referrals (Marks et al., 2019) and uncertainty about the optimal profession for early musculoskeletal care and gate-keeping (Foster et al., 2012).The findings of this review could help make surgical referrals more efficient, by prompting communication, supporting decision-making around conservative management of MSD and assisting the timing of orthopaedic referral.These findings suggest that patients with higher levels of symptoms, positive perceptions of candidacy and expected surgical outcomes are more likely to take up an offer of surgery, thus patients with this profile may benefit from earlier orthopaedic referral.Conversely, the absence of these features might prompt persistence with conservative care, knowing that the likelihood of surgical conversion is lower.Further research, involving mixed methods designs with pre and post-surgical data, are needed further inform tailored care.Future research should also interrogate the stability of patient's perceptions of surgical willingness and whether early identification of those with a preference for surgery results in more efficient musculoskeletal care.

| Limitations
Due to the heterogeneity of statistical methodologies and outcome measures, meta-analysis was not feasible.Consequently, we presented a tally of the consistency with which different quantitative factors impacted surgical preference (Table 2).Presentation of univariate analyses for each factor in future research would aid future pooling of data in this field.While hip and knee osteoarthritis studies are well represented, the low numbers of studies in some other types of MSD means that findings should be applied cautiously across other MSD.It may be that some conditions or settings prompt an impact of different influences upon the surgical decision to those reported here.Finally, surgical preference sampled early within care may represent a different phenomenon to surgical decisions sampled post-operatively.We believe this challenge reflects the present state of the literature and highlights the need for more longitudinal research in this field.

| CONCLUSION
For MSD, patients' surgical decision-making involves complex, individual, interlinked themes of sociodemographic/health factors, information sources, symptoms, perceptions of candidacy and surgical outcomes.Patients are more inclined to prefer surgery when their symptoms and/or disability is worse, when they perceive they are suitable candidates and have positive expectations about surgical outcomes.Other factors including age, general health, race, financial context, and information are also important considerations but less consistently impact propensity to prefer surgery.While these findings can cautiously be generalised across MSD and aid the efficient referral of patients to orthopaedics, more research is needed to validate these findings across the spectrum of MSD.

Summary
Twenty-one papers investigated the impact of a variety of information sources upon decision-making.Experiences and opinions of others (positive and negative) were the most influential.A perceived lack of information from medical professionals and poor doctorpatient relationships reduced willingness, while sharing information such as x-rays along with a positive doctor-patient relationship increased willingness for surgery.When different sources presented conflicting information, patients were less willing to choose surgery.LITERATURE REVIEW -19 first review to synthesise the breadth of qualitative, quantitative, and mixed methods research into the influences upon patient decision-making when considering surgery across the spectrum of MSD.Key themes relating to decision-making overlap across the qualitative and quantitative literature, revealing that patients are more inclined to prefer surgery based on their symptoms (patients with worse symptoms have greater propensity for preferring surgery), their perceptions about personal candidacy/suitability for the procedure and their perceptions about the likely outcomes of surgery (when perceptions/expectations are positive and fears are low, surgery is more likely to be chosen).Other factors such as age, general health, race, financial context and variety of professional and non-professional communication and information sources exert a less consistent impact upon the propensity to prefer surgery.Patients undergo a complex and individual decision-making process that involves assessment of individual sociodemographic, health, symptoms and information, integrated into individual perceptions of candidacy and surgery before reaching a decision whether to proceed with surgery.

Study Population (n) timing a Study process Measures and Statistics Results Quality Appraisal (%)
Baseline: Age, gender, employment status, EQ-5D, walking difficulties, fear of physical activity, willingness to have surgery, pain VAS, 30 s chair stand test (CST).Chi-square, t-tests, Wilcoxon's to compare differences between willing or unwilling to have surgery.T A B L E 1 (Continued)StudyPopulation (n) timing a Tally of results of association with a preference for surgery in commonly investigated factors, quantitative data from quantitative and mixed methods studies, arranged by theme (Zeni et al., 20106;Hawker et aKwoh et al., 2015;Modi et al., 2014;Pizones et al., 2017;Trask et al., 2020;Wouters et al., 2019)gistic regression investigated association between sociodemographic (age, gender, employment/health factors and pre-consultation willingness for surgery, also the decision to have surgery in those offered it.Surgical versus conservative cohorts were compared with the student t test, chisquare, and the mann-whitney U. Baseline: Demographics, radiographic scores, satisfaction with prior treatment, work status, education, living status, hip disability and osteoarthritis outcome score, knee injury and osteoarthritis outcome score, veterans RAND 12-item health survey score Surgical willingness: Participants selected from 4 categories with averse to surgery defined as selection of 'I am not interested … I want to avoid surgery at all costs' Treatment selection (surgery or conservative) determined at initial or subsequent visit.100Abbreviations:ADLs,Activities of daily living; BMI, Body mass index; CT, computed tomography; DVD, Digital video disk; LBP, low back pain; MRI, magnetic resonance imaging; OA, Osteoarthritis; OR, odds ratio; QoL, Quality of life; RCT, randomised controlled trial; WOMAC, Western Ontario and McMaster Osteoarthritis Index.aTiming of data collection (pre-surgery or post-surgery).10 -(Chung et al., 2006;Hawker et al., 2001;Hurley et al., 2020;Kinghorn et al., 2021;Riffin et al., 2018;Somerson et al., 2018)(Zeni et al., 2010)(Cronström, Nero, et al., 2019;Kwoh et al., 2015;Modi et al., 2014;Pizones et al., 2017;Trask et al., 2020;Wouters et al., 2019) Aggregated summary of main findings by data type and condition T A B L E 5