Table 3.

Supporting extracts

Quote number	Quote (participant code)
Q1	‘Ultimately, we will always do our best for the patient’. (024)
Q2	‘I don’t count it, but you get an impression. Around 10 per cent of my patients would be saying they are not entirely satisfied by surgery’. (016)
Q3	‘Often, to please you, patients say that it is doing better than it really is. So I would think my outcomes are better than 20 per cent, but I am aware of the glasses that I see it through as well as what patients might tell me’. (014)
Q4	‘There’s always a difference between how well you are doing and how well you think you are doing. Having formal feedback on patient outcomes gives you the opportunity to change things if you are not doing as well as you want to’. (023)
Q5	‘If patients choose not to come back, the only way you have got to track them is looking at your results from the registry. But I want to know the answers to the clinical questions – are you happy? Is your pain better than it was pre-op? How you ask the question matters’. (028)
Q6	‘If you received feedback that the rate of clinically meaningful improvement reported by your patients is not as high as you think it should be, you have to look at whether you are not picking the right patients, or you are operating on patients that are not going to do well. I think it would be more likely to be the way the question is asked. I would want to check who is asking the questions, what they are asking and how they are asking it’. (023)
Q7	‘To me a good result is: they are going to have some intermittent ache in the knee, they are not going to be able to kneel or squat, they are going to be aware that it is there. That to me is a good result. Now others on some assessment scale they might say well that is in our system considered a failure thing, so you have get those parameters right’. (010)
Q8	‘At the end of the day if there is a pathology that can be deleted by surgery and the patient accepts some improvement then that means that the surgery will happen’. (025)
Q9	‘If the patients’ expectations are not meeting mine, I won’t do the operation because then the patient isn’t happy and sometimes they have 2/10 pain and they are not happy’. (013)
Q10	‘It is patient factors more than anything else. Because it is very easy for me to look at xrays and use the Kellgren-Lawrence scale: 1, 2, 3, 4 for disease severity. There is not much of an argument over that. It is about the patient factors, the psychology and behavioural aspects of it which is more what you want reassurance for’. (016)
Q11	‘You spend all your life looking at patients and assessing them and you start to develop a bit of a gut feeling as to what might be happening when you sit in front of a patient and you might be saying you know you are telling me this but actually I know something else is happening’. (015)
Q12	‘I don’t think it would really influence my surgical decision making, I think it would more affirm my decision to not offer a patient an operation’. (029)
Q13	‘If I think they are OK and they score badly I will relook at it and say why is that? Am I missing something obvious? But at the end of the day if the tool says one thing and my sniff test says there is something not right, I am still following my nose’. (010)
Q14	‘Not every tool is perfect and it may not capture every patient… the danger is we may end up refusing to do something because of this tool and therefore the patient may not receive the appropriate treatment based on a decision aid and nothing is 100 per cent so you have to expect some patients would fall through the cracks’. (019)
Q15	‘I think people are mistrustful of things that come out of other institutions but I would trust that a study from [the Department] would be a rigorous design. Where people are invested in something, they are much more likely to use it. If the results showed the tool was valid, I guess I would be prepared to try it and see whether I thought it was valid in my hands, in my practice’. (026)
Q16	‘I never trust evidence because you only have to go to Dr x …even in research, there is a lot of doubtful stuff and you have got to be careful about basing something totally on results. I know we have got to be evidenced based but the evidence may apply to a certain situation in a certain individual at a period in time and there is always variations or exceptions around that. So I would try and correlate them in my own mind and if after a while I am seeing well that person is a bit odd and they are scoring badly on that, well ok, this has legs’. (010)
Q17	‘I think that the main benefit of a tool would be making the patient understand if I am saying no to the surgery it is not because I don’t like him or her, it is because there is data written black on white that they are not going to do well…It will not just be my gut feeling. I can give them data and say "sorry it is written here. It is not me it is the computer". So it backs up what I am saying’. (013)
Q18	‘It comes back down to getting patient consent, as part of that I would incorporate it into my consent form and say preoperatively you have a 50:50 chance and that has been discussed with a validated tool. If the patient wishes to go ahead, they can make that informed decision’. (021)
Q19	‘A patient may be so severely impacted that a 1 in 2 shot is worth it…it is totally patient dependent’. (023)
Q20	‘You have got to be 95 per cent and above. I wouldn’t accept anything less than that. I wouldn’t offer the operation. It is too big an operation, too big a deal, too big a cost’. (024)
Q21	‘You have to think the medico-legal implications of a patient having a risk value documented in their notes. If they don’t have a good result and then some have the lawyers look through and say you had this tool that was validated and you still went ahead where would we lie medico-legally?’. (024)
Q22	‘I guess the ethicists would say you are denying patient-centred care, so that is where there is a potential for a can of worms’. (021)
Q23	‘I don’t think it can become compulsory because it takes away patient-centred care’. (025)
Q24	‘If you could use the tool to triage patients and push them some where else, it would be more effective for the patient and there would be cost savings for the hospital and the community’. (016)
Q25	‘You have to be able to say: "although we don’t think you would benefit from surgery, we are going to put you in this intense physiotherapy program with dieticians and this is how we are going to improve your knee pain’" They need to be offered something. The problem is these things are available at an individual component level - we have got dieticians and physiotherapists and exercise groups, but I don’t think there is anything formally put in place that patients can be referred from arthroplasty clinics into these program’. (029)
Q26	‘A lot of surgeons would say in their hands they will get better results, that is just an inherent bias associated with surgical procedures and surgeons themselves so it would be hard to agree on a level’. (019)
Q27	‘Well compulsory to have it? Ok. That would be easy to do and surgeons wouldn’t care as long as they didn’t have to do any work. Making it compulsory to follow it would be dangerous. Because we are all individuals, what you are doing is taking the human experience aspect of the consultation out and then you turn us into proceeduralists that just look at a tick box and operate on someone’. (016)
Q28	‘I can imagine something working on the phone, an app. It needs to be simple and intuitive - so you put in a little info - BMI, age, degree of arthritis etc… tick tick tick. And then it gives you the number, bang’. (013)
Q29	‘I think it is something that should be done by the surgeon. It is also part of the process where the surgeon gets to know the patient as well - not just their xrays and physical examination but also their psychosocial situation’. (019)
Q30	‘I would want the tool to be applied within the consultation. Because I would never believe a value until I have seen the person. Because we might just have one of those weird situations that fall out of the ‘normal’ range’. (010)
Q31	‘When you have got 10 minutes for a consultation you don’t have time to spend another 10 minutes going through the tool. So it would have to be either the patient themselves or secretarial person prior to the consultation’. (012)
Q32	‘I have a lot of patients look me up on my website. You could have a thing on your website saying: ‘sometimes patients with certain problems may not be appropriate for a TKA, this test can give you a rough idea of your success rate’. You could put it out there before they even come to see you. ‘Is this operation for you?’ type of thing’. (028)