Factors Influencing Vascular Surgeons' Compliance with Elective Repair Guidelines for Abdominal Aortic Aneurysm: A Qualitative Study.

Abstract

Despite guideline recommendations to delay elective abdominal aortic aneurysm (AAA) repair until the diameter exceeds the intervention threshold, a notable proportion of repairs occur earlier. This study aimed to explore factors influencing vascular surgeons' compliance with the intervention threshold regarding AAA repair, adopting a behavioural science perspective. This qualitative study employed semi-structured interviews with vascular surgeons. Twelve vascular surgeons, randomly selected from 30 Dutch hospitals, participated in face to face interviews between January and May 2024. The study was guided by a behavioural science approach, using the Theoretical Domains Framework (TDF), which incorporates 14 theoretical domains that can be organised into three overarching categories of the COM-B model: capability, opportunity, and motivation. Together, these domains provide a comprehensive overview of factors influencing compliance with clinical guidelines. Data analysis involved thematic analysis using ATLAS.ti, with codes inductively and deductively derived based on the TDF. Surgeons exhibited varying perspectives on early AAA repair. Some justified early intervention for patient centred reasons, while others regarded it as poor practice. Key factors influencing compliance included: surgeons' interpersonal communication skills in reassuring patients; surgeons' knowledge about measurement methods; environmental constraints, such as limited consultation time; social influences, such as patient pressure; surgeons' beliefs about the risks associated with early repair; incentives related to the reimbursement system; and surgeons' perceived capabilities in proposing a watchful waiting approach slightly below the intervention threshold. Suggestions to reduce early repair included tools for accurate rupture risk prediction, updated research on intervention thresholds, and additional consultation time and enhanced psychological support for patients. Vascular surgeons' behaviour regarding AAA repair near the intervention threshold is shaped by a complex interplay of factors within the TDF domains of capability, opportunity, and motivation. Addressing these factors could enhance adherence to evidence based guidelines, leading to more consistent practices that prioritise patient outcomes.