title: Appropriateness for Total Joint Replacement: Perspectives of Decision-Makers.
abstract: Improving access to total joint replacement (TJR) has been a priority. Without robust mechanisms to ensure appropriateness, these procedures may be overused, incurring substantial costs. In that context, decision-makers are particularly concerned with the appropriateness of TJR.
  
  
  
  While our previous research focused on the appropriateness of TJR from clinical and patient perspectives, this study is aimed at understanding decision-makers' perspectives.
  
  
  
  Using a semi-structured guide, we interviewed a convenience sample of decision-makers in four Canadian provinces (Alberta, Manitoba, Nova Scotia and Quebec) between February and March 2013. For the purposes of this study, a decision-maker was defined as a manager, institutional leader or policy maker.
  
  
  
  Fifteen interviews were conducted with decision-makers at ministry (n = 3), regional (n = 6) and institutional levels (n = 8). Decision-makers see themselves as having a key role in the appropriateness discourse, that of optimizing resource allocation and efficient delivery of services for TJR, to improve population outcomes.
  
  
  
  The decision-makers' view of appropriateness recognizes the importance of the clinical view, but it offers a very different input into the appropriateness discourse, more closely aligned with appropriateness of setting, which refers to cost-effectiveness considerations.
authors.affiliation: PhD Student, École de Santé Publique de l'Université de Montréal (ESPUM), Université de Montréal, Montréal, QC.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Clavel
authors.affiliation: Adjunct Research Professor, Department of Community Health Sciences, University of Calgary, Calgary, AB.
authors.forename: Carolyn
authors.initials: C
authors.lastname: De Coster
authors.affiliation: Full Professor, École de Santé Publique de l'Université de Montréal (ESPUM), Université de Montréal, Montréal, QC.
authors.forename: Marie-Pascale
authors.initials: MP
authors.lastname: Pomey
authors.affiliation: Adjunct Research Professor, Department of Community Health Sciences, University of Calgary, Calgary, AB.
authors.forename: Claudia
authors.initials: C
authors.lastname: Sanmartin
authors.affiliation: Assistant Professor, Department of Surgery, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, MB.
authors.forename: Éric
authors.initials: É
authors.lastname: Bohm
authors.affiliation: Professor, Division of Orthopaedics, Dalhousie University, Halifax, NS.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Dunbar
authors.affiliation: Professor, Division of Orthopaedics/Department of Surgery, University of Calgary, Calgary, AB.
authors.forename: C Y
authors.initials: CY
authors.lastname: Frank
authors.affiliation: Department of Medicine, Women's College Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
authors.forename: Gillian
authors.initials: G
authors.lastname: Hawker
authors.affiliation: Professor, Department of Community Health Sciences and Institute for Public Health, University of Calgary, Calgary, AB.
authors.forename: Tom
authors.initials: T
authors.lastname: Noseworthy
mesh_terms: D000288:Administrative Personnel; D019643:Arthroplasty, Replacement / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D002170:Canada; D003362:Cost-Benefit Analysis; D006291:Health Policy / Q000191:economics; D006300:Health Services Misuse; D006801:Humans; D007407:Interviews as Topic; D000069342:Medical Overuse