REACT Study: do RandomisEd trials Alter Clinical pracTise? A Qualitative Study

Background The STITCH trial published high quality randomised data demonstrating the superiority of small bite over mass closure for the reduction of incisional hernias following elective laparotomy. Previous research has shown time taken for the implementation of evidenced based practise is, on average, 17 years. We aim to understand barriers to implementation of small bite closure into clinical practise. Methods Semi-structured interviews were completed with surgeons at a single institution in South West England. Interview transcripts underwent thematic analysis with themes identified following coding and subsequent iterative discussions within the research team. Results Nine interviews of eight general surgical consultants and registrars and one urological consultant were performed. Average duration of the interviews was 22:49 minutes (14:20-36.37). Three themes were identified as barriers to the introduction of small bite closure. ‘Trusting the Evidence & Critical Appraisal’ highlighted issues with the published trial and access to data. ‘Surgical Attitude to Risk’ identified differences in personality traits and the importance of guidelines from professional bodies to support practise change. ‘Adopting Evidence in Practise’ discussed training availability, system and patient issues within local hospitals. Conclusion Surgeons have to manage the balance between pushing boundaries to improve outcomes and a safety first approach. This influences the adoption of new techniques, such as small bite closure. This study has identified three themes that result in differences in the adoption of a new technique for midline closure. There are possible areas for intervention, to decrease the adoption time for randomised evidence.