AAOS Registry Program Blog

Risk-Adjusted Orthopaedic Outcomes Enable Fair Comparisons

In the current era of health care reform, cost containment, and the growing focus on the value of care provided, high quality data on the results of orthopaedic care will be critically important (and may soon be demanded) down to the level of the individual institution and even surgeon.

According to David G. Lewallen, MD, Professor of Orthopaedic Surgery, Consultant in the Department of Orthopaedic Surgery, Mayo Clinic, and American Joint Replacement Registry (AJRR) Medical Director: "The availability of risk-adjusted national benchmark data will be increasingly important in fairly interpreting such information and is best developed from large representative datasets that span all age groups and demographics like the AJRR."

Donald Fry, MD, MPA Healthcare Solutions, said, "Many surgeons and quality officers point to their perception that they have the sickest patients to explain suboptimal results or bolster good performance." He added, "There is no question that an accurate interpretation of outcomes and costs cannot be made without an objective measurement of risk adjustment. It is the science of separating the effect of patient characteristics from the effect of care delivered on cost or clinical outcomes."

The American Joint Replacement Registry (AJRR) became part of the American Academy of Orthopaedic Surgeons (AAOS) on October 17, 2017. As AAOS embarks on registry expansion and integration with the AJRR, they remain dedicated to improving the quality of musculoskeletal care that orthopaedic surgeons can deliver. Within this mission, the AJRR, the national hip and knee registry, has maintained a U.S. Centers for Medicare & Medicaid Services (CMS)-approved qualified clinical data registry (QCDR) since 2014. Now known as the AAOS Orthopaedic Quality Resource Center, this unit has been designated by CMS as a QCDR for 2018.

You will have several opportunities to hear AJRR Steering Committee Chair Kevin J. Bozic, MD, MBA, and AJRR Medical Director David G. Lewallen, MD, speak at the American Academy of Orthopaedic Surgeons (AAOS) 2018 Annual Meeting. Today we will have a conversation with each. Our blog will "sample" some of the salient points they plan to make during their respective presentations. We are also alerting you to a poster on the correlation between hospital size and revision indication and where total joint arthroplasty (TJA) revision surgery is performed. All three offerings have high relevance to registry participants. If your organization is already an AJRR participant, don't forget to register for the AJRR In-person User Group Network (Unet) Meeting.

In 2017, the American Joint Replacement Registry (AJRR) achieved a major milestone entering over 1 million arthroplasty procedures into its database. This year's AJRR Annual Report gives the most comprehensive picture to date of U.S. hip and knee replacement patterns. The AJRR 2017 Annual Report collected data from 2012 to 2016 and contains 860,080 procedures. Reflecting rapid and accelerating growth, the Registry's 1 million milestone was achieved in March of last year.

"The Registry has seen significant participation growth since our previous report: a 101 percent increase in procedures, a 57 percent increase in reporting institutions, and a 50 percent increase in surgeons," said AAOS Registry Oversight Committee Chair Daniel J. Berry, MD. "Growth leads to more and better data, enables more actionable analysis, and yields insights that improve surgical decision support."

"AJRR's data has been invaluable in our pursuit to provide better care for our joint replacement patients," said Amanda James, CEO, Swedish Covenant Hospital.

Last month we presented a blog series entitled How to Build a Patient-Reported Outcomes Program (PRO) for Hip and Knee Arthroplasty. Reporting patient outcomes occurs in the final phases of a long treatment and rehabilitation process. Smart patient and clinical decision making beforehand will increase the likelihood of successful outcomes. To maximize the benefit of medical information exchange between patients and their health care providers, patient education is critical. Not all proactive patient education occurs in the doctor's office, so how can you help?

The Joint Commission's mission: to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

Joint Commission Certification is widely recognized as an indicator of exceptional quality in health care by both professionals and the public.

In the specialty of orthopaedics, the American Joint Replacement Registry (AJRR) has been one of The Joint Commission's primary registry stakeholders. AJRR and The Joint Commission began to formally collaborate in 2012 by establishing productive discussions that were focused on recognizing hospitals that submitted data to AJRR. The AJRR Public Advisory Board membership includes a representative from The Joint Commission. AJRR continues to have an active collaborative relationship with The Joint Commission on a variety of topics including their Orthopaedic Joint Replacement Certification process and making registry participation a key component.

Both organizations also collaborate with the International Consortium of Orthopaedic Registers (ICOR), the International Society of Arthroplasty Registries (ISAR), and the Physician Clinical Registry Coalition among others.

Together, Joint Commission Certification and AJRR participation make the whole greater than the sum of its parts, as the hospital and ambulatory surgery center (ASC) quality improvement subsections below demonstrate. This blog's conclusion looks at how to apply what you've learned to your organization's future certification, data registry, and quality improvement efforts.

A successful orthopaedic patient-reported outcomes (PRO) program must have resources that allow it to collect, store, and access its data (i.e., clinical information, device data, and PRO data) so that participants have an ability to compare their data to aggregate, national benchmarks. Understanding your patient outcomes compared to peers can support quality improvement efforts at both the hospital and surgeon level. Having the data from a robust national registry like the American Joint Replacement Registry (AJRR) enables hospitals and clinical practices to make informed decisions based on clinical facts and figures. Click here to review the data elements collected by AJRR and used for national benchmarking efforts.

5 PRO Analytic Resources and Tools to Consider:

Patient-reported outcomes (PROs) provide insights beyond standard clinical quality-of-care measures and further guide physician and patient understanding concerning patient health status, the decision-making process regarding patient care, and the evaluation of effectiveness of quality improvement initiatives. Building your PRO program begins with setting program goals and creating a successful process for PRO data collection and reporting.

One of the biggest challenges within a developing PROs program is compliance with the data gathering process. The diagram at the link below represents the typical workflow supporting a hospital's electronic-based patient-reported outcome measures (PROMs) collection to action effort.

Research has shown that the five workflow features listed below demonstrate valuable efficiencies within this process, and help to ensure that clinicians and patients will find program data collection and reporting requirements manageable and worthwhile.

5 Workflow Features for Implementation:

The increased demand for patient-reported outcome (PRO) data by regulators, payers, accreditors, and professional organizations is widely recognized. However, this blog installment will primarily address government initiatives that focus on PRO quality improvement and reimbursement considerations. Both federal and state governments are actively launching pilots and passing legislation related to the utilization of PROs to underpin value-based reimbursement of care. Maximize your institution's quality improvement and related reimbursement by monitoring PRO quality measures and creating a PROs program design that considers the future direction and requirements of the key government initiatives listed below.

At the federal level, PROs have already been incorporated into a variety of Centers for Medicare & Medicaid Services (CMS) efforts. At the state level, Texas became the first legislature to pass a bill related to PROs for musculoskeletal care through SB55. Governor Greg Abbott signed the bill into law on June 15, 2017, and a pilot program has commenced. Other states are monitoring the results of the initiative. Even if your institution is not in Texas, this pilot program may be considered by other states in the future.

Because government initiatives are subject to change, Rulemaking Alerts (RA) will be incorporated as a supplement to core content throughout this blog.

Top 5 Government Initiatives (Inclusive of PRO Measures):

Three fundamental goals should stand out when starting a patient-reported outcomes (PRO) program. First, you are determined to evaluate care by including outcomes based on the patient’s viewpoint along with other clinical measures. Longitudinally tracking patient assessment of pain and function can provide insights into the effectiveness of hip and knee arthroplasty across a much broader patient population than the relatively small number of patients that suffer implant failures and require surgery.

Second, you are determined to enable your institution’s provision of PRO data to the Centers for Medicare & Medicaid Services (CMS) and other payers as they continue defining quality measures for value-based reimbursement. For example, CMS defines PRO requirements within their Medicare reimbursement programs such as Comprehensive Care for Joint Replacement (CJR) model and the Merit-based Incentive Payment System (MIPS). MIPS recently replaced the Physician Quality Reporting System (PQRS). The demand for PRO data by regulators, payers, accreditors, and professional organizations has accelerated, as patient care associated with PRO programs has demonstrated improvement. Better technology for data capture has also accelerated demand.  

Finally, you are determined to use comparative data and PRO benchmarking to provide evidence for needed quality improvement work at both the hospital and surgeon level. National Registry data is often used to enable this effort.

If these goals are important to your institution, the five steps shared below will help you launch a successful PRO program: