This blog is the second in a three-part series reporting on orthopaedic studies presented at the 2019 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting and utilizing American Joint Replacement Registry (AJRR) registry data. All presentations are reported by Terry Stanton, senior science writer for AAOS Now.

Paper 877, “An Early Look at Patient-Reported Outcome (PRO) Data” was presented by Kevin J. Bozic, MD, MBA, chair of the AJRR, on Thursday, March 14, 2019 at the AAOS Annual Meeting in Las Vegas, Nevada. The study offers an “early look” at patient-reported outcome (PRO) data from the AJRR, a part of the AAOS Registry Program. Dr. Bozic explained that the study covered differences between patient-reported outcome measures (PROMs) from submitters and nonsubmitters and the response rates tallied so far for PROMs.

AJRR developed a PROM platform that was made available to Registry participants in 2016. Suggested PROMs for total joint replacement patients included the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR.), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR.), Patient-reported Outcomes Measurement Information System (PROMIS) Global Health, and Veterans RAND 12-item health survey (VR-12). The California Joint Replacement Registry (CJRR), which was integrated into AJRR in 2017, required submission of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); VR-12; and University of California, Los Angeles Activity Score. 

By the end of October 2018, 142 of 753 (18.9 percent) AJRR institutions submitted PROM data.  Of those submissions, 134 sites (94.4 percent) submitted the AJRR-recommended PROMs (HOOS, JR.; KOOS, JR.; PROMIS-Global, and VR-12). Hospital size and teaching type of submitting institutions were defined per the AHA Annual Survey Database Fiscal Year 2015. There was no significant difference between PROM submitters and nonsubmitters in terms of teaching versus non-teaching institution. However, for bed count, PROM submitters were significantly different: 54.9 percent of submitters were medium size (versus 45.0 percent of nonsubmitters) and 31.3 percent of submitters were large size (versus 19.3 of nonsubmitters) (P < 0.001). Of all AJRR PROM submitters, 30 institutions (21.1 percent) were from CJRR. As such, significantly more hospitals in the western region submitted PROMs compared to other U.S. regions (P < 0.001). 

In terms of patient response rates, there was no difference in mean age or sex between patients who completed both a preoperative and one-year postoperative PROM (mean age, 68 ± 9.72 years; 57.3 percent female) and patients who did not complete both PROMs (mean age, 67 ± 11.2 years; 57.8 percent female). Although there was no difference in mean age, when age was stratified by decade of life, completion of PROMs was comparable in patients aged 70–79 years (33.3 percent) and 60–69 years (37.4 percent).

Sixty-three of the 142 AJRR institutions (44.3 percent) submitting PROMs had at least one linked (baseline and one-year postoperative) assessment. The overall response rates for patients with a linked PROM were 15.2 percent for HOOS, JR.; 18.1 percent for KOOS, JR.; 14.2 percent for PROMIS-Global; and 33.8 percent for VR-12.

For PROM submitters from CJRR, the average response rate for the WOMAC was 15.1 percent (range, 5.2–44.7 percent). Of the linked PROMs, 94.2 percent and 91.4 percent of patients reported clinically meaningful improvement in their scores from baseline to one-year postoperatively in the HOOS, JR. and KOOS, JR. scores, respectively. For quality-of-life measures, meaningful improvement was 43.1 percent for PROMIS Global Mental Health, 75.8 percent for PROMIS Global Physical Health, 39.0 percent for VR-12 Mental Component, and 77.0 percent for VR-12 Physical Component scores.

“PROM completion rates of 15 percent to 33 percent (depending on PROM) suggest that completion rates remain problematic for AJRR institutions, consistent with other studies,” the study authors wrote. “The true challenge of implementing PROMs in a registry while gaining and reporting meaningful results relates to data capture and response rates. Response rates for PROMs across orthopaedics can be a challenge. So, while a provider may intend to achieve high response rates, collection of PROM surveys requires significant manpower dedicated to ensuring high completion rates, and may not yield a robust volume of PROM data.”

The authors concluded: “As more providers begin to incorporate the use of PROMs into their care delivery model, further study is necessary to identify barriers and facilitators to use of registries for PROM measurement. Additional studies may further investigate mode of collection based on patient and institution characteristics, points of contact for collection, and provider buy-in and utilization of PROMs in patient interactions as factors related to data capture and response rates. Registries such as the AJRR reflect the current state of adoption of using PROMs in clinical decision-making, performance improvement, and implementation of value-based payment and delivery models across institutions.”

If you have any additional questions about the study, feel free to contact us at RegistryInfo@aaos.org. 

Dr. Bozic’s coauthors of “An Early Look at Patient-Reported Outcome Data from the AJRR” are Caryn D. Etkin, PhD, MPH; Peter B. Shores, MPH; and September R. Cahue, MPH.

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