The Equivalence of Remote Electronic and Paper Patient Reported Outcome (PRO) Collection

New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting

This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) - the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.

Capturing patient-reported outcomes: paper versus electronic survey administration

Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.

Does the use of telephone reminders to increase survey response rates affect outcome estimates? An ancillary analysis of a prospective cohort study of patients with low back pain

Background

Research is often undertaken using patient-reported outcomes from questionnaires. Achieving a high response rate demands expensive and time-consuming methods like telephone reminders. However, it is unknown whether telephone reminders change outcome estimates or only affect the response rate in research of populations with low back pain (LBP). The aim is to compare baseline characteristics and the change in outcome between patients responding before and after receiving a telephone reminder.

Methods

This is an ancillary analysis of data from a prospective cohort study employing questionnaires from 812 adults with LBP lasting more than 3 months. Patients not responding to the 52-week questionnaire were sent reminder emails after two and 3 weeks and delivered postal reminders after 4 weeks. Patients still not responding were contacted by telephone, with a maximum of two attempts. Patients were categorised into three groups: 1) patients responding before a telephone reminder was performed; 2) patients responding after the telephone reminder and 3) patients not responding at all. A positive outcome was defined as a 30% improvement on the Roland Morris Disability Questionnaire after 52 weeks.

Results

A total of 695 patients (85.2%) responded. Of these, 643 patients were classified in Group 1 and 52 patients were classified in Group 2. One hundred seventeen were classified in Group 3. No differences in outcome or baseline characteristics was found. In Group 1, 41.3% had a positive outcome, and in Group 2 48.9% had a positive outcome (P = 0.297). In group 3, non-respondents were younger, more often unemployed, more often smokers, more often reported co-morbidity, and reported higher depression scores than respondents.

Conclusions

Using a telephone reminder had no consequence on outcome estimates nor were there any differences in baseline characteristics between patients who responded before or after the telephone reminder.

Trial registration

The initial trial was registered in Clinicaltrials.gov (NCT03058315).

Implementation and quality assessment of a clinical orthopaedic registry in a public hospital department

BACKGROUND

The aim of this study was to demonstrate a novel method of assessing data quality for an orthopaedic registry and its effects on data quality metrics.

METHODS

A quality controlled clinical patient registry was implemented, comprising six observational cohorts of shoulder and knee pathologies. Data collection procedures were co-developed with clinicians and administrative staff in accordance with the relevant dataset and organised into the registry database software. Quality metrics included completeness, consistency and validity. Data were extracted at scheduled intervals (3 months) and quality metrics reported to stakeholders of the registry.

RESULTS

The first patient was enrolled in July 2017 and the data extracted for analysis over 4 quarters, with the last audit in August 2018 (N = 189). Auditing revealed registry completeness was 100% after registry deficiencies were addressed. However, cohort completeness was less accurate, ranging from 12 to 13% for height & weight to 90-100% for operative variables such as operating surgeon, consulting surgeon and hospital. Consistency and internal validation improved to 100% after issues in registry processes were rectified.

CONCLUSIONS

A novel method to assess data quality in a clinical orthopaedic registry identified process shortfalls and improved data quality over time. Real-time communication, a comprehensive data framework and an integrated feedback loop were necessary to ensure adequate quality assurance. This model can be replicated in other registries and serve as a useful quality control tool to improve registry quality and ensure applicability of the data to aid clinical decisions, especially in newly implemented registries.

TRIAL REGISTRATION

ACTRN12617001161314; registration date 8/08/2017. Retrospectively registered.

Evaluation of the Paper and Smartphone Versions of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) and the Patient Health Questionnaire-9 (PHQ-9) in Depressed Patients in China

PURPOSE

Smartphone-based questionnaires have advantages compared with their paper versions, but there is a lack of consistent research on depressive disorder questionnaires. This study aimed to assess the equivalence between the paper and smartphone versions of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) and Patient Health Questionnaire-9 (PHQ-9) for patients with depressive disorders in psychiatric hospitals in China.

PATIENTS AND METHODS

This was a randomized crossover study of 110 depressed patients recruited from the outpatient department of Beijing Anding Hospital from March 2016 to September 2018. Group 1 completed both the QIDS-SR16 and PHQ-9 in paper format and then completed the smartphone version 1-2 h later. Group 2 completed the scales in the reverse order. Reliability was evaluated using intraclass correlation coefficients (ICCs) with 95% confidence intervals (CI). The expected ICC was 0.9 (α=0.05).

RESULTS

The overall ICC score of the QIDS-SR16 paper and smartphone versions was 0.904 (95% CI: 0.861-0.934), and the ICCs of each item ranged from 0.769 to 0.923. The overall ICC score of the PHQ-9 paper and smartphone versions was 0.951 (95% CI: 0.929-0.967), and the ICCs of each item ranged from 0.779 to 0.914.

CONCLUSION

This study demonstrated the equivalence of the paper and smartphone versions of the PHQ-9 and QIDS-SR16 in depressed patients in China.

Is virtual clinic follow-up of hip and knee joint replacement acceptable to patients and clinicians? A sequential mixed methods evaluation

Objective

To evaluate the acceptability to key stake holders of a newly introduced virtual clinic follow-up pathway for hip and knee joint replacement.

Design

A service evaluation comprising a questionnaire sent electronically to 115 patients and interviews with 10 individuals.

Setting

A newly introduced virtual clinic follow-up pathway for hip and knee replacement patients in a district general hospital.

Participants

The electronic questionnaire was distributed to all patients treated under the virtual clinic service over a 5-month period (n=115). Purposive sampling from volunteers among respondents, leading to semi-structured interviews with eight patients. Two orthopaedic consultants were also interviewed.

Intervention

Consultant review of web-based patient reported outcome measures and digital radiographs, with feedback to patients via letter, replacing face-to-face outpatient appointments for the follow-up of hip and knee joint replacement.

Results

The response rate to the questionnaire was 40%. 44% indicated they would prefer a virtual appointment over a face-to-face consultation in future. The most common word in the free text comments was ‘good’ (n=107).

Seven main themes were identified from the patient interviews: patient understanding and expectations, patient confidence, patient voice, managing deterioration of condition, patient benefit, patient satisfaction using technology and navigating the website.

Two main themes were identified from the staff interviews: the adapting patient pathway and project management.

Combined analysis elucidated that patients who were doing well liked the ‘click and go’ approach but those with problems were concerned about how to report these and were therefore less satisfied.

Conclusion

The virtual clinic process appears to be well accepted by both patients and clinicians. However, appropriate patient selection and clear pathways of communication to address patient concerns are pivotal to success.

Asymptomatic reference values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation - electronic data collection and its clinical implications

The purpose of this study was to establish normal asymptomatic population values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation in healthy, asymptomatic individuals of different age, gender, ethnicity, handedness and nationality, using electronic data collection. Two-hundred and ninety-two Australian and 293 Canadian citizens with no active wrist pain, injury or pathology in their dominant hand, were evaluated. Participants completed an electronically administered questionnaire and were assessed clinically. There was no statistically significant association between both wrist scores and nationality. There was a statistically significant association between both wrist scores and age, demonstrating that as age increased, normal wrist function declined. This study has established an electronic, asymptomatic control group for future studies using these scores. When using the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation, the control group can be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin. Level of evidence: II.

Asymptomatic population reference values for three knee patient-reported outcomes measures: evaluation of an electronic data collection system and implications for future international, multi-centre cohort studies

OBJECTIVES

The aim was to assess whether the Knee Society Score, Oxford Knee Score (OKS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) were comparable in asymptomatic, healthy, individuals of different age, gender and ethnicity, across two remote continents. The purpose of this study was to establish normal population values for these scores using an electronic data collection system.

HYPOTHESIS

There is no difference in clinical knee scores in an asymptomatic population when comparing age, gender and ethnicity, across two remote continents.

METHODS

312 Australian and 314 Canadian citizens, aged 18-94 years, with no active knee pain, injury or pathology in the ipsilateral knee corresponding to their dominant arm, were evaluated. A knee examination was performed and participants completed an electronically administered questionnaire covering the subjective components of the knee scores. The cohorts were age- and gender-matched. Chi-square tests, Fisher's exact test and Poisson regression models were used where appropriate, to investigate the association between knee scores, age, gender, ethnicity and nationality.

RESULTS

There was a significant inverse relationship between age and all assessment tools. OKS recorded a significant difference between gender with females scoring on average 1% lower score. There was no significant difference between international cohorts when comparing all assessment tools.

CONCLUSIONS

An electronic, multi-centre data collection system can be effectively utilized to assess remote international cohorts. Differences in gender, age, ethnicity and nationality should be taken into consideration when using knee scores to compare to pathological patient scores. This study has established an electronic, normal control group for future studies using the Knee society, Oxford, and KOOS knee scores.

LEVEL OF EVIDENCE

Diagnostic Level II.

An international, multicenter cohort study comparing 6 shoulder clinical scores in an asymptomatic population

HYPOTHESIS

The study purpose was to assess 6 shoulder patient-reported outcome measure (PROM) values in asymptomatic, healthy, pathology-free individuals. We hypothesized that there would be no difference in PROM values in pathology-free individuals when considering sex, age, ethnicity, and geographical location.

METHODS

Electronic questionnaires were completed by 635 individuals (323 Australians and 312 Canadians) without dominant shoulder pathology for the American Shoulder and Elbow Surgeons (ASES) shoulder score; Constant-Murley Shoulder Score (CSS); Oxford Shoulder Score (OSS); University of California, Los Angeles (UCLA) shoulder score; Shoulder Pain and Disability Index (SPADI); and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Shoulder range of motion and strength were assessed.

RESULTS

No difference was identified between subjective-only and subjective-objective PROMs. Handedness and a current elbow or wrist problem were not associated with differences in PROM values. Poorer PROM values were associated with a history of an inactive shoulder problem and increasing age. Female participants tended to report similar or poorer PROM scores. No significant difference was found between ethnicities. Geographical location was associated with differences in the ASES shoulder score, UCLA shoulder score, and SPADI but not the CSS, SPONSA, and OSS.

CONCLUSIONS

Differences in sex, age, and geographical location will affect PROM shoulder scores in pathology-free individuals and should be taken into consideration when PROMs are being used to compare patient outcomes. This study has established normative values for the ASES shoulder score, CSS, OSS, UCLA shoulder score, SPADI, and SPONSA. Future studies assessing a pathologic patient cohort should perform comparisons against a sex- and age-matched control cohort, ideally sourced from the same geographical location.

Normal population reference values for the Oxford and Harris Hip Scores - electronic data collection and its implications for clinical practice

BACKGROUND

The aim of this study was to assess whether the Harris Hip Score (HHS) and the Oxford Hip Score (OHS) were comparable in normal, healthy, pathology-free individuals of different age, gender, ethnicity, handedness and nationality. The purpose of this study was to establish normal population values for the HHS and OHS using an electronic data collection system.

METHODS

317 Australian and 310 Canadian citizens with no active hip pain, injury or pathology in the ipsilateral hip corresponding to their dominant arm, were evaluated. Participants completed an electronically-administered questionnaire and were assessed clinically. Chi-square tests, Fisher's exact test and Poisson regression models were used where appropriate, to investigate the association between hip scores, ethnicity, nationality, gender, handedness and age.

RESULTS

There was a statistically significant association between the OHS and age (p<0.0001) and the HHS and age (p = 0.0006); demonstrating that as age increased, normal hip scores decreased. There was no statistically significant association between the HHS and gender (p = 0.1389); or HSS and nationality, adjusting for age (p = 0.5698) and adjusting for gender (p = 0.6997). There was no statistically significant association between the OHS and gender (p = 0.1350). Australians reported a statistically significant 4.2% higher overall OHS value compared to Canadians (p = 0.0490). There was no statistically significant association between the OHS and nationality in age groups 18-79 years. Participants >80 years reported a statistically significant association between the OHS and nationality (p<0.0001).

CONCLUSIONS

Studies using an electronic control group should consider differences in gender, age, ethnicity and nationality when using the HHS and OHS to assess patient outcomes. This study has established an electronic, normal control group for studies using the HHS and OHS. When using the OHS, the control group should be sourced from the same country of origin. When using the HHS, the control group should be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin.

Multiple sclerosis: clinical profiling and data collection as prerequisite for personalized medicine approach

Multiple sclerosis (MS) is a highly heterogeneous disease as it can present inter-individually as well as intra-individually, with different disease phenotypes emerging during different stages in the long-term disease course. In addition to advanced immunological, genetic and magnetic resonance imaging (MRI) profiling of the patient, the clinical profiling of MS patients needs to be widely implemented in clinical practice and improved by including a greater range of relevant parameters as patient-reported outcomes. It is crucial to implement a high standard of clinical characterization of individual patients as this is key to effective long-term observation and evaluation.

To generate reliable real-world data, individual clinical data should be collected in specific MS registries and/or using intelligent software instruments as the Multiple Sclerosis Documentation System 3D. Computational analysis of biological processes will play a key role in the transition to personalized MS treatment. Major breakthroughs in the areas of bioinformatics and computational systems biology will be required to process this complex information to enable improved personalization of treatment for MS patients.

Subjects with osteoarthritis can easily use a handheld touch screen electronic device to report medication use: qualitative results from a usability study

OBJECTIVES

Electronic data capture is increasingly used to improve collection of patient-reported outcome measures in clinical trials and care. The validation of electronic patient-reported outcome devices requires information on patient preference and ease of use. This study conducted usability testing for a General Symptom Questionnaire and Medication Module™ on a handheld device for subjects with osteoarthritis (OA) to determine whether subjects can report on their symptoms and medication use using an electronic diary.

METHODS

Nine subjects with OA participating in a large US mode equivalency study were surveyed independently in this study. Subjects completed a General Symptom Questionnaire and Medication Module™ using the LogPad^® LW handheld device. Demographic and technology use information was collected, and the subjects were queried on device usability.

RESULTS

Subjects reported that the handheld device was easy to use and that they were able to complete a General Symptom Questionnaire and Medication Module™ with little or no assistance. They did not report any issues with the screen or size of the device. Subjects were willing to travel with the device to complete electronic diaries at home or in public. Participants indicated that they would be able to use the handheld device to answer questions during a clinical trial. Subjects with OA experienced no physical discomfort during completion of either questionnaire.

CONCLUSION

The General Symptom Questionnaire and Medication Module™ were usable and acceptable to subjects with OA on a handheld device. This was consistent regardless of previous experience and confidence with technology, despite the potential physical restrictions for an OA cohort.

Pathophysiology and risk factors for osteonecrosis

Osteonecrosis, also known as avascular necrosis or AVN, is characterized by a stereotypical pattern of cell death and a complex repair process of bone resorption and formation. It is not the necrosis itself but rather the resorptive component of the repair process that results in loss of structural integrity and subchondral fracture. Most likely, a common pathophysiological pathway exists involving compromised subchondral microcirculation. Decreased femoral head blood flow can occur through three mechanisms: vascular interruption by fractures or dislocation, intravascular occlusion from thrombi or embolic fat, or intraosseous extravascular compression from lipocyte hypertrophy or Gaucher cells. In this review, we emphasize etiologic relationships derived mostly from longitudinal cohort studies or meta-analyses whose causal relationships to osteonecrosis can be estimated with confidence. Understanding risk factors and pathophysiology has therapeutic implications since several treatment regimens are available to optimize femoral head circulation, interrupt bone resorption, and preserve the subchondral bone.