New CMS Policy on the Mandatory Collection of Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty by 2027: What Orthopaedic Surgeons Should Know

What Matters Most for Patient Satisfaction Following Total Knee Arthroplasty? A Prospective Institutional Assessment of Individual Questions Captured by KOOS and VR-12 Mental Composite Score

Patient-reported outcome measures (PROMs) are crucial in evaluating the success of primary total knee arthroplasty (TKA). This study aimed to determine the individual significance of each question of the Knee Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12 (VR-12) Mental Composite Score (MCS) in achieving a Patient Acceptable Symptom State (PASS).A prospectively collected cohort of 9,942 unilateral elective TKAs was analyzed. Responses were collected for 17 KOOS questions (KOOS-Pain subscore, KOOS-Physical Function Short form [PS], and KOOS-Joint related [JR]) and 6 MCS questions preoperatively and 1-year postoperatively. Achievement of PASS was assessed through a positive response to a binary satisfaction-related question. The association between responses to questions and outcomes was examined via multivariable logistic regression models.A poorer preoperative response to knee pain frequency (odds ratio [OR] = 0.86 [0.77-0.97], p = 0.017) and knee pain while sitting or lying (OR = 0.88 [0.79-0.99], p = 0.029) was independently associated with reduced odds of achieving PASS at 1-year post-TKA. A more favorable preoperative response in knee pain during full knee straightening was independently associated with an increased odds of PASS attainment (OR = 1.10 [1.01-1.19], p = 0.035). No other metric was independently associated with PASS attainment at 1 year.Individual KOOS questions evaluating knee pain frequency, knee pain while sitting or lying down, and knee pain during full knee straightening were linked to patient satisfaction 1 year following TKA. Patients experiencing frequent or persistent knee pain at rest may represent those with more advanced joint disease or heightened pain sensitivity, contributing to lower postoperative satisfaction. Conversely, patients reporting minimal or no pain during specific movements, such as full knee straightening, likely had a less severe baseline condition, making their postoperative expectations more easily attainable, thereby leading to higher satisfaction.Level of evidence III.

Comparing Facility Costs, Patient-Reported Outcome Measures, and Revision Rates in Cementless and Cemented Primary Total Knee Arthroplasty: Findings from a Propensity Score Matched Patient-Level Value Analysis of 380 Procedures with Mean 4.3-Year Follow-Up

BACKGROUND

Healthcare value accounts for clinical outcomes and cost. A methodology for more accurate cost accounting is time-driven activity-based costing (TDABC). No prior study has evaluated the value of cementless total knee arthroplasty (TKA) using TDABC.

METHODS

We performed a retrospective propensity score-matched analysis of 76 cementless TKAs and 304 cemented TKAs with a mean follow-up of 4.3 years (range, 1.7 to 8.5 years). Reference pricing for implants was used, and cementless implants were available at a premium price relative to reference pricing. Value was the primary outcome and was defined twofold: Absolute Value KOOS-PS was the quotient of 1-year Knee Osteoarthritis Outcome Score-Physical Function Short-Form KOOS-PS and facility cost; Incremental Value KOOS-PS was the quotient of delta KOOS-PS and facility cost. Revision rate was also compared, but not factored into our value equation.

RESULTS

Cementless TKAs had significantly higher total facility costs than cemented TKAs (971 versus 800 cost units [CUs]; percent difference: +21.4%; P < 0.001). The cost difference was principally related to cementless TKAs having higher implant costs (542 versus 367 CUs; percent difference: +47.7%; P < 0.001). There were no significant differences in KOOS-PS scores. Cementless TKA was found to have significantly reduced mean Absolute Value KOOS-PS (48.3 versus 58.1; P < 0.001) and Incremental Value KOOS-PS (16.5 versus 20.3; P = 0.038). The revision rate at the mean 4.3-year follow-up was low and similar (3.9 versus 2.3%; P = 0.42).

CONCLUSION

We compared value (defined as 1-year PROMs relative to facility costs) between cementless and cemented TKA. Cementless TKAs demonstrate lower value at a mean 4.3-year follow-up due to differences in implant cost. Increased value for cementless TKA is ultimately plausible if reductions in revision rates beyond 5-year follow-up are observed or if cementless TKA implants are incorporated in reference pricing matrices to reduce their cost.

Mapping the importance of each individual element accounted by HOOS and VR-12 on 1-year patient satisfaction after primary total hip arthroplasty: a prospective institutional analysis

BACKGROUND

This study aimed to determine the significance of individual questions from the hip osteoarthritis outcome score (HOOS), HOOS Physical Function Shortform (PS), HOOS Joint Replacement (JR), and Veterans-Rand (VR)-12 mental composite score (MCS) in achieving a patient acceptable symptom state (PASS).

METHODS

A retrospective study of a prospectively collected cohort of 8236 unilateral elective primary THAs was analyzed. Responses were collected for 18 HOOS questions (pain, PS, and JR) and 6 VR-12 questions used to calculate MCS preoperatively and 1-year postoperatively. PASS was assessed through a positive response to a binary satisfaction-related question. The association between responses to questions and outcomes was examined via multivariable logistic regression models stratified by sex.

RESULTS

Sex-specific differences in PASS attainment were observed. In males, a poorer preoperative response in HOOS-PS assessing a patient's difficulty to sit or run comfortably due to their hip was independently associated with reduced odds of achieving PASS at 1-year post-THA (odds ratio [OR] = 0.66 [95% confidence interval [CI] 0.52-0.83], P = 0.001, and OR = 0.83 [0.73-0.95], P = 0.01, respectively). Additionally, a more favorable preoperative response in the MCS metric of feeling down and blue (OR = 1.15 [95% CI 1.03-1.28], P = 0.01) was associated with increased PASS attainment, whereas a poorer preoperative response to having energy (OR = 0.86 [95% CI 0.76-0.97], P = 0.02) was associated with reduced PASS attainment. In females, only a poorer preoperative response in feeling calm and peaceful (OR = 0.87 [95% CI 0.78-0.96], P = 0.01) was associated with reduced odds of PASS attainment.

CONCLUSION

Individual questions of the HOOS and VR-12 MCS were identified as being independently associated with achieving patient satisfaction at one-year following THA. Notably, predictors of satisfaction differed by sex, with both physical function and mental health factors playing a larger role in males, while mental health alone was predictive in females. Understanding specific aspects that matter most to patients, such as mental health, allows healthcare providers to tailor their care to better meet patients' needs. This approach could involve counseling, stress management techniques, and interventions aimed at reducing feelings of depression and anxiety.

LEVEL OF EVIDENCE

III.

How Can the Use of Patient-Reported Outcomes Data by Orthopaedic Surgeons Be Improved? A National Qualitative Study

BACKGROUND

Routine collection of patient-reported outcome measures (PROMs) is increasing within orthopaedic settings. Although PROMs have the potential to aid orthopaedic surgeons in clinical decision-making, surgeon engagement with and use of these data is limited. Identifying and addressing the facilitators and barriers to the use of PROMs data by orthopaedic surgeons may increase their usage in routine clinical practice.

QUESTIONS/PURPOSES

In a qualitative study, we asked: (1) What are the barriers to the use of PROMs data by orthopaedic surgeons? (2) What are the facilitators to the use of PROMs data by orthopaedic surgeons? (3) How can orthopaedic surgeons' uptake of and engagement with PROMs data in clinical practice be enhanced?

METHODS

A descriptive qualitative study design was undertaken by enrolling 20 orthopaedic surgeon participants (18 of whom were men). The surgeons were purposively sampled from a carefully curated matrix developed from the research team's professional contacts. This sampling database comprised surgeons performing arthroplasty and endeavored to span a range of demographic and professional characteristics including practice setting (metropolitan and regional Australia, private and public hospitals), clinical experience (< 10 years to 30+ years), and surgeon age (30 to 39 years to 70 to 79 years). In total, 28 orthopaedic surgeons were invited to participate, of which 25 were determined to be eligible. Following established qualitative methods, surgeon recruitment, data collection, and data analysis occurred concurrently. Specifically, invitations to participate were sent to potentially eligible surgeons in successive batches, with ongoing consideration of diversity in sample characteristics. The interviewer determined that thematic saturation had occurred after analyzing the final four interviews, which revealed repetitive themes and no new insights, leading to the cessation of recruitment after 20 interviews. Individual semistructured interviews explored participants' perceptions of factors that support and hinder the use of orthopaedic PROMs data in clinical practice. Surgeons' views on enhancing the utilization of PROMS data were also sought, including opportunities for improving electronic PROMs reporting systems, using a national registry platform as an exemplar. To enhance methodological rigor and reduce researcher bias, five randomly selected, deidentified interview transcripts were independently reviewed by two researchers to ensure consistency in coding and theme development. A combined deductive and inductive approach was then used for data analysis, enabling the categorization of themes into barriers, enablers, and opportunities for improving PROMs use by orthopaedic surgeons.

RESULTS

Key barrier themes impacting orthopaedic surgeons' use of PROMs data included time constraints and a lack of awareness or understanding of PROMs and how these data could be used. Key facilitator themes included better availability of PROMs-specific reports, including reporting within hospital-level audits and providing opportunities for surgeon participation in PROMs research activities to improve familiarization with PROMs data. To increase the use of PROMs data in clinical practice, participants suggested the development and delivery of multiple PROMs education options (for example, seminars and written materials such as email communications with practical examples of PROMs use in clinical practice) for orthopaedic surgeons, continuing education incentives for using PROMs data (for continuing professional development points for reviewing individual PROMs reports), and modern technology solutions (including portable options of PROMs systems) to improve ease of access.

CONCLUSION

Despite the widespread availability of PROMs data, an incomplete understanding of how to interpret and utilize the data effectively could be addressed if surgeons are provided with supportive educational tools. We will conduct further research to facilitate the development of these tools through codesign methods with surgeons, with careful consideration of the time limitations that impact surgeons' abilities to access and utilize PROMs data.

CLINICAL RELEVANCE

Targeted educational tools, codeveloped with orthopaedic surgeons, could help realize the potential of PROMs data to support shared decision-making and patient care.

Achieving the Centers for Medicare and Medicaid Services Defined Substantial Clinical Benefit Following Total Knee Arthroplasty and Total Hip Arthroplasty in the Michigan Arthroplasty Registry Collaborative Quality Initiative

INTRODUCTION

The Centers for Medicare & Medicaid Services (CMS) mandates patient-reported outcome measure (PROM) reporting for inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) starting July 1, 2024, requiring preoperative (zero to 90 days) and postoperative (300 to 425 days) scores for ≥ 50% of claims. Substantial clinical benefit (SCB) is defined as a 22-point Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) improvement for THA and a 20-point Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) improvement for TKA, with a CMS-defined goal for hospitals to achieve SCB for ≥ 60% of patients. The purpose of this study was to assess the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) sites' readiness to meet these CMS PROM collection requirements and their success in achieving SCB thresholds.

METHODS

We analyzed 8,826 THAs and 12,210 TKAs performed between January 1, 2022, and June 30, 2022, in MARCQI. Matched pre- and postoperative PROMs and SCB rates were assessed across 81 sites.

RESULTS

Only 22.1% of the patients who underwent THA and 22.7% of the patients who underwent TKA had matched PROMs, and 7.4% of sites met CMS thresholds for collection. However, 90% of sites with matched PROMs met the SCB threshold.

CONCLUSION

For a statewide registry in Michigan, few sites met CMS collection requirements, but most achieved SCB targets. These findings reflect the experience of a diverse group of MARCQI sites and may not be generalizable to other states or institutions.

Measures of Clinical Meaningfulness for the Hip Disability and Osteoarthritis Outcome Score Vary by Aseptic Revision Total Hip Arthroplasty Diagnosis

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly important in assessing revision total hip arthroplasty (THA) outcomes, yet diagnosis-specific thresholds for clinical relevance remain largely undefined. This study aimed to determine diagnosis-specific minimal clinically important difference (MCID), patient-acceptable symptom state (PASS), and substantial clinical benefit (SCB) thresholds for the Hip Disability and Osteoarthritis Outcome Score (HOOS) subscales in aseptic revision THA.

METHODS

A prospective cohort of 466 patients who underwent aseptic revision THA between 2016 and 2022 was analyzed. Patients were stratified by diagnosis: aseptic loosening (n = 232), implant failure (n = 112), instability (n = 78), and periprosthetic fracture (n = 44). The HOOS-pain, HOOS-physical function short form (PS), and HOOS-Joint Replacement (JR) scores were collected preoperatively and at a 1-year follow-up. The MCID was calculated using distribution-based methods, while PASS and SCB were determined using anchor-based approaches.

RESULTS

The MCID thresholds ranged from 10.0 (aseptic loosening) to 12.9 (periprosthetic fracture) for HOOS-pain, 9.9 (instability) to 12.9 (periprosthetic fracture) for HOOS-PS, and 8.7 (aseptic loosening) to 12.1 (periprosthetic fracture) for HOOS-JR. The PASS thresholds varied from 67.5 (implant failure) to 72.5 (periprosthetic fracture) for HOOS-pain, 76.6 (periprosthetic fracture) to 80.0 (aseptic loosening, implant failure, and instability) for HOOS-PS, and 64.7 (aseptic loosening) to 73.5 (implant failure and instability) for HOOS-JR. The SCB thresholds spanned 15 (implant failure) to 35 (aseptic loosening) for HOOS-pain, 4.6 (periprosthetic fracture) to 22.0 (instability) for HOOS-PS, and 16.1 (instability) to 25.9 (implant failure) for HOOS-JR.

CONCLUSIONS

This study established diagnosis-specific thresholds for MCID, PASS, and SCB across HOOS subscales in aseptic revision THA, demonstrating significant variability by preoperative diagnosis. Patients who have aseptic loosening showed the greatest improvement and highest likelihood of achieving clinically meaningful benefits, while those who have periprosthetic fractures and instability had lower rates of meaningful recovery. These findings provide a critical framework for outcome assessment and personalized patient counseling.

Patient Characteristics Associated With Loss to Follow-Up After Total Joint Arthroplasty

BACKGROUND

Maintaining follow up after total joint arthroplasty (TJA) is critical to monitor patient outcomes and complications. However, patient factors associated with follow-up compliance have not been described previously. This study aimed to characterize demographic and perioperative characteristics associated with TJA follow-up compliance.

METHODS

This was a retrospective review of all primary, elective total hip and knee arthroplasty (THA and TKA) procedures at an urban, tertiary care center from 2011 to 2022. Patient follow ups were categorized as early (0 to 90 days), mid-term (91 days to 2 years), and late-term (greater than 2 years) follow ups. Patient characteristics, including age, sex, race, smoking status, spoken language, body mass index, income class, insurance type, distance from hospital, 90-day readmission, American Society of Anesthesia Status, and Charlson Comorbidity Index, were compared at each period, and logistic regression identified predictors of follow up.

RESULTS

In total, 2,836 TKA and 3,056 THA procedures were analyzed, with overall follow-up rates of 78.9 and 76.8%, respectively. Among all TJA patients, those who did not have follow ups were more likely to be younger, men, White, active smokers, live further from the hospital, and have lower Charlson Comorbidity Indices. Uniquely, for TKA patients, higher income status predicted lower overall and early follow-up rates, while English-speaking status predicted lower early and higher late follow-up rates in this subgroup. Differences between groups based on follow-up status decreased as follow-up time increased. Regression analyses showed loss to follow up increased with increased distance from the hospital and current smoking. Uniquely, for THA, men predicted loss to follow up.

CONCLUSIONS

Younger age, men, White race, higher income, current smoking, and increased distance from the hospital are associated with increased early, but not late, loss to follow up after TJA. Future studies should assess the influence of other factors, including home support and telemedicine use, on follow-up rates.

Contralateral THAs More Than 1 Year Apart: Do PROMs and Healthcare Utilization Differ After Each Procedure?

BACKGROUND

Patients who undergo a second THA at least 1 year after the first one may experience different recovery courses after each THA. It is unknown what the clinically relevant improvements and healthcare utilization are after each THA in patients undergoing contralateral THA > 1 year apart.

QUESTIONS/PURPOSES

(1) Do patient-reported outcome measures (PROMs) differ at baseline and 1 year after THA for the first and second hip arthroplasty? (2) Does the likelihood of achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds differ for the first and second hip arthroplasty? (3) Does utilization of healthcare within 90 days of THA, using discharge disposition, length of stay (LOS), and 90-day readmission risk as proxies, differ between the first and second hip arthroplasty?

METHODS

Between January 2016 and December 2021, a total of 14,023 primary THAs for hip osteoarthritis were performed at a large tertiary academic center, and data from each were longitudinally maintained in an institutional database. In this retrospective study, we excluded nonelective (n = 265), simultaneous bilateral (n = 89), staged bilateral < 1 year apart (n = 1856), unilateral THAs (n = 7541), and those who were lost prior to the minimum study follow-up of 1 year or had incomplete data sets (n =3618), leaving 654 contralateral THAs > 1 year apart (327 patients) for analysis here. The median (range) patient age was 64 years (26 to 88) at the time of the first THA and 66 years (27 to 88) at the second THA. The mean (IQR) time from first THA to second THA was 696 days (488 to 1008). In all, 62% (204 of 327) of patients were women, and 89% (286 of 321) were White. The median (range) BMI was 29 kg/m 2 (first THA 16 to 60, second THA 18 to 56) at both THAs. PROMs were obtained preoperatively and at 1 year after each of the THAs and included Hip Disability and Osteoarthritis Outcome Score pain (HOOS-pain), physical function (HOOS-PS), and joint replacement (HOOS-JR) scores, as well as the Veterans Rand 12-Item Health Survey mental component summary score. Each was scored from 0 to 100, with higher scores representing better patient perceived outcomes. A distribution-based method was used to calculate the MCID thresholds (HOOS-pain 8.35, HOOS-PS 9.47, and HOOS-JR 7.76), while an anchor-based method was utilized for the PASS thresholds (HOOS-pain 80.6, HOOS-PS 83.6, and HOOS-JR 83.6). Healthcare utilization outcomes included discharge disposition, LOS, and 90-day readmission rates.

RESULTS

Patients had slightly lower baseline PROM scores in all HOOS subdomains before the first THA compared with the second THA (median HOOS-pain 38 versus 42, p < 0.001; HOOS-PS 54 versus 58, p < 0.001; HOOS-JR 43 versus 47, p < 0.001). The difference between baseline and 1-year postoperative scores was slightly larger in all HOOS subdomains after the first THA (median HOOS-pain difference 52 versus 50, p < 0.001; HOOS-PS difference 38 versus 31, p < 0.001; HOOS-JR difference 42 versus 39, p < 0.001). There was no difference in the percentage of patients achieving the MCID in HOOS-pain (97% versus 97%; p = 0.93), HOOS-PS (92% versus 88%; p = 0.17), and HOOS-JR (96% versus 94%; p = 0.18) between the first and second THAs. Although there was also no difference in the percentage of patients achieving PASS thresholds in HOOS-pain (81% versus 77%; p = 0.11), HOOS-PS (82% versus 79%; p = 0.055), and HOOS-JR (71% versus 71%; p = 0.39) between the first and second THAs, considerably fewer patients were reaching the PASS threshold in both THAs. After the second THA, slightly more patients were discharged home (95% versus 91%; p = 0.03) and had a very slightly shorter LOS (1.28 versus 1.35 days; p < 0.001). There was no difference in 90-day readmission rates between the first and second THA (4% versus 5%; p = 0.84).

CONCLUSION

In patients undergoing contralateral THA > 1 year apart, baseline PROMs were slightly worse before the first THA, and improvements were slightly greater compared with the second THA, although these differences were likely not clinically significant. Clinically meaningful improvements, based on MCID and PASS thresholds, were similar at 1 year for both THAs, yet 20% to 25% of patients reported inadequate pain relief after both surgeries. Healthcare utilization was also comparable between both procedures. Surgeons can use these findings to counsel patients on the likely similar outcomes following both their THAs. Future studies should explore factors contributing to inadequate pain relief and identify strategies to improve patient outcomes after both THAs.Level of Evidenc e Level III, therapeutic study.

A Study of Arthroplasty Surgeons Who Opt Out of Medicare

BACKGROUND

Physicians may choose to opt out of accepting reimbursements through the Medicare program. There is limited information on arthroplasty surgeons who elect to opt out of Medicare.

METHODS

The public Centers for Medicare & Medicaid Services Opt-Out Affidavits Dataset was used to identify individual orthopaedic surgeons performing hip and knee arthroplasty who had opted out of Medicare as of February 2024. Publicly available internet pages were used to investigate individual surgeon characteristics and evaluate trends among those surgeons who opted out of Medicare over time.

RESULTS

Of the 308 orthopaedic surgeons who did not accept Medicare, 85 performed hip and/or knee arthroplasty. Of these surgeons, 37% practiced in or near New York City, while 27% practiced in the Southwest United States. All practiced in urban areas. At the time of opt out, physicians had an average time in practice of 21.3 years and a median of 20 years (range, five to 46). Surgeons had an average H-index of 17.6 and a median of six (range, zero to 82). Approximately, half of the surgeons were fellowship-trained in arthroplasty. Of these, 39% completed their training at the same institution. Surgeons received a mean of $377,178 and a median of $2,520 (range, zero to $10,631,606) from industry payments in the most recent year. This includes 47 (56%) who received less than $5,000 and nine (11%) who received over $1,000,000. In addition, 53% accepted insurance plans other than Medicare, and 25% had ownership of outpatient surgery centers. Also, the annual incidence of arthroplasty surgeon opt outs was higher in 2023 than in any year previously.

CONCLUSIONS

Arthroplasty surgeons who opt out of Medicare have diverse demographic, academic, and financial characteristics. Features commonly shared were geographic location and fellowship institution, while other characteristics vary substantially.

The Patient Acceptable Symptom State (PASS) has Little Utility Before Total Hip or Knee Arthroplasty

BACKGROUND

A better understanding of patient's a preoperative symptom state may assist in a more holistic evaluation of patients pursuing total joint arthroplasty (TJA). This study aimed to determine factors associated with preoperative Patient Acceptable Symptom State (PASS) scores in TJA patients and to determine the predictive ability of patient-reported outcome measures (PROMs) for achieving PASS preoperatively.

METHODS

All patients undergoing primary, elective TJA between January and October 2021 at a single institution and who had completed a preoperative PASS, preoperative Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires, and joint-specific PROMs were eligible for inclusion. Descriptive statistics and independent samples t-tests were utilized. Receiver operating characteristic curves and area under the curve analyses were created to determine threshold values for PROMs representing PASS achievement.

RESULTS

A total of 287 total hip arthroplasty (THA) patients and 378 total knee arthroplasty (TKA) patients completed PASS preoperatively, with 12.9% of THA patients and 29.6% of TKA patients reporting acceptable symptom states. The PASS responses were associated with PROMIS Physical Function (PROMIS-PF) (P < 0.001) but not Hip Dysfunction and Osteoarthritis Score, Joint Replacement (P = 0.073) scores in THA. The PASS responses were similarly associated with PROMIS-PF (P < 0.010) as well as Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (P = 0.030) scores in TKA. The Hip Dysfunction and Osteoarthritis Score, Joint Replacement and PROMIS-PF threshold values of 55.6 and 40, respectively, only weakly predicted preoperative PASS achievement in THA. The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement and PROMIS-PF threshold values of 52.5 and 39, respectively, only weakly predicted preoperative PASS achievement in TKA.

CONCLUSIONS

In patients undergoing THA or TKA, 12.9 and 29.6% of patients were satisfied with their symptoms before surgery, respectively. None of the threshold values for the assessed PROMs strongly predict PASS achievement. Given that not all patients indicated for TJA reported unacceptable health states, these findings question the validity of the PASS questionnaire preoperatively.

Patient-Reported Outcome Measure Collection for TKA: What Surgeons Need to Know

As the population ages and the prevalence of knee osteoarthritis increases, total knee arthroplasty (TKA) is expected to grow in demand. Traditionally, the success of TKA has been measured through clinical assessments, imaging, and the incidence of postoperative complications. Over the past decade, patient-reported outcome measures (PROMs) have become crucial in evaluating clinical outcomes. PROMs are soon to be tied to financial incentives in value-based payment programs as a measure of the quality of care provided. Centers for Medicare and Medicaid Services (CMS) has implemented a nationwide policy to enhance and standardize the collection of PROMs for those undergoing total joint arthroplasty. The policy is titled Patient Reported Outcome based Performance Measure or "PRO-PM." This requires mandatory reporting in 2025, and by 2028, hospital payment evaluations will incorporate this data. CMS will require hospitals to achieve at least 50% postoperative PROM collection rates to qualify for full annual payment in 2028. Providers are incentivized to improve scores on PROMs, such as pain levels and physical function after procedures, as higher PROM scores often correlate with better reimbursement rates under these programs. Recent advancements in interactive technology, including mobile apps and telemedicine platforms, have enabled the collection of PROMs from patients without requiring or prior to a clinic visit. Looking ahead, the mandatory PROM reporting requirements set by the CMS highlight the urgency of adopting scalable, technology-driven solutions. Literature suggests women, individuals with lower socioeconomic status, lower educational attainment, and non-English speakers have significantly lower PROM response rates. While these mandates aim to standardize care quality, they also risk exacerbating disparities if underserved populations face barriers to participation. Equity-focused strategies, alongside continued investment in technology, will be critical to achieving widespread adoption and maximizing the benefits of PROMs in TKA care. Ultimately, the integration of electronic and adaptive PROM systems has the potential to transform the TKA landscape, offering a model for leveraging technology to enhance patient engagement, optimize care delivery, and improve outcomes across diverse populations.

From Policy to Practice: Challenges in Implementing PROMs Reporting Under the New CMS Mandate

ABSTRACT

The Centers for Medicare & Medicaid Services (CMS) recently introduced mandatory reporting of patient-reported outcomes (PROs) following primary, elective total joint arthroplasty (TJA) procedures. This article explores the implications and implementation challenges of this policy shift in the field of orthopaedic surgery. With a review of the existing literature, we analyze the potential benefits and limitations of PROs, discuss the role of CMS in health-care quality improvement initiatives, explain the predicted difficulties in the successful implementation of this new mandate, and provide recommendations for the successful integration of the reporting of PROs in clinical practice.

Preoperative Expectations and Functional Scores for Primary Total Knee Arthroplasty Vary Based on Health Literacy

BACKGROUND

Health literacy (HL) is essential for managing medical conditions, including primary total knee arthroplasty (TKA). We evaluated whether HL was related to patient-reported preoperative expectations for improvement and baseline patient-reported functional scores.

METHODS

Elective primary TKAs (n = 345) performed at an academic hip and knee center were prospectively enrolled in a study evaluating mediators of patient-reported outcomes. The sample consisted of 68% women, with an average age and body mass index of 67 years (range, 42 to 90) and 36 (range, 18 to 70). Validated preoperative measures included a single-item assessment of HL, Knee Society expectations for pain and functional improvement, Knee Injury and Osteoarthritis (KOOS JR) joint health, and Patient-Reported Outcomes Measurement Information System (PROMIS) global mental and physical health. Multivariable analyses controlling for covariates were conducted.

RESULTS

Higher HL was reported by 77% of patients, with 23% reporting lower HL. Higher HL was associated with higher mean expectation scores for pain relief (P = 0.014) and improvement in activities of daily living (P = 0.009) and recreational, sports, and leisure activities (P < 0.001). These differences were reflected in a higher mean total expectations score (P = 0.001). The mean PROMIS global mental (P < 0.001) and physical (P = 0.010) health were significantly higher in patients who have higher HL. The mean KOOS JR scores did not differ based on higher versus lower HL (P = 0.57). HL remained a significant mediator of preoperative functional scores in multivariable analyses.

CONCLUSIONS

Study findings suggest that lower HL correlated with lower preoperative expectations and PROMIS baseline scores, despite equally poor KOOS JR scores, indicating equal knee dysfunction between groups. These differences may influence patient-reported postoperative outcomes, which will soon be tied to reimbursement. Preoperative patient education may benefit from a better understanding of individual differences in HL.

Challenges in Meeting Centers for Medicare and Medicaid Services Patient-Reported Outcome Measures Collection Requirements and Patient Predictors of Substantial Clinical Benefit Achievement in Total Joint Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are highly effective procedures, with the Centers for Medicare & Medicaid Services (CMS) mandating patient-reported outcome measures (PROMs) for Medicare patients starting July 1, 2024. This study evaluated PROM collection rates and identified predictors of substantial clinical benefit (SCB), defined by CMS as a 22-point improvement in Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement for THA and a 20-point improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement for TKA at four surgical sites across an academic tertiary referral center.

METHODS

This retrospective cohort study analyzed PROM data for all patients who underwent THA or TKA from January 2021 to December 2022. Collection rates for PROMs were assessed by meeting the CMS requirement of "matched pairs" of preoperative and 1-year postoperative PROM and meeting SCB. Logistic regression was used to identify predictors of SCB.

RESULTS

Collection rates of PROMs improved from 2021 to 2022, but matched pair rates remained below 33%. The SCB was achieved by 70.9% of THA patients and 62.1% of TKA patients. Significant predictors of SCB included younger age, lower preoperative PROM scores, and absence of comorbidities such as diabetes or preoperative opioid use. Non-White race patients had significantly lower odds of achieving SCB for TKA (P = 0.003), while preoperative education did not significantly impact SCB rates for either procedure.

CONCLUSIONS

The collection of PROMs remains a major challenge, particularly for postoperative intervals, but patients who had greater initial limitations showed substantial improvement. Targeted interventions to optimize preoperative risk factors and enhance long-term follow-up may improve SCB rates and CMS compliance.

Establishing Diagnosis-Specific Measures of Clinical Meaningfulness for the Knee Injury and Osteoarthritis Outcome Score in Aseptic Revision Total Knee Arthroplasty

BACKGROUND

Revision total knee arthroplasty (rTKA) projections indicate substantial growth. Although patient-reported outcome measures are valuable for assessing rTKA outcomes, interpretation of clinical relevance remains challenging. This study aimed to determine diagnosis-specific thresholds for minimal clinically important difference (MCID), patient-acceptable symptom state (PASS), and substantial clinical benefit (SCB) for Knee Injury and Osteoarthritis Outcome Score (KOOS) scores in aseptic rTKA.

METHODS

A prospective cohort of 752 patients who underwent aseptic rTKA between 2016 and 2022 was analyzed. Patients were stratified by the following preoperative diagnosis: aseptic loosening (n = 313), implant failure (n = 93), instability (n = 320), and periprosthetic fracture (n = 26). The KOOS-Pain, KOOS-Physical Function Short Form (PS), and KOOS-Joint Replacement (JR) scores were collected preoperatively and at a 1-year follow-up. The MCID was calculated using distribution-based methods; PASS and SCB were determined using anchor-based approaches.

RESULTS

The MCID thresholds ranged from 8.5 to 11.0 for KOOS-Pain, 8.8 to 12.0 for KOOS-PS, and 7.7 to 9.8 for KOOS-JR. The PASS thresholds varied from 62.5 to 80.6 for KOOS-Pain, 58.0 to 63.0 for KOOS-PS, and 59.4 to 76.3 for KOOS-JR. The SCB thresholds spanned 30.6 to 44.5 for KOOS-Pain, 13.3 to 26.2 for KOOS-PS, and 11.8 to 42.0 for KOOS-JR. Periprosthetic fracture consistently showed the highest achievement rates across all measures (MCID: 76 to 92%, PASS: 44 to 77%, SCB: 41 to 62%), whereas instability demonstrated the lowest (MCID: 64 to 75%, PASS: 44 to 53%, SCB: 15 to 33%).

CONCLUSIONS

This study established diagnosis-specific thresholds for MCID, PASS, and SCB across multiple KOOS measures in aseptic rTKA. The findings reveal notable variability in these thresholds depending on preoperative diagnosis, highlighting the importance of individualized assessment and expectation management in rTKA, rather than applying uniform thresholds across all revision indications.

A perspective on the use of patient-reported experience and patient-reported outcome measures in ambulatory healthcare

INTRODUCTION

Patient-reported experience measures (PREMs) are patient reports about their healthcare, whereas patient-reported outcome measures (PROMs) are reports about their functioning and well-being regarding physical, mental, and social health. We provide a perspective on using PREMs and PROMs in ambulatory healthcare.

AREAS COVERED

We conducted a narrative review of the literature about using PREMs and PROMs in research and clinical practice, identified challenges and possibilities for addressing them, and provided suggestions for future research and clinical practice.

EXPERT OPINION

Substantial progress in using PREMs and PROMs has occurred during the last half-century. Collecting and reporting PREMs to clinicians in ambulatory care settings has improved communication with patients, diagnosis, and treatment, which may improve patients' health. Optimal use requires appropriate data analysis, minimizing implementation barriers, and facilitating interpretation of PREMs and PROMs in clinical practice. Also, formal structures and processes that include patient and family input into care improvement are needed (e.g. patient and family advisory councils as partners in co-design and coproduction of quality improvement). PREMs and PROMs have been used primarily in more affluent countries (e.g. the United States, Australia, United Kingdom, Netherlands, Japan, and Portugal), but this is expected to increase in many countries.

Internet-Based Patient Portals Increase Patient Connectivity Following Total Knee Arthroplasty

Many healthcare-related processes have undergone substantial transformation by the internet since the turn of the century. This technological revolution has fostered a fundamental shift from medical paternalism to patient autonomy and empowerment via a "patient-centric approach." Patient portals, or internet-enabled access to an electronic medical record, permit patients to access, manage, and share their health-related information. Patient connectivity following total knee arthroplasty (TKA) has the potential to positively influence overall outcomes, patient experience, and satisfaction. To understand current trends in patient portal usage, modalities of connectivity, and the implications following TKA. A systematic literature review was performed by searching PubMed and Google Scholar. Articles specific to portal usage and connectivity after TKA or total joint arthroplasty were subsequently identified for further review. Patient portals and internet-based digital connectivity platforms enable physicians, team members, and patients to communicate in the perioperative period both directly and indirectly. Communication can be through web-based patient portals, messaging services/apps, preprogrammed alerts (e.g., mobile applications or wearable devices), audio mediums, or videoconferencing. The spectrum and utilization of available patient engagement platforms continues to expand as the importance and implications of patient engagement and connectivity continue to be elucidated. Connectivity through patient portals or other mediums will continue to have an expanding role in all aspects of orthopedic surgery, patient care, and engagement. This includes preoperative education, postoperative rehabilitation, patient care, and, perhaps most importantly, collection of outcome measures. The level of evidence is V (expert opinion).

Neighborhood Socioeconomic Disadvantage May Influence 1-Year Patient-Reported Outcome Measures After Total Hip Arthroplasty

BACKGROUND

The impact of socioeconomic status on achievement of clinically relevant patient-reported outcome measure (PROM) improvements and satisfaction after total hip arthroplasty (THA) is unknown. Area Deprivation Index (ADI) is a metric that can be used as a proxy for a patient's neighborhood socioeconomic status. This study aimed to assess the association between ADI and failure to achieve: (1) clinically relevant improvements in PROMs; and (2) self-reported satisfaction at 1 year following THA.

METHODS

A prospective cohort of 7,506 patients who underwent primary unilateral THA from January 2016 to July 2021 was included. The ADI was stratified into quintiles based on their distribution in our sample. Multivariable logistic regression models were created to investigate the effect of ADI on 1-year PROMs. The included PROMs were the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain, Physical Function Shortform (PS), and Joint Replacement (JR). Clinically relevant improvements were assessed through minimal clinically important difference and patient acceptable symptom state threshold achievement.

RESULTS

There was no significant association between ADI and failure to achieve minimal clinically important difference for HOOS pain (P = 0.42), PS (P = 0.91), or JR (P = 0.20). However, higher ADI scores were independently associated with increased odds of failing to achieve patient acceptable symptom state for HOOS Pain (P = 0.002), PS (P = 0.003), and JR (P = 0.017). The ADI was not associated with failure to achieve patient satisfaction at 1 year (P = 0.93).

CONCLUSIONS

Greater neighborhood socioeconomic disadvantage was associated with decreased odds of achieving clinically relevant improvement in patient-perceived symptomatic state, but not associated with patients' perception of their overall pain and function 1 year after THA. Targeted interventions to address access and care pathways for low socioeconomic status patients may present an opportunity to improve patient-perceived outcomes following THA.

LEVEL OF EVIDENCE

Level III.

The CCJR® Gerard A. Engh Excellence in Knee Research Award: Patient-Reported Outcomes Collection and Mandatory Medicare Inpatient Total Knee Arthroplasty Patient-Reported Outcome Performance Measures: How to Optimize the Process

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) has mandated that patient-reported outcomes (PROs) reporting for total knee arthroplasty (TKA) start on July 1, 2024, which will impact reimbursement in 2028. The financial penalty for not reporting 50% of eligible patients is 25% of the Annual Payment Update (usually 2 to 4%). The CMS will evaluate for a substantial clinical benefit, defined as a 20-point increase in the Knee Injury and Osteoarthritis Outcome Score (KOOS JR) score. A final "risk-standardized improvement rate" will be calculated based on all risk variables and claims data submitted. The purpose of this study was to present our process for complying with these mandates.

METHODS

We employed a multiprong approach in a 12-hospital enterprise to collect PROs. We utilized a web-based PRO collection system embedded in our electronic medical record, a tablet in-person collection system in the clinic, and a patient engagement platform.

RESULTS

Since 2019, we enrolled 7,354 TKA patients in a patient engagement platform and 6,942 (94%) have opted in and used the platform. Percentages of PRO completion were 90% preoperatively, 80% at 3 months postoperatively, 76% at 6 months postoperatively, and 79% at 1 year postoperatively. Patient satisfaction scores averaged 4.51 out of five at 90 days. The KOOS JR. scores improved on average from 52.0 preoperatively to 74.9 in 1 year. Utilizing our web-based electronic medical record collection system in addition to the in-person tablet PRO collection achieved minimum collection performance.

CONCLUSIONS

Our study found that using a multiprong approach to comply with the Inpatient Prospective Payment System CMS Inpatient TKA-PRO Performance Measures will meet the minimum standards of 50% paired PROs reporting. Furthermore, our hospital system was able to meet the required substantial clinical benefit of 20 points on the KOOS JR and collect this information for reporting.

Collection of Patient-Reported Outcome Measures: Comparing Paper to Online Data Collection Among Knee Arthroplasty Patients

BACKGROUND

At our institution, patient-reported outcome measures were completed on paper forms until 2021, when we began sending emails to knee arthroplasty patients so they could complete surveys electronically. This study evaluated our transition from paper-based to electronic collection of the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

METHODS

We compared 276 knee arthroplasty procedures performed from March 2020 through June 2020 that were eligible to complete paper KOOS JR surveys with 490 knee arthroplasty procedures performed from March 2022 through June 2022 that were eligible to complete electronic surveys. Survey completion rates at preoperative and 1-year follow-up were evaluated as well as the relative frequency of patients achieving a substantial clinical benefit (SCB) KOOS JR score increase of 20 points or more. Multivariate regressions were used to assess the potential influence of covariates, including age at surgery, sex, body mass index, type of insurance, surgery site, and the distance patients traveled to our institution.

RESULTS

Response rates for preoperative surveys completed within 90 days of surgery increased from 53% (146 of 276) with paper to 83% (406 of 490) with electronic surveys, while 1-year follow-up response rates improved from 38% (105 of 276) to 65% (320 of 490). Multivariate analyses indicated that only the survey type (paper or electronic) was associated with response rates. Electronic data collection also reduced incomplete (13 to 0.4%) and unnecessary (38 to 0.4%) surveys. The annual cost of data collection decreased from $140,696 with paper-based forms to $105,742 with electronic surveys. However, patients achieving a SCB declined from 81% (42 of 52) with paper to 64% (176 of 276) with electronic surveys (P = 0.02).

CONCLUSIONS

Compared to paper forms, electronic data collection at our institution increased follow-up rates and improved data quality at lower costs, but the relative frequency of patients reporting a SCB decreased.

Impact of a Recently Accredited Orthopedic Surgery Residency on Patient Outcome Scores in Total Shoulder Arthroplasty: A Retrospective Study

BACKGROUND

Patient-reported outcome measures are a valuable tool to evaluate an intervention from a patient's perspective. Previous evidence shows that, while resident involvement may increase operative times, it does not affect complications or patient-reported outcomes. This study sought to assess the impact of a new residency program on patient-reported outcome measures, operative time, and complication rates in total shoulder arthroplasty.

MATERIALS AND METHODS

A retrospective cohort study was performed of patients who underwent total shoulder arthroplasty at a single health care system. Demographic data, resident presence during shoulder arthroplasty, arthroplasty type, procedure duration, complications, and American Shoulder and Elbow Surgeons (ASES) score change were collected. Patients 18 years or older who underwent primary anatomic or reverse total shoulder arthroplasty were included. Patients who did not meet the inclusion criteria, had a preoperative diagnosis other than primary osteoarthritis, lacked preoperative and postoperative ASES scores, and canceled procedures were excluded.

RESULTS

A total of 139 patients were identified and included in our analysis. Ninety-seven total shoulder arthroplasties were performed with a resident not present, and 42 with a resident present. This study showed no significant effects of the presence or absence of a resident on ASES scores, complication rates, or surgery times.

CONCLUSION

This study adds to previous evidence indicating that attending orthopedic surgeons can support resident learning and surgical skill development while maintaining patient-reported outcome measures, surgical time, and complication rates similar to those without resident involvement when performing shoulder arthroplasty. [Orthopedics. 2025;48(2):104-110.].

Patient-reported outcome measures offer little additional value two years after arthroplasty : a systematic review and meta-analysis

Aims

The use of patient-reported outcome measures (PROMs) to assess the outcome after total knee (TKA) and total hip arthroplasty (THA) is increasing, with associated regulatory mandates. However, the robustness and clinical relevance of long-term data are often questionable. It is important to determine whether using long-term PROMs data justify the resources, costs, and difficulties associated with their collection. The aim of this study was to assess studies involving TKA and THA to determine which PROMs are most commonly reported, how complete PROMs data are at ≥ five years postoperatively, and the extent to which the scores change between early and long-term follow-up.

Methods

We conducted a systematic review of the literature. Randomized controlled trials (RCTs) with sufficient reporting of PROMs were included. The mean difference in scores from the preoperative condition to early follow-up times (between one and two years), and from early to final follow-up, were calculated. The mean rates of change in the scores were calculated from representative studies. Meta-analyses were also performed on the most frequently reported PROMs.

Results

A total of 24 studies were assessed. The most frequently reported PROMs were the Oxford Knee Score (OKS) for TKA and the University of California, Los Angeles activity scale for THA. The mean rate of follow-up based on the number of patients available at final follow-up was 70.5% (39.2% to 91.0%) for knees and 82.1% (63.2% to 92.3%) for hips. The actual rates of collection of PROM scores were lower. For TKA, the mean OKS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and transformed WOMAC changes were -16.3 (95% CI -17.5 to -15.2), 23.2 (95% CI 17.2 to 29.2), and -29.7 (95% CI -32.4 to -27.0) points for short-term follow-up. These decreased to 1.3 (95% CI -0.8 to 3.3), -3.4 (95% CI -7.0 to 0.3), and 4.7 (95% CI -1.5 to 10.9) points for the remaining follow-up. A similar meta-analysis was not possible for studies involving THA. We commonly observed that the scores plateaued after between one and two years, and that there was little or no change beyond this time.

Conclusion

The long-term PROMs for TKA and THA beyond one or two years are often incomplete and lose sensitivity at this time. Given the considerable resources, costs, and challenges associated with the collection of these scores, their clinical value is questionable. Therefore, consideration should be given to abandoning the requirement for the collection of long-term PROMs in favour of more robust and reliable measures of success that offer more clinical relevance and use.

Medical Causes Account for 75% of Readmissions After Primary Total Hip Arthroplasty: Differences in Episodes of Care

BACKGROUND

Recent reports have suggested that readmissions due to medical or orthopaedic surgical causes after total hip arthroplasty (THA) differ regarding risk factors and cost. Further work is needed to elucidate explanations for cost differences to develop targeted initiatives for improved quality of care and health care utilization surrounding THA. This study aimed to determine differences in episodes of care (EOC) between patients readmitted within 90 days of THA for medical and orthopaedic causes.

METHODS

The study included all patients who underwent elective, unilateral, primary THA at a tertiary medical center from 2016 to 2020 and were subsequently readmitted within 90 days. Readmissions were classified as related to medical or orthopaedic surgical causes. Demographic and clinical information related to the EOC for the readmission hospital stay was collected.

RESULTS

The 90-day readmission rate after THA was 5.6% (502 of 8,893 patients), with 75.1% (377 of 502) related to medical causes and 24.9% (125 of 502) related to orthopaedic causes. The EOC between the two groups differed in several ways. Patients readmitted for medical causes more frequently required intensive care unit admissions (12.0 versus 4.9%, P = 0.024), while a larger proportion of patients who had orthopaedic-related readmissions required blood product transfusions (36.3 versus 12.0%, P < 0.001), minimally invasive procedures (34.4 versus 18.9%, P < 0.001), and surgical interventions (79.2 versus 7.2%, P < 0.001).

CONCLUSIONS

Understanding differences in readmission EOC related to medical and orthopaedic causes after THA can help optimize health care allocation strategies and inform targeted quality improvement initiatives. As the demand for THA grows and reimbursement declines, insights into the predominance of medical readmissions and key differences in EOC are crucial for enhancing the quality and cost-effectiveness of THA care delivery models.

Evaluating Surgeon-influenced Factors for Total Knee Arthroplasty Value-based Reimbursement

INTRODUCTION

Clinical outcome measures used under value-based reimbursement models require risk stratification of patient demographics and medical history. Only certain perioperative patient factors may be influenced by the surgeon. The study evaluated surgeon-influenced modifiable factors associated with achieving literature-defined KOOS score thresholds to serve as the foundation of the newly established alternative payment models for total knee arthroplasties (TKA).

METHODS

We retrospectively reviewed a consecutive cohort of 4,324 patients undergoing TKA. Surgeon-influenced modifiable risk factors included thromboprophylaxis with aspirin, tourniquet use, tranexamic acid (TXA), body mass index, smoking, alcohol or illicit drug use, surgical time, length of stay (LOS), and bilateral TKA. Outcomes included complications, 90-day readmissions, discharge disposition, knee injury and osteoarthritis outcome score (KOOS) minimal clinically important difference (MCID), KOOS patient acceptable symptom state (PASS), and short form-12 (SF-12) MCID achievement. A bivariate analysis and regression were built to determine the likelihood of primary outcomes based on modifiable factors.

RESULTS

Bilateral TKA was associated with a higher odds ratio (OR) for home discharge (OR = 5.40, P < 0.001), KOOS MCID (OR = 2.60, P < 0.001), PASS (OR = 2.4, P ≤ 0.001), and SF-12 PCS MCID achievement (OR = 3.21, P < 0.001). Similarly, LOS was inversely associated with KOOS MCID (OR = 0.88, P = 0.002) and PASS (OR = 0.81, P < 0.001) but directly associated with home discharge (OR = 2.5, P ≤ 0.001) in-hospital complications (OR = 1.50, P < 0.001) and 90-day readmissions (OR = 1.23, P = 0.005). The KOOS MCID and PASS achievement was positively influenced by TXA (OR = 1.33, P = 0.008; OR = 1.29, P = 0.020) use and negatively influenced by aspirin use (OR = 0.68, P = 0.013; OR = 0.73, P = 0.040). In-hospital opioid use was an independent risk factor for not achieving SF-12 MCS MCID (OR = 0.56, P = 0.006).

CONCLUSION

In this study, modifiable perioperative variables, such as TXA, aspirin use, opioid use, LOS, and bilateral TKA, were found to markedly increase quality metrics threshold achievement and should be considered as risk variables in the current value-based care models. Future studies should investigate the effect of modifiable risk factors on quality metrics to build new risk adjustment tools that incentivize patient perioperative optimization.

Assessing Physician and Patient Agreement on Whether Patient Outcomes Captured in Clinical Progress Notes Reflect Treatment Success: Cross-Sectional Study

BACKGROUND

It remains unclear if there is agreement between physicians and patients on the definition of treatment success following orthopedic treatment. Clinical progress notes are generated during each health care encounter and include information on current disease symptoms, rehabilitation progress, and treatment outcomes.

OBJECTIVE

This study aims to assess if physicians and patients agree on whether patient outcomes captured in clinical progress notes reflect a successful treatment outcome following orthopedic care.

METHODS

We performed a cross-sectional analysis of a subset of clinical notes for patients presenting to a Level-1 Trauma Center and Regional Health System for follow-up for an acute proximal humerus fracture (PHF). This study was part of a larger study of 1000 patients with PHF receiving initial treatment between 2019 and 2021. From the full dataset of 1000 physician-labeled notes, a stratified random sample of 25 notes from each outcome label group was identified for this study. A group of 2 patients then reviewed the sample of 100 clinical notes and labeled each note as reflecting treatment success or failure. Cohen κ statistics were used to assess the degree of agreement between physicians and patients on clinical note content.

RESULTS

The average age of the patients in the sample was 67 (SD 13) years and 82% of the notes came from female patients. Patients were primarily White (91%) and had Medicare insurance coverage (65%). The note sample came from fracture-related encounters ranging from the second to the tenth encounter after the index PHF visit. There were no significant differences in patient or visit characteristics across concordant and discordant notes labeled by physicians and patients. Among agreement levels ranging from poor to perfect agreement, physician and patient evaluators exhibited only a fair level of agreement in what they deemed as treatment success based on a Cohen κ of 0.32 (95% CI 0.10-0.55; P=.01). Furthermore, interpatient and interphysician agreement also demonstrated relatively low levels of agreement.

CONCLUSIONS

The findings suggest that physicians and patients demonstrated low levels of agreement when assessing whether a patient's clinical note reflected a successful outcome following treatment for a PHF. As low levels of agreement were also observed within physician and patient groups, it is clear the definition of success varied highly across both physicians and patients. Further research is needed to elucidate physician and patient perceptions of treatment success. As outcome measurement and demonstrating the value of orthopedic treatment remain important priorities, it is important to better define and reach a consensus on what treatment success means in orthopedic medicine.

Satisfied with the worst health outcomes or unsatisfied with the best: explaining the divergence between good patient-reported outcomes and low satisfaction and vice versa among knee arthroplasty patients - a retrospective cohort study

OBJECTIVES

Total knee arthroplasty (TKA) is an effective treatment for patients with end-stage knee osteoarthritis but some patients exhibit a discrepancy between patient-reported outcomes (PROs) and patient satisfaction (PS). This study aims to identify predictors for patients reporting unfavorable PROs but high PS and vice versa.

MATERIALS AND METHODS

This retrospective cohort study categorized patients from nine German hospitals into four groups based on (i) whether they achieved a minimal clinically important difference (MCID) in knee functionality, measured with a joint-specific PRO from admission to 12-month post-surgery; and (ii) whether they were satisfied at 12 months post-surgery. The groups were (A) Satisfied Achievers (satisfied, MCID reached), (B) Dissatisfied Achievers (not satisfied, MCID reached), (C) Satisfied Non-Achievers (satisfied, MCID not reached) and (D) Dissatisfied Non-Achievers (not satisfied, MCID not reached). Exploratory analyses were performed to understand differences between the four groups using chi-squared tests and ANOVA. Multinomial logistic regression models were conducted to identify predictors for the allocation of patients in groups.

RESULTS

A total of 1546 knee arthroplasty patients with a mean age of 65.9 years, 54.1% female, were included. 1146 (74.1%) patients were Satisfied Achievers, 131 (8.5%) were Dissatisfied Achievers, 141 (9.1%) were Satisfied Non-Achievers, and 128 (8.3%) Dissatisfied Non-Achievers. The results showed that higher improvements in health-related quality of life, pain and fatigue symptoms significantly decreased the likelihood of being a Dissatisfied Achiever and a Satisfied Non-Achiever. Comorbidities of blood circulation, chronic back pain or diabetes increased the likelihood of being a Dissatisfied Achiever, while depression decreased the likelihood of being a Satisfied Non-Achiever.

CONCLUSION

Addressing individual health concerns, e.g. through expectation management, and assessing alternative treatment options might improve satisfaction in line with functional improvements. A closer evaluation at which physical impairment level surgery is beneficial could help to improve the care of Satisfied Non-Achievers.

Distinct Care Needs and Episodes of Care: Comparing Medical versus Orthopaedic Readmissions after Elective Primary Total Knee Arthroplasty

Hospital readmissions after primary total knee arthroplasty (TKA) significantly drive health care expenditure and resource utilization. Recent studies have suggested differences between medical and orthopaedic readmissions after TKA and their episodes of care (EOCs) but lack patient-level data reporting. This study aimed to compare EOCs for medical and orthopaedic-related readmissions regarding initial readmission wards, services consulted, intensive care unit (ICU) admissions, blood transfusions, surgical interventions, length of stay, and discharge disposition.All patients enrolled in a prospective data collection system at a tertiary medical center undergoing elective, unilateral, primary TKA from 2016 to 2020 and readmitted within 90 days of discharge were included. Readmissions were categorized as related to medical or orthopaedic causes. Patients' electronic medical records were reviewed to collect demographic and clinical information about EOC associated with the readmission hospital course.In total, 82.4% (580/704) of 90-day readmissions after elective, primary TKA were related to medical causes, with the remaining 17.6% (124/704) of readmissions due to orthopaedic causes. Medical readmissions most often pertained to gastrointestinal complaints, while wound complications accounted for most orthopaedic readmissions. Most readmissions (63.1%, 444/704) occurred within the first 30 days after TKA. Patients with medical and orthopaedic readmissions had differences in EOC, such that more medical readmissions required ICU care (10.6 vs. 1.6%, p < 0.001), and more patients with orthopaedic readmissions needed a surgical intervention (65.4 vs. 6.7%, p < 0.001).By understanding differences in EOC for medical and orthopaedic readmissions after TKA, targeted initiatives can be developed to deliver more efficient, cost-effective orthopaedic surgical care, as the orthopaedic surgical community continues to provide value-based care.

Global Health Inequities in Orthopaedic Care: Perspectives Beyond the US

PURPOSE OF REVIEW

The burden of musculoskeletal disease is increasing globally and disproportionately affecting people in low and middle income countries (LMIC). We sought to review global access to orthopaedic care, burden of trauma, research infrastructure, impact of surgical mission trips, implant availability, and the effect of COVID-19 upon the delivery of orthopaedic care worldwide.

RECENT FINDINGS

The majority of people in LMIC do not have access to safe, quality surgical care, and there are few fellowship-trained orthopaedic traumatologists. Road traffic accidents are the leading cause of long bone fractures in LMIC and result in significant morbidity and mortality. Of the orthopaedic literature published globally in the last 10 years, less than 15% had authors from LMIC. There has been growth in surgical mission trips to LMIC, but few organizations have established bidirectional partnerships. Among the challenges to delivering quality musculoskeletal care in LMIC is timely access to quality orthopaedic implants. Implant options in LMIC are more limited and subjected to less rigorous testing and regulation than high income countries (HIC). The COVID-19 pandemic dramatically reduced elective surgeries but saw the increase in telemedicine utilization which has prevailed in both HIC and LMIC. Awareness of global inequities in orthopaedic care is growing. Much can be learned through collaborations between orthopaedic surgeons from HIC and LMIC to advance patient care worldwide. There is a need for high quality, accurate data regarding incidence and prevalence of musculoskeletal disease, care utilization/availability, and postoperative outcomes so resources can be allotted to make orthopaedic care more equitable globally.

Artificial Intelligence for Clinically Meaningful Outcome Prediction in Orthopedic Research: Current Applications and Limitations

PURPOSE OF REVIEW

Patient-reported outcome measures (PROM) play a critical role in evaluating the success of treatment interventions for musculoskeletal conditions. However, predicting which patients will benefit from treatment interventions is complex and influenced by a multitude of factors. Artificial intelligence (AI) may better anticipate the propensity to achieve clinically meaningful outcomes through leveraging complex predictive analytics that allow for personalized medicine. This article provides a contemporary review of current applications of AI developed to predict clinically significant outcome (CSO) achievement after musculoskeletal treatment interventions.

RECENT FINDINGS

The highest volume of literature exists in the subspecialties of total joint arthroplasty, spine, and sports medicine, with only three studies identified in the remaining orthopedic subspecialties combined. Performance is widely variable across models, with most studies only reporting discrimination as a performance metric. Given the complexity inherent in predictive modeling for this task, including data availability, data handling, model architecture, and outcome selection, studies vary widely in their methodology and results. Importantly, the majority of studies have not been externally validated or demonstrate important methodological limitations, precluding their implementation into clinical settings. A substantial body of literature has accumulated demonstrating variable internal validity, limited scope, and low potential for clinical deployment. The majority of studies attempt to predict the MCID-the lowest bar of clinical achievement. Though a small proportion of models demonstrate promise and highlight the utility of AI, important methodological limitations need to be addressed moving forward to leverage AI-based applications for clinical deployment.

Variation in processes of care for total hip arthroplasty across high-income countries

Total hip arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems "ration" care. This novel qualitative study explores processes of care for hip replacement in the United States and 6 high-income countries with a focus on eligibility, wait times, decision-making, postoperative care, and payment policies. We found no evidence of rationing or government interference in decision-making across high-income countries. Compared with the 6 other high-income countries in our study, the United States has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7-9 days and receive 2-3 weeks of inpatient rehabilitation. However, the payment per THA in the United States remains far above other countries, despite far fewer inpatient days.