The Rationale for Registries

By: Terry Stanton

Symposium presented the global case for the power of data collection, portending success for the Academy’s own initiative

At yesterday’s symposium “What Can a Registry Do for Me?” a dozen panelists representing both the burgeoning U.S. registry movement and the more experienced international data repositories offered their perspectives.

As the Academy embarks on its ambitious plan to create a family of registries across orthopaedics to build on the success of the American Joint Replacement Registry (AJRR), the symposium speakers related the many benefits that registry participation provides the practicing surgeon. These include improved patient safety and outcomes, better informed implant selection, equitable reimbursement policies, and other desirable ends.

David G. Lewallen, MD, medical director of AJRR and a symposium panelist, commended the Academy’s “bold and aggressive” foray into the registry front. “Part of the reason for doing this is an alignment of the planets and doing the right thing to show what we all know—that most of what we do for patients works well,” he told AAOS Now before the symposium. “The objective is to have that data available for documentation of what works and what doesn’t work, look for areas of improvement, and then be able to show that information as proof of what we do. As there is increasing scrutiny of payments, it’s fine to say we do a great job, but if we don’t have any data, we might not be believed. If we have that data, we can defend ourselves.”

Symposium moderator Henrik Malchau, MD, adviser to the International Society of Arthroplasty Registries (ISAR), and Liz Paxton, director of Kaiser Permanente’s national implant registry program, opened the session with an outline of the importance of patient registries, arising from the need for the following:

  • real-world evidence, drawn from diverse patient groups; multiple exposures procedures; and a variety of participating centers
  • large numbers that enhance capability to identify differences
  • longitudinal follow-up
  • signal detection
  • use as a quality improvement mechanism

Dr. Lewallen provided an overview of AJRR and its progress since its incorporation in 2009. From 2012 through 2016, it has registered more than 1,130,000 procedures and counts 1,047 participating hospitals and ambulatory surgery centers and some 8,900 surgeons among its members. In 2016, the 281,746 procedures for which it collected data eclipsed the numbers tallied by the more pedigreed registries of the United Kingdom, Australia, New Zealand, and Sweden, although Dr. Lewallen acknowledged that AJRR does not yet collect as many data elements as its more experienced counterparts. “We have a lot of work to do because our goal is to cover the country and gather data on 90 percent of procedures that are performed in the world’s largest market.”

Dr. Lewallen said that the success of AJRR, and of the Academy’s nascent portfolio of new registries, hinges on the efforts of individual “surgeon champions.” Almost all the hospitals that have joined AJRR “did so because of the efforts of these individual surgeons who voiced their opinion that participation is important,” he said.

Along with the benefits registries can yield in terms of improved patient outcomes, they can also serve surgeons’ interests by revealing the full value of orthopaedic care. “Physicians need to understand that there is a potential reimbursement benefit in the future and an advocacy benefit,” Dr. Lewallen said. “We may be able to use the data in Washington, D.C., to defend payments for the things we do that work well. Because there are so many things we do that are of benefit to patients, having the data to prove that will be invaluable to hospitals and doctors as they move forward in a sometimes Darwinian environment.”

Kevin J. Bozic, MD, MBA, chair of the AJRR Steering Committee, offered some guidance in navigating that U.S. environment, as the federal payment model migrates from fee-for-service in favor of payment for value or quality. A robust U.S. registry apparatus will empower physicians in the shift to bundled payments and other payment programs that reward positive outcomes and improvement. “Having access to your data will allow you to be more successful in those programs as they move from paying you for the procedure to paying you for the outcome.”

Registry participation has demonstrable financial benefits, but the most compelling incentive should derive from a commitment to improvement, Dr. Bozic said.

“If we want to get better at what we do, we want to be able to better track the outcomes of what we’re doing. Registries are a turnkey way to do that, as opposed to setting up an internal measurement system that lets you measure your outcomes and compare yourself to other providers.”

Around the nation, around the world

Other symposium panelists offered insights from various perches and perspectives.

On the state level, Brian R. Hallstrom, MD, reported on the achievements of the Michigan Arthroplasty Registry Quality Initiative (MARCQI), an ongoing initiative involving 67 sites, 525 surgeons, and more than 200,000 cases. Its participants meet quarterly to identify variations in care, review their data transparency, review evidence and current guidelines, and “decide what we all need to work on and do it again in three to four months.”

The MARCQI group had a conspicuous success in a campaign to reduce the use of blood transfusions, which had been running at a high rate and with considerable variation, as well as sparse use of tranexamic acid. The effort resulted in a MARCQI transfusion rate of 0.9 percent for total knee arthroplasty versus a national rate of 4.4 percent. It also nearly eliminated what were deemed unnecessary transfusions in patients with hemoglobin greater than 8 g/dL.

A registry can be viewed as a quality improvement project, Dr. Hallstrom said. “It identifies variation and allows us to share best practices.”

Robert S. Namba, MD, of Kaiser Permanente explained how leveraging registry data aided efforts to reduce prolonged opioid use after total joint arthroplasty. Use of opioids after 90 days postsurgery was reduced from 39 percent of total knee replacement and 35 percent of total hip replacement patients to 12 percent and 9.1 percent, respectively.

In Sweden, where arthroplasty registries date back to 1976, use of registry data yielded a number of success stories, reported Maziar Mohaddes, MD, PhD. In 2003, registry reporting alerted practitioners to a heightened risk of dislocation with commonly used FAL cup for hip arthroplasty, leading to sharply curtailed use of the cup. At Dr. Mohaddes’s institution, Sahlgrenska Hospital, use of registry information helped identify 17 areas of improvement that led to changes that yielded marked reductions in risk of reoperation, number of dissatisfied patients, length of stay, and cost, while the number of procedures rose 60 percent.

“Using a patient-oriented management philosophy and employing data from registries has contributed to a marked improvement in quality of care and increased availability, while decreasing costs,” Dr. Mohaddes said.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at