(From left) Kevin Bozic, MD, MBA, OQI co-chair, and panelists Steven Stern, MD, MBA, of UnitedHealthcare; William Martin, III, MD, AAOS Medical Director; Patrick Conway, MD, chief medical officer for the Centers for Medicare & Medicaid Services; and David Lansky, PhD, CEO of the Pacific Business Group on Health, brought various perspectives to the discussion of quality and performance measurement in orthopaedics.


Published 12/1/2011
Madeleine Lovette

Who defines quality in orthopaedics?

AAOS sets stage with inaugural Orthopaedic Quality Institute

“There is a critical need for data to help us define the strengths and shortcomings of orthopaedic practice in terms of cost and quality,” said AAOS President Daniel J. Berry, MD, during the AAOS inaugural Orthopaedic Quality Institute (OQI), held Oct. 5–6, in Washington, D.C. “AAOS is committed to quality as a core value and will continue to develop tools to assist our members in improving the quality of care for our patients.”

The issue of quality care in orthopaedics is critical, particularly during these times of budget deficits, rising healthcare costs, and concerns about overuse of high cost surgical procedures such as total joint replacement and back surgery. Without substantive changes in medical practice, healthcare costs are projected to make up 34 percent of the country’s gross domestic product by 2040. As a result, orthopaedic surgeons and other specialists who perform high volume and costly procedures are under increasing pressure to better define how and when such procedures should be performed and to develop measures that quantify whether those procedures deliver quality outcomes for patients.

Understanding that this pressure will not subside, the AAOS invited payers, purchasers, government officials, representatives from industry, and other healthcare stakeholders to the OQI to help find workable solutions that improve the quality of patient care. Although AAOS has been participating in quality efforts since the early 1990s and has produced many tools to improve quality and fill some of the knowledge gaps in orthopaedics, Kristy L. Weber, MD, and Kevin J. Bozic, MD, MBA, co-chairs of the OQI, admit that much remains to be done.

“We want to continue to be leaders in the quality movement, but we cannot reach our goals by working alone,” said Dr. Bozic. “We hosted the OQI to learn what stakeholders see as the most fertile areas for future efforts and to see how we can work together to achieve these common goals.”

Why is quality important?
“Quality performance and payment policy are not a passing fad,” said Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), during her keynote speech. The economic downturn, the unsustainable growth in Medicare, and rising healthcare costs are forcing payers (public and private) and purchasers (individuals and businesses) to demand fair costs for services and an infrastructure that enables employers and employees to choose cost-efficient and quality doctors.

“Hospital charges for hip and knee replacement surgery range from $15,000 to $110,000, with no measurable differences in outcome or quality,” said David Lansky, PhD, president and CEO of the Pacific Business Group on Health, an organization that helps businesses moderate the cost of employee health coverage. “Many employers are responsible for their employee’s claims … they want to pay the cheaper price.”

Dr. Lansky noted the increasing popularity of value-based health care purchasing, a movement to give purchasers more buying power so that they can ensure that the care that their employees receive is appropriate and that it is being provided by the best-performing physicians. According to AHRQ, in a value-based purchasing model, “employers and other purchasers gather and analyze information on the costs and quality of various competing providers and health plans and then contract selectively with plans or provider organizations based on demonstrated performance, or at least proposed approaches for improving performance.”

Private and public purchasers are also asking for increased provider accountability, specifically for evidence that identifies what care is appropriate and leads to the best patient outcomes.

“Healthcare costs are rising to unprecedented levels … our healthcare system must show its value,” said Steven H. Stern, MD, MBA, vice president for cardiac, orthopedics, and neuroscience at United Healthcare, Inc. “Orthopaedics needs more robust measures to discern what is appropriate or inappropriate musculoskeletal care.”

When audience members emphasized the need for risk adjustment in developing measures—to ensure accuracy and prevent physicians from being unfairly judged or penalized—Dr. Stern replied, “I agree that there should be risk adjustment, but there really isn’t that much difference among patients who are treated by surgeons. It’s easy to find fault in measures because when you have metrics, unfortunately, not everyone is going to get an A.”

Representing public payers was Patrick Conway MD, MSc, chief medical officer and director of the Office of Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS). He addressed the federal initiatives that CMS is using to encourage provider participation and optimize health outcomes.

According to Dr. Conway, CMS wants to lower costs without compromising quality by aggregating and comparing data and measuring performance. Some of the agency’s quality initiatives include the Physician Quality Reporting System, E-Prescribing Incentive Program, Medicare Electronic Health Record Incentive Program, and the Medicare Shared Savings Program. Each of these unique programs seeks to promote accountability, reduce fragmentation, and lower healthcare costs.

Does this stuff really work?
Clearly, payers and purchasers want more evidence to prove that various interventions are necessary and will bring value to a patient’s quality of life. But, will there be a worthwhile return on such a huge investment of physicians’ time, energies, and money to acquire and disseminate such information? According to Michael J. Goldberg, MD, chair of the AAOS Guideline Oversight Committee and director of the skeletal health program at Seattle Children’s Hospital, the answer is, “Yes.”

“The foundation for all quality initiatives is evidence-based clinical practice guidelines,” he said. “Incorporating evidence into the fabric of orthopaedic clinical practice will improve the care of our patients.”

To prove his point, Dr. Goldberg revealed findings from a program he recently instituted, using AAOS guidelines for pediatric femur fractures and supracondylar humerus fractures. Dr. Goldberg and his team developed electronic order sets and patient safety checklists based on the guidelines to standardize work, reduce duplication, and improve patient safety. The checklists are incorporated into the patients’ charts and flow through the hospital.

According to Dr. Goldberg, the checklists help improve processes, performance, and communication, while reducing error rates. A unique aspect of the electronic checklist is the inclusion of a text explanation box that can be used if a physician chooses not to follow a particular order set.

Registries established by physician organizations, insurance companies, and academic institutions are helping build an infrastructure for the collection of data on outcomes of select interventions. According to Thomas C. Barber, MD, chairman of the department of orthopaedic surgery at Kaiser Permanente and a founder of the Kaiser Total Joint Replacement Registry (TJRR), registries should no longer be considered simply as ways to track device usage and performance. Data extracted from registries can facilitate comparative effectiveness research, the development of clinical practice guidelines (CPGs) and quality measures, changes in practice behavior, and patient empowerment through increased knowledge and information.

Dr. Barber described how the TJRR has contributed to the following quality improvements:

  • A reduction in the number of partial knee replacements when the registry showed a 10 percent difference in revision rates between partial and total knee replacements
  • The identification of other techniques associated with higher revision rates, which reduced the usage of certain procedures
  • A change in implant selection behavior when the registry showed that less costly implants performed as well as more costly implants
  • The identification of devices that had a higher risk of revision
  • The development of Patient Empowerment Risk Calculators to facilitate patient-centered decision making, based on the identification of patient risk factors
  • Ralph Brindis, MD, MPH, MACC, FSCAI, immediate past president of the American College of Cardiology (ACC), echoed Dr. Barber’s remarks. “We need to articulate the value of the registries,” he said.

The ACC’s National Cardiology Data Registry (NCDR) is one of the most preeminent registries in the country and served as a model for the American Joint Replacement Registry (AJRR). With data from more than 2,200 hospitals, the NCDR has been described as a “national treasure” by both the U.S. Food and Drug Administration and President Obama for its postmarket device surveillance capability. Like Dr. Barber, Dr. Brindis believes that registries can do much more than device surveillance.

“Registries have helped us to develop meaningful national consensus measures by evaluating, in real time, the characteristics, treatments, and outcomes of our patients,” he said. “Registries help to answer the questions stakeholders continue to pose.”

Dr. Brindis acknowledged the short-term financial burden of registries like the NCDR and the AJRR, yet noted that the AJRR is necessary for the AAOS to become a powerful player in the quality movement. “Registries give us a framework for decision making. If we don’t monitor ourselves within our own specialty, some other entity with less understanding of our practice will police us,” he said.

Looking ahead
Breakout sessions, led by Drs. Bozic and Weber, focused on the future of CPG development, accountable care organizations (ACOs) and other quality initiatives, and integrating appropriate use criteria (AUCs) into daily practice. Recommendations included the following:

  • The AAOS should involve a broad range of stakeholders, including patients, early in the development of CPGs to ensure that the best questions are asked at the onset.
  • Patient safety checklists and other tools should be developed along with CPGs to foster their integration into clinical practice.
  • Multistakeholder collaboration to identify a common set of goals and standards is needed when developing an ACO.
  • The integration of musculoskeletal education into the curriculum of all care providers is necessary for the success of ACOs and other collaborative care efforts.
  • Performance measures are necessary to improve quality and should be developed in concert with CPGs and AUCs.
  • Physician payments should reflect physician adherence to appropriate use criteria.
  • Physicians must be involved in defining clinical quality in order for quality initiatives to have an impact on improving care.

“We, as physicians, have to be willing to lead,” said Dr. Brindis. “If we are not at the table, then we will be on the menu.”

Madeleine Lovette is the communications specialist in the AAOS office of government relations. She can be reached at lovette@aaos.org