Clifford W. Colwell, MD

AAOS Now

Published 12/1/2012

The AJRR: Becoming a National U.S. Joint Registry

A roundtable discussion with participating physicians

The American Joint Replacement Registry (AJRR) is a national total joint replacement registry, governed by an independent, not-for-profit entity, under the direction of orthopaedic surgeons in partnership with stakeholders. The goal of the AJRR is to improve the quality, outcomes, and cost-effectiveness of total joint replacement (TJR) surgeries.

Recently, E. Anthony Rankin, MD, AAOS representative to the AJRR Board of Directors and a former president of the AAOS, conducted a roundtable discussion with several orthopaedic surgeons about the value of a joint registry. The following AAOS members shared their experiences:

  • George F. Chimento, MD, section head of adult reconstruction at the Ochsner Health System in New Orleans and associate professor, University of Queensland School of Medicine
  • Clifford W. Colwell, MD, clinical professor, University of California, San Diego School of Medicine, and medical director, Shiley Center of Orthopaedic Research and Education at Scripps Clinic, La Jolla, Calif.
  • Michael P. Dohm, MD, a member of the Western Slope Study Group who is in private practice with Rocky Mountain Orthopaedic Associates, Grand Junction, Colo.
  • Ali R. Oliashirazi, MD, professor and chairman of the department of orthopaedic surgery at the Joan C. Edwards School of Medicine, Marshall University, Huntington, W.Va.
  • Jeffrey L. Pierson, MD, a joint replacement surgeon with St. Francis Medical Group in Carmel, Ind.
  • William J. Robb III, MD, associate clinical professor in the department of orthopaedic surgery at the Pritzker School of Medicine at the University of Chicago, and chair of the AAOS Patient Safety Committee


George F. Chimento, MD


Michael P. Dohm, MD


Jeffrey L. Pierson, MD


William J. Robb III, MD

 

Dr. Rankin: The AJRR has experienced considerable growth since it officially began operations in August 2011. To date, we have information on more than 30,000 arthroplasty procedures. We’ve enrolled more than 86 participating hospitals and have key staff in place, including a new executive director and directors in the areas of information technology, research, and strategic initiatives.

Two of our participants, Drs. Dohm and Pierson, were part of the pilot project. Why did your hospitals consider becoming early adopters? What made your hospitals want to join the AJRR?

Dr. Dohm: We recognized the importance of a registry more than 20 years ago. Being in western Colorado, we wanted to link into a national system and we appreciate that the Academy helped us link into a data project through MODEMS [Musculoskeletal Outcomes Data Evaluation and Management System].

We joined the AJRR early, still using our tools from the MODEMS project, and then linked to the International Society for Arthroplasty Registers. We’re also involved in projects such as the Dartmouth Institute’s Data Collection Project.

Our hospital is interested in working with physicians not only to do some surveillance on joints, but also to work on early activities and patient outcomes. We believed that participation in the AJRR would help us to improve efficiency, effectiveness, and outcomes.

Dr. Pierson: We’ve had a local database for 25-plus years, and it’s proven to be an enormous value for us in research, improving patient care, and making data-driven decisions. We have also been aware of the power of national registries, particularly from many countries outside the United States.

We became an early adopter because we do this on a routine basis anyway, so it wasn’t that much of a cultural change to continue to do it. We wanted to be part of something that we are confident is going to provide very valuable information for our patients and surgeons and improve the value of what we do.

Dr. Rankin: Drs. Oliashirazi and Chimento, your hospitals came on after the pilot project. What were some of the challenges you faced in getting the AJRR started at your hospitals?

Dr. Oliashirazi: We wanted to be part of the project at the outset, but our legal counsel had some issues with the initial contract, so we waited till the new contract came out in mid-2012.

That essentially resolved most of the original issues—except for liability. Who incurs the liability if there is a breach of the database? Once that was resolved, we signed the contract.

Another challenge was the staffing needed to enter the data. Part of our information needs to be entered manually, and we needed to overcome that funding barrier, which we were able to do.

Dr. Chimento: Those were two of the issues we had as well. In addition, we had a concern about the Institutional Review Board (IRB) approval. The AJRR had approval from the Western IRB, but our attorneys also wanted approval from our IRB. That was a minor issue, but it did take time.

A second challenge was the issue of HIPAA privacy and security compliance. Everything that goes out needs to be encrypted the entire way. Our information technology (IT) people worked with the AJRR staff to resolve that issue.

As for support staff, we are entering data manually right now. We will soon have a system-wide electronic medical record system, and we hope that will make it much easier to enter and transmit data and reduce the need for a full-time employee.

Dr. Rankin: Dr. Colwell, your hospital is not participating yet. Could you address how a national registry would help your practice and your hospital?

Dr. Colwell: We have a local database that goes back to 1970 and includes Level 4 data, so we’re well aware of the benefits at a local level. Many of the advanced countries now are collecting data at a national level, which adds so much to local or even state registry.

We believe it’s important to be involved in the AJRR. We have two or three problems we have to work through, particularly with information services. It passed our IRB without difficulty, but we are concerned about patient safety, liability, and, obviously, HIPAA compliance issues.

Dr. Rankin: Dr. Robb, speaking as both an orthopaedic surgeon and as chair of the AAOS Patient Safety Committee, how could a national registry help your practice?

Dr. Robb: The AJRR initiative is critically important from the perspective of patient safety. When fully operational, the AJRR will, at a minimum, provide implant-specific data on all hip and knee replacement patients in the United States. It will complement other national data bases, providing reliable implant safety and basic performance data. Additionally, the required hospital data collection will serve to increase the infrastructure of local hospital safety and quality programs, adding value for our orthopaedic patients.

Dr. Rankin: What issues have your hospitals faced in implementing the AJRR? Dr. Dohm, will you start?

Dr. Dohm: When we started with the MODEMS project, we found that we really needed to establish a separate entity—other than our practice—to do data collection. So we established a 501(c)(3) organization, hired some data collectors, and linked together with the hospital, which helped fund a quarter of a full-time equivalent (FTE). We found that when we worked together, we could actually move projects forward.

Clifford W. Colwell, MD
Ali R. Oliashirazi, MD
E. Anthony Rankin, MD

I think the National Surgical Quality Improvement Program from the American College of Surgeons recommends having at least one data collection nurse or somebody to do that data collection, and we’ve found that to be true. So at this point we have a 501(c)(3) that has at least one FTE collecting data, along with the hospital that has at least a part of an FTE to collect data.

Dr. Pierson: We’ve been able to implement without adding any new FTEs, which, of course, is a barrier from many hospitals’ perspective. But we have been collecting data like this—and even more extensive data than this—for some time. We’ve done it collaboratively … through our research foundation, through the hospital coders, through our IT partners at the hospital, and with the support of surgeons.

At this point, most of the data needed by the AJRR are not difficult to collect. The problem is creating a culture in the institution that supports doing it. Some hospitals will have a little more work to do than others, but it’s not an onerous project.

I don’t want hospitals to think that they need a history of research or data collection or trained people to make this happen. It can be done largely by having a commitment to doing it; few, if any, new FTEs would be needed.

Dr. Chimento: Our experience has been similar. The attorneys and the IT people are instrumental in getting the project off the ground. We did need to hire 0.4 FTE to do data entry.

Our hospital quality improvement officer did a very good job of convincing the administration that participating in the AJRR was in the system’s best interests. Aside from the patient safety issues, by tracking outcomes and participating in a registry, hospitals can become preferred providers for some insurance plans and increase their reimbursement. Once the administration heard that, it was much easier to convince them to go forward.

Dr. Oliashirazi: Our initial meeting included the surgical director of the joint replacement center, the medical director, the program manager, the IT director, the hospital’s legal counsel, and both the chief executive officer and vice president of the hospital. We needed buy-in from all those entities, and we were able to successfully achieve it.

Right now the program manager of our Joint Replacement Center is the primary staff member. The Level 1 data that we have to provide are simple. We do have to enter two data points—laterality and implant information—manually, but we’ve been able to do it without hiring an extra FTE.

Dr. Rankin: What are some of the benefits you anticipate seeing once your hospital does join AJRR, Dr. Colwell?

Dr. Colwell: I think orthopaedic surgeons fear that somehow their data are not going to stack up against others, and that’s why they hesitate to get involved. But within our hospital system registry, we recently reviewed how each hospital is rated in administering prophylactic modalities for venous thromboembolism and they did very well. This was helpful to those hospitals that are not collecting Level 4 data.

I believe registry participation can help the entire hospital complex perform better. If problems surface, we’ll learn about them early—what they are and how they can be addressed. I’m excited about it from both the local and national level.

Dr. Robb: Public reporting of hospital quality data by the Centers for Medicare and Medicaid Services (CMS) is already underway. CMS plans to begin reporting quality data on physicians, including orthopaedic surgeons, in 2014. Local hospital data collection and analysis will be important, as the CMS data will rank hospital performance and drive improvement initiatives within hospitals.

The AJRR and the CMS public reporting of quality data will encourage hospitals to invest locally in their safety and quality initiatives—driving improvements at the site of care. National data collection will support surveillance and benchmarking efforts that aren’t possible with local data collection. Ultimately, these safety and quality initiatives may emerge as mandates and components of payment systems.

Dr. Rankin: What advice would you give your orthopaedic surgeon colleagues who are interested in joining the AJRR?

Dr. Chimento: I want to address the fear issue—that your data won’t stack up or that they could be used in a punitive manner. That’s not the goal of a registry. As the numbers add up, we can see which implants work and get the best long-term results over the course of years. We can use this information to decrease variations in care and deliver better value by providing the best possible care at a reasonable cost. In the future, our reimbursements will be based on quality of care, value, and outcomes, and the registry will provide valuable information.

I think by having the registry at our disposal, it will help us dictate how we get to practice in the future. I hope most surgeons would understand that’s a good thing, a benefit of the AJRR as we move forward.

Dr. Pierson: I think people are generally aware of the benefit of a national registry in terms of identifying negative outliers in performance. But I also think that health care is headed in a value-based direction. A national registry can not only identify the poor performers, but also help us sort out value propositions. As patient advocates, orthopaedic surgeons need to embrace that idea. And to do that, we need to participate in meaningful initiatives such as the AJRR.

Dr. Dohm: We’ve been working at this since about the mid-1990s, and I just want patience. So many others have gone before us with efforts to improve quality—from Ernest Amory Codman in the early 20th century to Jack Wennberg and Bob Keller with the Maine Medical Assessment Foundation in the 1970s and today with James Weinstein, DO, MS, with the Spine Patient Outcomes Research Trial, and Marc F. Swiontkowski, MD, with the Musculoskeletal Function Assessment Tool.

We’re all on the same path and are starting to see the products of all these seeds that have been planted over the years. Finally, we can manage the data. We can actually see things quickly with computer systems. And I think we’re at the cusp of realizing the value of all this.

Dr. Colwell: Occasionally, I got discouraged over this issue. Although I would prefer to use the “carrot” over the “stick,” I think the stick—in terms of reimbursement—will make the difference. If doctors are not willing to participate, ultimately they’re not going to get paid.

Dr. Oliashirazi: The number of revision total joint replacements is increasing tremendously. We are constantly introducing new techniques and technologies. Feedback, like that we will get from a registry, will make us better.

As others have said, we’re going to be paid based on our outcomes. We need this feedback to improve what we’re doing and identify outliers in techniques and technologies before they are used on a large number of patients.

As orthopaedic surgeons, we have to make sure that this project succeeds. The only way we can do that is for all joint replacement surgeons—and even those who are not primarily joint replacement surgeons—to participate. Every joint replacement should be in the AJRR. We shouldn’t have an option in this. This has to succeed. I can envision a time when disease-specific Joint Commission certification or even board certification will depend on participation in the AJRR.

Dr. Rankin: What advice would you give your orthopaedic surgeon colleagues who are interested in joining the AJRR?

Dr. Robb: As a specialty, we identified collection of outcomes data as important with the MODEMS project in the 1990s. Although well-intended, it was perhaps before its time and eventually failed. With the AJRR, we recommit to collecting data that will provide better outcomes for our patients. It has to succeed. The AJRR will require successful collaboration and alignment of surgeons and hospitals that provide joint replacement care. Surgeons, however, need to take the lead and embrace this effort on behalf of our patients to improve the safety, quality, and value of the joint replacement care we provide.

Dr. Dohm: The pillars of the AAOS include education, research, and advocacy. Registry data provide the initial information, the data substantiation of how we practice. I think participation in these registries will help us with advocacy in the future.

Dr. Chimento: From the patient’s standpoint in this age of transparency, I think registry participation by their surgeon and hospital will increase their peace of mind and allay any fears that they may have regarding implant choices. I think it will be very beneficial from a patient safety aspect also.

Dr. Rankin: I agree—it is going to succeed. We’ve got a good board and excellent staff, and we’re moving in a positive direction.

Disclosure information: Dr. Rankin—Orthopedics; AJRR; J. Robert Gladden Society; Orthopaedic Research and Education Foundation (OREF); Dr. Chimento—no conflicts; Dr. Colwell—Medical Compression Systems, Ltd.; Stryker; Norvartis; Isis; Journal of Arthroplasty; Journal of Bone and Joint Surgery–American; Clinical Orthopaedics and Related Research (CORR); Dr. Dohm—Kyphon Inc./Medtronic; Dr. Oliashirazi—DePuy, A Johnson & Johnson Company; Dr. Pierson—Accelero Health; Zimmer; Biomet; Exactech, Inc.; Journal of Arthroplasty; CORR; Dr. Robb—Innomed; Blue Cross Blue Shield Association; Smith & Nephew; Abbott; Baxter; Emmi Solutions; Johnson & Johnson; Stryker; OREF.