Published 1/1/2014
Elizabeth Fassbender

AAOS Hosts Orthopaedic Quality Institute

On Nov. 14–15, 2013, stakeholders from around the country gathered in Washington, D.C., for the 2013 Orthopaedic Quality Institute (OQI), “Partnerships in Improving Value in Musculoskeletal Care.” Since 2011, OQI has helped shape the debate on quality initiatives aimed at reducing healthcare costs and bolstering healthcare quality.

At the 2013 OQI, the orthopaedic community, together with consumer advocates, government representatives, and others, discussed topics such as clinical practice guidelines (CPGs), appropriate use criteria (AUC), registries, and performance measures.

The 2013 OQI sought feedback from participants on priority topic areas and provided information on trends in value-based payment and delivery models. Participants were also encouraged to explore models for partnerships between the AAOS and the payer/purchaser/ policymaker communities that could help expand AAOS quality initiatives and meet the needs of other stakeholders. Identification of potential funding sources was a third goal of the OQI.

AAOS quality efforts
AAOS President Joshua J. Jacobs, MD, outlined the AAOS commitment to quality and provided a timeline of AAOS involvement in quality efforts. He noted that, at their September 2013 meeting, the AAOS board of directors approved a plan to develop performance measures. Under the approved business plan, the AAOS will expand staffing and endeavor to develop four specific orthopaedic performance measures over the next 4 years.

Following Dr. Jacob’s presentation, David Jevsevar, MD, MBA, chair of the Evidence-Based Practice Committee, gave an update on evidence-based CPGs and the rationale behind them. CPGs, he stressed, are educational tools that integrate the current scientific literature and the proficiency and sound judgment that physicians typically acquire in clinical practice. They are not intended to be absolute, or to set a “standard of care.” CPGs are a synthesis and synopsis of the best available clinical studies published in peer-reviewed journals or formats.

James M. Sanders, MD, discussed AUCs, which are developed to ensure the highest quality of care for patients undergoing musculoskeletal procedures. AUCs specify when it is appropriate to use a particular procedure and are becoming increasingly important in today’s changing healthcare environment. According to Dr. Sanders, AUCs can be used to influence good policy as well as to educate providers. He provided an overview of the AUC development process, which includes using evidence-based information in conjunction with the clinical expertise of physicians from multiple medical specialties.

Other quality initiatives
Steven H. Stern, MD,
vice president cardiac and orthopaedic/neuroscience serviceline, United Healthcare, and secretary/treasurer of the American Joint Replacement Registry (AJRR), discussed the role of registries in quality initiatives. (See
“AJRR Surpasses Enrollment Goal.”) According to Dr. Stern, some of the challenges in enrolling hospitals include the lack of a federal mandate for registry participation, as well as legal and privacy issues.

Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research & Quality and cochair of the OQI, discussed performance measures and defining value in health care. According to Dr. Bozic, when patients are asked who should define quality in orthopaedics, they prefer to have physician societies involved. To that end, Dr. Bozic highlighted some of the charges for a newly initiated performance measure committee and asked for help in defining its priorities moving forward.

Dr. Bozic noted that performance measures are the metrics by which a healthcare provider’s or a facility’s performance is compared with national benchmarks. He pointed out that performance measures are part of the quality cycle (Fig. 1), which begins with evidence analysis and evidence-based systematic reviews, and leads to the development of quality tools such as CPGs, AUC, shared decision making instruments, checklists, and performance measures.

Thomas C. Barber, MD, chair of the AAOS Council on Advocacy, discussed the quality efforts being implemented by Kaiser Permanente, an integrated healthcare delivery system with 9 million members and more than 12,000 physicians. According to Dr. Barber, Kaiser’s quality activities include quality monitoring, quality improvement, patient safety, and marketing.

Michael Suk, MD, JD, MPH, spoke on the Geisinger Health System and value-based orthopaedics. Dr. Suk shared the Geisinger mission: to enhance quality of life through an integrated health service organization. He also discussed the ways that quality and innovation are a part of their philosophy.

The CMS perspective
Karen Nakano, MD, MS, from the Centers for Medicare & Medicaid Services (CMS), asked that program attendees keep the Department of Health and Human Services and the CMS vision of “the right care for all patients every time” in mind when developing quality measures. She also asked that performance measures take into account consumers, private sector needs, and compatibility with electronic health record systems. She stressed that physicians should stay engaged with the agencies and with policy makers as they continue to develop quality measures.

Next Steps
During facilitated breakout sessions, participants explored ways to expand AAOS quality initiatives to meet the goals and needs of external stakeholders. As a result of these discussions, they developed a series of recommendations and next steps to guide future efforts in this area.

Participants agreed that the AAOS should continue to provide leadership on quality issues and to be proactive in setting the stage and defining the direction for orthopaedic quality measures.

They also acknowledged the importance of understanding the quality landscape and developing multiple types and levels of partnerships to advance a quality agenda. Key issues were identified, including standardization, alignment, and consistency of measures and reporting requirements across various practice settings.

Participants also recommended the following steps that would support AAOS quality efforts: expanded efforts to standardize EHRs, the inclusion of data from EHR vendors such as EPIC in registries such as the AJRR, and the expansion of Patient Reported Outcomes Measurement Information System. Patient-centered outcome and process measures, participants agreed, should also be a key focus and consideration for AAOS in its quality work.

Looking forward, participants suggested that AAOS consider including representatives from hospitals, chambers of commerce, and academia—as well as patient advocates—in future OQI meetings.

Elizabeth Fassbender is the communications specialist in the AAOS office of government relations. She can be reached at fassbender@aaos.org