In the United States, widespread use of clinical registries–—collections of prospectively gathered data from a group of patients with a common characteristic (usually a diagnosis or treatment)—has been limited for many reasons, including the challenge of obtaining longitudinal patient follow-up data in a multiple-payer system. Within the field of orthopaedic surgery, registries have historically been used for surveillance of implants—particularly in total hip and knee arthroplasty—as a measure of patient safety. Recent health policy reforms, however, have prompted a reexamination of the role of registries.

In view of the increasing emphasis on demonstrating both the clinical effectiveness and the economic value of treatments, registries can be powerful and robust vehicles for reporting outcomes and improving the overall delivery of care. Although participating in a registry can be logistically and financially challenging in the beginning, doing so can benefit orthopaedic surgeons in a number of areas including practice improvement, demonstration of value, and physician reimbursement.

Practice improvement
Recent registry initiatives, such as the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) and the American Joint Replacement Registry (AJRR), include longitudinal collection of patient-reported outcomes measures (PROMs). Once a sufficient sample has been collected, orthopaedic surgeons will be able to use PROMs data to enhance their interactions with patients, specifically with respect to treatment expectations and postoperative recovery timeframes. Registry data will also give both individual surgeons and orthopaedic groups the opportunity to benchmark themselves against peers and to critically assess the outcomes of their practices, with an eye toward improving both efficiency and quality of care.

Demonstration of value
Widespread adoption of registries and the inclusion of PROMs in data collection will provide clinicians and researchers with an unprecedented ability to demonstrate the effectiveness and value of the care provided. Robust data collection will create large sample sizes and allow appropriate risk-adjustment, which will enhance an understanding of recovery and can help preserve access to musculoskeletal health for vulnerable patient populations. Registries will also provide a common platform for orthopaedic surgeons to report quality measures, which will become increasingly important in an era of public reporting of outcomes.

Physician reimbursement
The 2014 Medicare Physician Fee Schedule (MPFS) issued by the Centers for Medicare & Medicaid Services (CMS) includes updates to the Physician Quality Reporting System (PQRS). These changes incorporate an increase in the number and breadth of required measures that physicians must report to earn a payment incentive (for 2014) and avoid a payment adjustment/penalty (for 2016). They are also designed to encourage physicians to participate in clinical data registries that foster quality improvement. The number of reporting measures in PQRS has been expanded, with a particular focus on increasing the number of outcome measures and decreasing the number of process measures.

Providers can meet the PQRS requirement using claims-based filing, electronic health records, a CMS-approved registry, or, new for 2014, a subset of registries called “qualified clinical data registries” (QCDR). Instead of being limited to reporting the measures prescribed in the PQRS system, physicians who report using this specifically vetted subset of registries will have greater flexibility in the reporting measures. In theory, using a QCDR enables physicians to participate in a registry that is focused on promoting specialty-driven clinical effectiveness and quality improvement and is not solely a mechanism for collecting and transmitting data to payers.

Registries categorized as QCDRs must meet specific criteria, including the following:

• the inclusion of data from multiple payers
• the capacity to benchmark providers in relation to their peers
• the provision of quarterly feedback to providers on the quality measures collected

Recognizing that the quality measures collected by the QCDR will not always align with PQRS-specific measures, CMS has proposed that providers who participate in a QCDR will meet the requirement for satisfactory participation in PQRS. The 2014 MPFS would allow the QCDR flexibility in determining the nine quality measures that are reported for its participants, provided that the measures span three of the National Quality Foundation’s strategic domains and that at least one of the measures is outcomes-based.

Participation
In the United States, total joint arthroplasty registries (FORCE-TJR and AJRR) are the farthest along in development, although the North American Spine Society is completing pilot data collection for its new registry. In addition, some orthopaedic spine surgeons participate in the American Association of Neurological Surgeons’ National Neurosurgery Quality and Outcomes Database.

Surgeons interested in reporting PQRS-specific measures using a registry can find information for approved third-party vendors on the CMS website. Registries could begin the self-nomination process for designation as a QCDR as of January 2014, and CMS is expected to issue a list of QCDRs by midyear.

Registries provide an intriguing avenue for orthopaedic surgeons to participate in quality improvement and value demonstration initiatives. The encouragement of registry participation by CMS coincides with an overall sentiment that orthopaedic surgeons should take part in large registries as part of a general effort to improve quality. Access to large-scale registry data, including patient-related outcomes, will provide new opportunities for practice improvement, research, quality improvement, and advocacy in an era of increasing competition for healthcare resources and increasing accountability for the delivery of high-quality care.

Christopher J. Dy, MD, MPH, and Eric C. Makhni, MD, MBA, are the 2013 Washington Health Policy Fellows. The Washington Health Policy Fellowship was established in 2001 to encourage participation of orthopaedic residents in the national, state, and local health policy arenas.

Disclosure information: Drs. Dy and Makhni report no conflicts.

Learn more at Annual Meeting
The AJRR will host an educational session on “Worldwide Orthopaedic Arthroplasty Registries” during the AAOS 2014 Annual Meeting in New Orleans, at 9 a.m. on Wednesday, March 12, in room 260 of the Morial Convention Center. Moderated by William J. Maloney, MD, chair of the AJRR board of directors, and David G. Lewallen, MD, AJRR medical director, the session will be an opportunity for orthopaedic surgeons, hospital executives, nurses, and others to learn how orthopaedic registries collaborate and what benefits they can provide.

The “Lessons on the Outcomes of ACL Reconstruction Surgery from International Registries” (Symposium CC) will be held on Friday, March 14, 1:30 p.m.–3:30 p.m. in Theater C of the Morial Convention Center. Moderated by Scott A. Rodeo, MD, the symposium will present approaches to the study of anterior cruciate ligament (ACL) reconstruction from registries that collect data on large numbers of ACL patients.