Published 12/1/2015
Mary Ann Porucznik

Capturing Outcomes in Clinical Practice

How can a small- or medium-sized practice do it?

Patient-reported outcomes (PROs) are an increasingly important aspect of the healthcare landscape. As the emphasis shifts from volume to value, PROs are seen as critical tools that can help providers assess and improve their treatment strategies. At the 2015 Fall Meeting of the AAOS Board of Councilors (BOC)/Board of Specialty Societies (BOS), a panel of experts sought to help attendees understand not only which PROs are important to collect, but also how smaller or medium-sized practices could implement this data collection.

According to moderator David A. Halsey, MD, PROs have been used routinely in controlled research studies to help develop evidence-based practices. More recently, federal regulators have proposed payment policy changes that require PRO data collection.

"We know that payment reform, including value-based purchasing is compelling to orthopaedic surgeons," said Dr. Halsey. "Because the ultimate measure by which to judge the quality of any effort is whether it helps patients and their families as they see it, their voices are the most important."

Although many of the quality measures currently being discussed are simply process measures, the shift to PROs as performance measures is underway, noted Dr. Halsey. "When risk-adjusted, these tools can be very helpful to identify, develop, and study areas of disease-specific entities and outcomes in relation to what we do."

However, for the most part, the experience and infrastructure necessary to routinely collect PROs has occurred in big settings—research centers and healthcare institutions. The challenge now is to have processes and pathways that can be implemented in smaller communities and practices.

"The challenges are significant," said Dr. Halsey, pointing to the need for information technology, patient compliance, and buy-in from both patients and staff.

Why bother?
Reviewing the landscape of orthopaedic value-based care was Nicholas A. Abidi, MD, immediate past president of OrthoNorCal, a 10-physician group practice with four offices in northern California. Dr. Abidi noted that insurance companies are increasingly seeking to shift risk to providers to decrease their medical loss ratios.

Citing the importance of physician leadership, Dr. Abidi remarked, "In the end, it's only the doctor in the room who cares about his patients, his practice, and his partners. Consultants are not stakeholders. Administrators come and go. Doctors in private practice are generally in the community for the long haul."

With that in mind, Dr. Abidi began examining how his practice, which included primarily general orthopaedic surgeons, could reduce costs while improving care processes and outcomes. "We found that the biggest impediments to getting orthopaedic patients out of bed and discharged home were extreme pain, hypotension, and nausea related to narcotics in the epidural or spinal anesthesia, combined with extended release oral opiods," he said. Implementing standardized care and a multimodal pain management approach helped drive down nausea rates from 25 percent to just 0.4 percent (Fig.1).

"We got rid of extended-release narcotics and epidurals. We switched to regional anesthesia and spinal anesthetics." he noted, "and got patients out of bed the same day of surgery. We decreased complications, increased the percentage of patients discharged to home, and improved the patient experience, beginning with up-front education to reduce their anxiety, foster early mobilization, and reduce infections."

Although the practice had to rely on hospital tools for tracking outcomes, they were able to establish baselines and gauge progress using the new clinical methodologies. Each quarter, they put aside some money in hopes of finding a validated musculoskeletal instrument and administrative tools that would help measure quality.

The practice finally settled on using the Patient-Reported Outcomes Management Information System (PROMIS), a validated, license-free program developed by the National Institutes of Health and Northwestern University. Physicians can customize surveys and enter operative data for registry use.

One of the program's features is an individualized patient dashboard, showing preoperative and postoperative functional scores. "We look at the data with the patient at every visit," said Dr. Abidi. "It takes 5 to 7 minutes, and we have an 85 percent compliance rate."

In conclusion, he noted, "Quality payment reform is underway, with or without our consent. But physician leadership through comanagement agreements can generate measurable decreased costs and process improvements."

Collect what?
"Everyone is telling us to collect outcome measures," said Mark S. Vrahas, MD, chief of the Partners Orthopaedic Trauma Service, "but there is never a clear answer when we ask what measures to collect, or how."

As principal investigator on the AO Foundation Patient Outcomes Center project, Dr. Vrahas began by reviewing the requirements for complying with the Physician Quality Reporting System (PQRS). To avoid a "financial hit," he noted, physicians have to collect data on nine measures from three domains. Of the 175 measure choices, 17 are relevant to orthopaedics. Dr. Vrahas's picks for the measures that would most easily satisfy the criteria are shown in Table 1.

"We already do several of these things," said Dr. Vrahas, "we just need to collect an outcome measure for pain and one for physical function. The only stipulation is that it be appropriately normalized and validated."

Although a number of orthopaedic measures meet these qualifications, many are specialty-specific. "I am going to argue that all orthopaedists should use the same two measures—pain and physical function—regardless of the patient's condition," said Dr. Vrahas. "This will make it easy and the specialists will get just as much information as they would using their disease-specific measures."

Dr. Vrahas pointed out that comparing various instruments results in a list of thousands of questions, but only 136 unique questions. He explained the difference between classical test theory, which relies on completion of an entire series of questions for validity, and the item-response theory, in which each question is independently validated.

When an item-response test is combined with a computer algorithm, the result is a computer adaptive test (CAT) that can measure pain and physical function with just 8 to 12 questions. That, he said, is the promise of PROMIS.

Think outcomes
Although academic orthopaedics originally drove the movement to multiple outcomes measures, it is now driving a move toward more simple measures, noted Michael Suk, MD, JD, MPH, orthopaedic surgery chair for the Geisinger Health System. That movement may have a substantial effect on innovation.

"The beauty of these multiple outcome measures and the reason for their diversity are that they ultimately spur innovation," said Dr. Suk. "As we move toward more randomized, controlled trials—the gold standard for evidence—we cannot forget that it is testing expert opinions that may ultimately lead to changes in practice."

Locating the best available evidence is challenging, due to the number of papers published, the time required to access and read them, and the difficulty in critically appraising the available evidence. "Reading the abstract is insufficient for decision-making," admonished Dr. Suk.

Therefore, he suggested, "When looking for evidence, start with the end in mind—think outcomes." He reviewed three types of outcomes—physiologic, clinician-based, and patient-reported.

Physiologic outcomes are generally considered to be objective and often not tested for reliability or validity. Examples include fracture union, joint motion, strength, or alignment. These outcomes are usually surrogates for other measures.

Clinician-based outcomes—such as the Neer shoulder score or the Mayo hip score—are often a combination of signs and symptoms assessed by the clinician, sometimes in concert with the patient. They are often summarized in a single rating (excellent to poor).

PROs, which historically have been considered "soft" or "subjective," are concerned with patients' perceptions of their symptoms, functional ability, and quality of life. They may be general (pain and symptoms, functional ability, and health-related quality of life) or specific (return to sports, activities of daily living).

"By limiting the number of PROs in use, are we affecting our ability to innovate?" asked Dr. Suk. "When did we stop caring about fracture union or range of motion? When did a surgical opinion on outcome cease to matter? Does the trend toward PRO for payment make sense? When we measure PROs post hoc, is there anything we can do to improve them?"

PROs may have a basis in patient expectations prior to treatment. In trauma situations, noted Dr. Suk, patients often go from young and healthy to severe disability, and rarely return to baseline status. However, patients with chronic conditions may exceed baseline outcomes a year after treatment.

Similarly, patient satisfaction with treatment may have little to do with the actual treatment. According to a 2013 prospective cohort study of total joint replacement patients, overall patient satisfaction was predicted by the following factors: meeting preoperative expectations, satisfaction with pain relief, and satisfaction with the hospital experience. Clinical measures carried little weight.

"In the end," said Dr. Suk, "how we deliver heath care may be of key importance."

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Bottom Line

  • Physician leadership and engagement is necessary to lower costs, improve care, and ensure patient access to health care.
  • Standardizing care, managing pain, and empowering patients are key to improving care quality, functional outcomes, and the patient experience.
  • Low patient numbers for a particular service at a small center may skew datasets.
  • Computer-adaptive testing may be a way to reduce the number of questions and the time involved to obtain PROs.

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