Developing orthopaedic-specific performance measures, said Kevin J. Bozic, MD, MBA, is the “most important new initiative” undertaken during his tenure as chair of the Council on Research and Quality.


Published 1/1/2015
Jennie McKee

Taking the Next Step in Improving Value

Kevin J. Bozic, MD, MBA, discusses efforts to develop orthopaedic performance measures

Dr. Bozic, who addressed members of the Board of Councilors and Board of Specialty Societies at their 2014 fall meeting, noted that all current value-based payment strategies require a definition of “quality,” and emphasized that performance measures will play an important role in determining how physicians are paid going forward. Input from AAOS members as well as members of orthopaedic specialty societies, he stated, must guide development of performance measures. (See “Specialty Societies Tackle Performance Measures.”)

Recently, AAOS Now spoke with Dr. Bozic about orthopaedic-specific performance measures, including two performance measures currently being developed by the AAOS and other orthopaedic societies: one focusing on hip fractures and the other focusing on osteoarthritis (OA) pain and functional assessment.

AAOS Now: Right now, where does data on healthcare quality come from?

Dr. Bozic: Currently, it comes from multiple sources, some of which are not very credible. Much of the “quality” data that is publicly available comes from administrative claims—ie, information that was submitted to insurers regarding services performed. These data are not really based on quality, but are instead based on utilization of services. Data also come from online reputation sites, which are important but not the most valid and thorough sources of information on quality. As physicians, we have access to much better data than do any other reporting sources. We have the unique opportunity to define quality in our own specialty.

AAOS Now: What was the catalyst for the AAOS and other orthopaedic societies to begin developing orthopaedic-specific performance measures?

Dr. Bozic: In recent years, a number of different stakeholders—including the public, payers, public reporting agencies, and professional certifying boards, such as the American Board of Orthopaedic Surgery (ABOS)—have expressed interest in the concept of using performance measures to define “quality” in orthopaedic surgery. Because of this interest, a number of different performance measures have been put forward, most of which are not particularly clinically relevant, and are not performance measures by which orthopaedic surgeons would choose to be judged. So, the real motivating factor is what is going on in the market. We want to be more proactive about defining what quality means in our specialty, rather than having it defined for us by others.

AAOS Now: How would you define “performance measures?” How are they used?

Dr. Bozic: I like to make an analogy to golf: If you play golf, the only way you will get better is to keep score. If you want to get better at what you do, you have got to measure your performance.

In medicine, many factors contribute to defining a physician’s performance, making it difficult to define and measure. However, performance measures are used in two general categories: accountability and performance improvement. Accountability refers to holding providers accountable for their performance in terms of how they are paid and how their outcomes are reported to other stakeholders, including the public. With performance improvement, the golf analogy applies. Golfers don’t keep score to prove to everybody else that they are good players, or that they are better than someone else. They keep score to improve their own performance. The primary goal of performance measurement is to use it to improve one’s own performance. Performance improvement has implications in the practice setting as well as in Maintenance of Certification (MOC), because the ABOS requires performance to be measured as part of MOC.

AAOS Now: What role do physicians play in the development of performance measures?

Dr. Bozic: The role of the AAOS and other professional medical societies in developing performance measures is to decide which conditions should be prioritized for measures, and how to define “quality” for each of those conditions.

In addition, orthopaedic specialty societies must review the evidence to correlate process measures—such as giving patients appropriate antibiotics or supervising rehabilitation in a certain way—with outcomes of care. It is important to choose outcomes measures such as infection rates or hospital readmissions that can be influenced by the actions of providers. A patient’s living situation, for instance, would not be a good performance measure, because a provider cannot influence a patient’s living situation.

After the performance measures are drafted, they then need to be shepherded through the approvals process, which could include review by external bodies such as the National Quality Forum. The measures would also need to be updated over time. If we encounter a ceiling effect—meaning that all providers are suddenly getting a perfect score on a certain measure—that measure would need to be re-evaluated.

AAOS Now: The AAOS is collaborating with other orthopaedic societies to develop performances measures on the treatment of hip fractures and the treatment of OA function and pain assessment. How were these topics selected?

Dr. Bozic: At the first meeting of the newly formed Performance Measures Committee, chaired by Warren Dunn, MD, MPH, the group selected potential topics for performance measures using six criteria. Outcome measures, which are the most meaningful measures of performance, must be important to patients and providers and something providers can influence, such as postoperative pain and function.

It is also important to choose something with a high degree of variability and room for improvement. In addition, it should be something that affects many patients and has a sizeable impact, both clinically and economically. Another criterion is that it should also be something that has not yet been measured—or, if it has been measured, it should be something that we think can be improved.

We chose the treatment of hip fractures because it met all of the criteria. We also opted to update a measure on pain and functional assessment in patients with OA of the lower extremity. The AAOS and other organizations originally developed that performance measure years ago, but it was not validated on a regular basis. Assessing pain and function in patients is important and AAOS members should be encouraged to systematically measure pain and function in their patients. Those who do so should be recognized for their efforts.

The orthopaedic specialty societies that are working with the AAOS to develop these performance goals have provided invaluable input. They help determine what is important to measure, what the important clinical variables are, what sources the measures can be derived from, and how this information should be communicated.

The AAOS will not develop performance measures for every single orthopaedic condition in every specialty, which is why working with our specialty partners is so important. Once they have the processes and a blueprint for how to do this, the AAOS can encourage and support them in developing performance measures on their own.

The AAOS can only develop two or three performance measures each year. It would take decades to develop enough performance measures for all of orthopaedics; with the help of specialty societies, this can be done on a larger scale and at a faster pace.

AAOS Now: What challenges do you foresee in developing performance measures?

Dr. Bozic: The first one is communication. There are a lot of misconceptions about why the AAOS is getting involved in performance measurement. My response is that our input is needed to make performance measures clinically relevant and to increase the likelihood that the measures will help providers improve their performance, because we have the relevant expertise.

The second challenge is that the evidence base in orthopaedics is not as robust as we would like it to be. Therefore, defining performance based on evidence is more of a challenge in orthopaedics than it is in other medical specialties.

In addition, we do not have a good source of data to use for measuring outcomes. For example, for the past 20 years, the Society of Thoracic Surgeons has had a very robust registry that it can use to measure surgical outcomes and validate performance measures. Because that information isn’t available for orthopaedics, we are exploring alternative sources of information.

Another challenge is developing performance measures within the desired time frame of other stakeholders, which is urgent. The Centers for Medicare and Medicaid Services, for instance, has statutory guidelines that require each specialty to have a certain number of performance measures in place so that their members can participate in programs such as the Physician Quality Reporting System or the Value-Based Payment Modifier. So, we need to develop relevant performance measures as quickly as possible.

And finally, there is the issue of resources—both human and financial—that are needed. While daunting, none of these challenges is insurmountable.

AAOS Now: How do you see performance measures fitting in with other Academy quality initiatives and the AAOS 20/20 Strategic Plan?

Dr. Bozic: Performance measures are a natural extension of our existing quality initiatives. The Academy’s evidence-based clinical practice guidelines (CPGs) are essentially a systematic review or synthesis of the evidence outlining the factors that, based on the literature, influence health outcomes. Appropriate use criteria (AUC) help define when it is appropriate to undertake a certain healthcare intervention. CPGs and AUC use both evidence and the collective wisdom and judgment of experts. All that information can then be used to help define the process and outcome variables that should be used to measure provider performance.

Performance measures also fit well with the AAOS mission of “Serving our profession to provide the highest quality musculoskeletal care.” Performance measures will help us fulfill that mission by giving members the tools they need to improve the quality of care they provide to their patients.

AAOS Now: Any final thoughts?

Dr. Bozic: The AAOS appreciates the support of our members as we embark on this important new initiative. Their input and guidance throughout this journey will be absolutely critical to our success.

I would also emphasize that other entities involved in measuring performance are looking to the AAOS for leadership. We have a unique opportunity to step up and fill that void because the public and our patients—and even the payers and the government—trust us to determine what is important in orthopaedics, in terms of measuring quality. Our members want tools to help them improve the outcomes associated with care we provide to our patients. Performance measures can help us do that.

Dr. Bozic’s disclosure information, including any potential conflicts of interest, can be accessed at

Jennie McKee is a senior science writer for AAOS Now. She can be reached at

For more information
Dr. Bozic encourages AAOS members to contact him via email ( with any questions or concerns regarding efforts to develop performance measures for orthopaedics.

More information about performance measures is also available on the AAOS website at