During the Board of Councilors and Board of Specialty Societies 2014 fall meeting, representatives from the American Association of Hip and Knee Surgeons (AAHKS) and the Pediatric Orthopaedic Society of North America (POSNA) joined Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality, in a discussion on performance measures.

Dr. Bozic began by providing examples of different types of performance measures as well as the pros and cons of each type.

“Structural measures, such as adoption of an EMR, are easy to define, but may not have an impact on quality or outcomes,” he explained. “Process measures, such as administration of antibiotics or VTE prophylaxis, are commonly used as performance measures today. They have the advantage of being relatively easy to measure and provide actionable feedback to providers, but they don’t always correlate directly with quality.

“Outcome measures are the gold standard for measuring, where we would like to be,” he continued. “However, outcomes require risk-adjustment, and there is often a time lag between the intervention and the outcome of interest. Finally, patient experience and efficiency measures are here to stay.” Dr. Bozic also pointed out that most narrow networks are based on efficiency measures, which are simply utilization and cost of care.

Dr. Bozic also reviewed the results of a recent performance measures summit that involved all orthopaedic specialty societies. The goal of the summit was to identify what was important for each specialty society in terms of performance measures. Because “every single member of the AAOS deserves to have measures that can be used to help them improve their performance,” each society was asked to identify measures that could be used today (based on current available data), as well as aspirational measures.

“This is absolutely our moment,” said Dr. Bozic. “Either we find ways to do things better and at a lower cost or we just simply take our lumps and accept the fact that there will be across-the-board cuts in reimbursement and limited access to patients. Those are really the two choices we have.”

AAHKS
According to Mark I. Froimson, MD, MBA, chair of the AAHKS Health Policy Committee, performance measures have four key categories. First is the accountable (measured) entity, such as the physician, hospital, or health system. Second is the grading or evaluating entity (the measurer), which may be a payer, the public, or the government. Third is the measure developer (authority), such as the National Quality Forum, a professional society, or outside consultants. Finally is the consequence of performance, or the impact on the measured entity’s reputation, referrals, or payments.

In addition, noted Dr. Froimson, performance measures have the following key domains:

• Indications—Did the right person get the right intervention?
• Clinical quality—Did we solve the problem?
• Patient safety—Did we avoid adverse or undesired events?
• Patient experience—Did we treat the patient well, as a person?
• Operational efficiency—Did we avoid waste and unnecessary resource use?

Dr. Froimson reviewed the process undertaken by AAHKS to develop a total knee arthroplasty measure set. By focusing on the achievable (process measures) and using a validated process, AAHKS was able to develop a set of four measures that add value and are not onerous for the end users.

“They are very practical, focusing on shared decision making, risk assessment, antibiotic infusion, and identification of the implant prosthesis. It was a practical effort that resulted in a measure set that is available for AAOS members. All you need is 20 patients, 11 of whom are Medicare patients,” he said.

AAHKS is now working with the AAOS and the Hip Society on developing a measure set for total hip arthroplasty.

POSNA
Since the Performance Measures Summit was held, noted POSNA’s President Gregory A. Mencio, MD, the organization has developed a performance management workgroup chaired by James J. McCarthy, MD, POSNA vice president. The group is charged with identifying relevant, actionable measures.

Because orthopaedic measures should be developed with input from orthopaedic surgeons, Dr. Mencio reviewed the POSNA timeline for identifying and drafting performance measures that could apply to pediatric orthopaedists. He outlined POSNA’s Quality, Safety, Value Initiative and identified various workgroups within that program whose charges and ongoing efforts provided background and infrastructure for the formation of the teams now developing performance measures.

“We want to establish measures that are rigorous enough to be acceptable to payers, but reasonable enough to be acceptable to our membership,” he said. A partial list of proposed measures includes not only immediate, structural measures but also aspirational process and outcome measures in spine, sports, trauma, and safety.

“As a small society, POSNA realizes it is important to partner with other societies,” Dr. Mencio said. He pointed out that about half of the members of POSNA are also members of the Scoliosis Research Society, so one measure examining surgical site infection after pediatric spinal fusion is being considered for development in tandem with SRS. Another collaborative effort, focused on reoperation after anterior cruciate ligament surgery, may be undertaken with the American Orthopaedic Society for Sports Medicine.

“We view this as an iterative process,” continued Dr. Mencio. “You have to have member buy-in; you have to have collaboration with other societies; you have to educate members; and, as new evidence becomes available, you have to incorporate it—and that starts the process over again.”

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

For more information on performance measures, see “Taking the Next Step in Improving Value.”.