AAOS working on establishing partnerships to gather and sort quality data
An AAOS initiative to facilitate collection of outcomes data by orthopaedic surgeons is moving forward with plans to identify the means to collect and review patient-reported outcomes (PROs) in their practices.

About a year ago, the Quality Outcomes Data (QOD) Work Group was convened with a charge to investigate quality data collection opportunities for the AAOS to partner with organizations such as the National Surgical Quality Improvement Program, American Joint Replacement Registry, and other organizations. The work group was also charged with investigating and evaluating platforms/systems, including the Patient Reported Outcomes Measurement Information System (PROMIS) as well as other PROs to suggest ways Academy members could utilize appropriate instruments for data collection.

In February, the QOD work group, under the leadership of David S. Jevsevar, MD, MBA, chair, and Kevin J. Bozic, MD, MBA, oversight chair, recommended to the Board that the Performance Measures Committee (PMC) seek proposals from vendors to establish collection systems for members to use with PRO instruments endorsed by the Academy. The vendor-partnership route was chosen over the Academy implementing its own system and registry as the cost and value advantages of third-party involvement became clear.

The envisioned PRO system(s) will provide members with a cost-effective, user-friendly resource to generate outcomes data that can be integrated into the electronic health record (EHR) and aid in diagnosis and treatment decisions. PRO collection capability will also help physicians meet mandates accompanying the Comprehensive Care for Joint Replacement (CJR) model.

In an interview with AAOS Now, Dr. Jevsevar elaborated on efforts of the QOD Work Group and on what members can anticipate for PRO collection capability in their practices.

AAOS Now: What was the genesis of this effort to develop outcomes data collection for orthopaedics?

Dr. Jevsevar: We were concerned that orthopaedic surgeons didn't have a big enough playing field or input into the development or utilization of outcomes or outcomes measurement in orthopaedics, both clinical outcomes and patient-reported outcomes. The Board of Directors asked the Council on Research and Quality to develop a project work group to look at this issue, and that became the QOD work group. I was the chair, and we had representation from the Board of Councilors, the Board of Specialty Societies, and subject matter experts from the field.

Our direction was to identify clinical or patient-reported outcomes that were important to orthopaedics and to show how we would encourage collection by orthopaedic surgeons. We also wanted to determine if there were other opportunities in this arena, to collect this data or partner with others to do something with the data.

AAOS Now: What are some of the areas on which you focused?

Dr. Jevsevar: We decided that with the limitation of time we had, we would focus on PROs. We sent out a survey to the specialty societies—so they acted as the site or disease-specific subject matter experts—and asked them to highlight the important PROs in each of their areas.

We sought to give surgeons basic information and to say, if you are going to put your toe in the water, these might be the things that you start with. After hearing from the specialty societies, for each of the areas we addressed, we had three general quality-of-life outcomes that we recommended: the Veterans Rand 12, or VR-12; any of the PROMIS 10 or computer-adaptive testing (CAT); and EuroQol (EQ-5D). And then for each specialty area we had regional, anatomic, and diagnosis-specific PROs (see box above, "More about the PRO Measures.")

AAOS Now: How did you decide to turn to vendors rather than develop a program within the Academy?

Dr. Jevsevar: We asked ourselves if the AAOS should develop its own PRO registry or should partner with somebody else. We talked to several well-known vendors about these opportunities. Theoretically we could be the repository for this information, but we are behind other organizations in capability. These organizations told us that if we partnered with them, they would cut the costs to our members for collecting these outcomes. So we thought that was the huge value proposition for our members.

After recommending these steps to the Board, we now are housing the effort in the PMC. It has the charge of developing a request for proposal for vendors in this arena. Basically we are asking the vendors that if AAOS endorses you, we want you to cut the cost to our members for collecting data. We also are asking that the blinded data be shared with the AAOS and our specialty societies to further our quality and research efforts. We think we will be able to create a pretty good value.

The Council on Research and Quality is also crafting a letter to go to EHR vendors suggesting that they have PRO collection capability in the EHR. We are not looking to partner with them, but are saying that this should be a part of every EHR.

AAOS Now: When PRO tools are made available, how will members go about using them, and how will they benefit?

Dr. Jevsevar: There are many different ways in which it will be done. In the best of all worlds, the collection of PRO data would be part of the routine flow in your office. In the very best of worlds, patient completion would occur before the patient comes to the office, so it would be a web-based or smart-phone application, and the PROs would end up in your EHR. Right now, there are very few healthcare organizations where that can occur.

As an alternative, what we would like is the ability to collect PROs—web-based, with an app, or at the office using pencil and paper—with the vendors collecting the information and giving physicians back reports telling them how they are doing and benchmarking their practices against others. In other words, if I do a knee replacement, and my patient gets an average of a 20-point improvement on the PROMIS 10, I could compare that with [an orthopaedic surgeon] in Michigan and see if his or her patients are doing better or the same.

This is becoming a bigger issue, because Medicare suggests using PROs with the CJR model. Down the road we are thinking Medicare will mandate PRO collection.

The data benefit the practice, and if the Academy partners with a vendor, we would like to have access to the blinded data, so that our quality and performance measures programs would be able to use some of that data to guide our efforts. We lack these data now.

AAOS Now: What should Academy members know and be doing in regard to this effort now?

Dr. Jevsevar: They should at least be evaluating how they can integrate the collection of PROs into their practices, and start to understand how PROs can be used for improving patient care and aiding in treatment decisions. For those who are further along in the process, they can be serious about what we think vendors should be able to offer them.

In terms of cost, it could be anywhere from $5,000 per physician to $15,000 a year for a practice. The estimates are all over the place. We think we can drive the costs down significantly if we can find appropriate value propositions with the vendors. We think that this will be an overarching benefit. Given the CJR, many physician groups know that this is coming. We don't know the number of orthopaedic surgeons collecting PROs, but the number is pretty small, probably less than 5 percent of practices.

When the Centers for Medicare & Medicaid Services (CMS) asks AAOS and the American Association of Hip and Knee Surgeons, for example, what PROs orthopaedic surgeons should collect for hip and knee replacements, these efforts will enable us to submit recommendations that CMS could accept. We really want to be able to rally around a core group of measures that CMS will use. It is better that we are all collecting the same instruments or measures, instead of going in multiple directions, so that when CMS asks us, it will listen to our suggested measures for any specific musculoskeletal area or disease.

Something that perhaps has not encouraged physicians to collect PROs is that they are not aware of how to use them in practice. The most important aspect of PROs is to use them to improve patient diagnostics, treatment, and outcomes. The future of PROs depends on how we use them at the bedside to improve the clinical care we deliver.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

More about the PRO measures
The following are the consensus-recommended PRO measures identified by the QOD Work Group with the specialty societies for regional, anatomic, and diagnosis-specific categories:

General Quality of Life

• VR-12
• PROMIS 10 or CAT
• EQ-5D

Treatment Outcome

• Single Assessment Numeric Evaluation (SANE)

Foot and Ankle

• Foot and Ankle Ability Measure (FAAM)
• Foot and Ankle Disability Index (FADI)

Knee (ACL)

• International Knee Documentation Committee (IKDC) Subjective Knee Form (Pedi-IKDC)
• Marx Activity Rating Scale

Knee (OA)

• Knee Injury and Osteoarthritis Outcome Score  (KOOS; KOOS Jr. in publication)

Hip (OA)

• Hip Disability and Osteoarthritis Outcome Survey (HOOS; HOOS Jr. in publication)

Shoulder

• American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form
• Oxford Shoulder Score (OSS)

Shoulder (Instability)

• ASES Standardized Shoulder Assessment Form
• Western Ontario Shoulder Instability Index (WOSI)

Elbow

• Disabilities of the Arm, Shoulder and Hand (DASH)
• Quick DASH

Wrist

• DASH
• Quick DASH

Spine

• Oswestry Disability Index (ODI)
• Neck Disability Index (NDI)

These instruments can be viewed online at www.aaos.org/Quality/Performance_Measures/Patient_Reported_Outcome_Measures/