The burden and utility of routine follow-up at one year after primary arthroplasty

New CMS Policy on the Mandatory Collection of Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty by 2027: What Orthopaedic Surgeons Should Know

ABSTRACT

The Centers for Medicare & Medicaid Services (CMS) has finalized a landmark national policy to standardize and expand the collection and reporting of patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This policy will be rolled out through phased implementation, beginning with voluntary reporting starting in 2023 and transitioning to mandatory reporting starting in 2025, which will be tied to hospital payment determinations in fiscal year 2028. The overarching goal of this policy is to gather meaningful pre- and postoperative PROM data directly from patients to enhance clinical care, shared decision-making, and quality measurement for these common elective procedures. This national initiative underscores the value of incorporating patient perspectives and priorities into assessments of surgical care quality. For orthopaedic surgeons and hospitals, participating in the initial voluntary reporting period provides an opportunity to integrate PROM collection into clinical workflows and to leverage these data to improve patient care. The achievement of robust PROM response rates and a strong performance on the underlying THA/TKA Patient-Reported Outcome-Based Performance Measure may have increasing relevance as payment models shift toward value-based care. The aim of the present forum was to provide an in-depth review of this new CMS policy and key details regarding required PROM instruments, data-collection time frames, and other specifications that surgical teams should understand as they prepare for implementation. The goal was to equip orthopaedic surgeons with actionable information as they embark on this new era of national PROM collection and reporting.

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty

BACKGROUND

Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively.

METHODS

We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks.

RESULTS

All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003).

CONCLUSIONS

This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

How to Raise the Bar in the Capture of Patient-Reported Outcome Measures in Total Joint Arthroplasty: Results from Active and Passive Follow-up Measures

BACKGROUND

With the upcoming U.S. Centers for Medicare & Medicaid Services 2027 policy for mandatory reporting of patient-reported outcome measures (PROMs) for total hip or knee arthroplasty (THA or TKA), it is important to evaluate the resources required to achieve adequate PROM collection and reporting at a clinically relevant rate of follow-up. This study aimed to (1) determine follow-up rates for 1-year PROMs when the follow-up was conducted with active methods (attempted contact by staff) and passive (automated) methods, and (2) evaluate factors associated with higher odds of requiring active follow-up or being lost to follow-up following THA or TKA.

METHODS

A prospective cohort of patients undergoing primary elective THA (n = 7,436) or TKA (n = 10,119) between January 2016 and December 2020 at a single institution were included. The primary outcome was the response rate achieved with active and passive follow-up methods at our institution. Patient characteristics, health-care utilization parameters, PROM values, and patient satisfaction were compared between follow-up methods.

RESULTS

Passive and active measures were successful for 38% (2,859) and 40% (3,004) of the THA cohort, respectively, while 21% (1,573) were lost to follow-up. Similarly, passive and active measures were successful for 40% (4,001) and 41% (4,161) of the TKA cohort, respectively, while 20% (2,037) were lost to follow-up. Younger age, male sex, Black or another non-White race, fewer years of education, smoking, Medicare or Medicaid insurance, and specific baseline PROM phenotypes (i.e., with scores in the lower half for pain, function, and/or mental health) were associated with loss to follow-up. Older age, male sex, Black race, and a residence with a higher Area Deprivation Index were associated with requiring active follow-up.

CONCLUSIONS

One of 5 patients were lost to follow-up despite active and passive measures following THA or TKA. These patients were more likely to be younger, be male, be of Black or another non-White race, have fewer years of education, be a smoker, have Medicaid insurance, and have specific baseline PROM phenotypes. Innovative strategies aimed at targeting individuals with these baseline characteristics may help raise the bar and increase follow-up while mitigating costs after total joint arthroplasty.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Missed Short-term Follow-up After Arthroscopic Rotator Cuff Surgery: Analysis of Surgical and Demographic Factors

INTRODUCTION

Few current studies have examined loss to follow-up after rotator cuff-related shoulder arthroscopy. Understanding the demographic and surgical factors for missed follow-up would help identify patients most at risk and potentially mitigate the onset of complications while maximizing clinical outcomes.

METHODS

A retrospective review of consecutive rotator cuff arthroscopic procedures with a minimum of 12-month follow-up done by a single, fellowship-trained surgeon was undertaken from February 2016 through January 2022. Demographic patient and surgical data, including age, sex, marital status, self-identified race, and body mass index, were collected. Follow-up at ≤3, 6 weeks, 3, 6, and 12 months was determined. Patient-related and surgical predictors for missed short-term follow-up, defined as nonattendance at the 6 and 12-month postoperative visits, were identified.

RESULTS

There were 449 cases included, of which 248 (55%) were women. The median age was 57 years (interquartile range [IQR], 51 to 62). Patients with commercial insurance (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.23 to 0.64; P < 0.001) or workers' compensation (OR, 0.15; 95% CI, 0.05 to 0.43; P < 0.001) were less likely to miss the 6-month follow-up compared with patients with Medicare, whereas increased socioeconomic deprivation (OR, 0.86; 95% CI, 0.77 to 0.97, P = 0.015) was associated with decreased odds of missing that visit. Patients who missed the ≤3 weeks (OR, 1.77; 95% CI, 1.14 to 2.74, P = 0.010) and 3-month (OR, 8.55; 95% CI, 4.33 to 16.86; P < 0.001) follow-ups were more likely to miss the 6-month follow-up. Use of a patient contact system (OR, 0.55; 95% CI, 0.35 to 0.87, P = 0.01) and increased number of preoperative visits (OR, 0.91; 95% CI, 0.84 to 0.99, P = 0.033) were associated with decreased odds of missing the 12-month follow-up. Patients who missed the 6-month follow-up were more likely to miss the 12-month follow-up (OR, 5.38; 95% CI, 3.45 to 8.40; P < 0.001).

CONCLUSION

Implementing an electronic patient contact system while increasing focus on patients with few preoperative visits and who miss the 6-month follow-up can reduce the risk of missed follow-up at 12 months after shoulder arthroscopy.

Prevalence and Risk Factors for Missed Short-term Follow-up After Primary Total Shoulder Arthroplasty

INTRODUCTION

The importance of consistent postoperative follow-up has been established for collecting patient-reported outcomes and surveilling for potential complications. Despite this, the prevalence of and risk factors for missed short-term follow-up after elective shoulder arthroplasty remain limited.

METHODS

A retrospective review of consecutive primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty cases with a minimum of 12-month follow-up performed by a single, fellowship-trained shoulder surgeon was undertaken from January 2015 to December 2021. Demographic patient and surgical data, including age, sex, marital status, self-identified race, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder surgery and/or contralateral arthroplasty, distance from home to clinic, smoking status, and hospital length of stay, were collected. The follow-up at 1 week, 6 weeks, 6 months, 12 months, and 24 months and beyond was determined. Patient-related and surgical predictors for missing the 12-month and 24-month follow-up were identified.

RESULTS

There were 295 cases included (168 aTSA and 127 reverse total shoulder arthroplasty), of whom 199 (67%) were women. Of the total cases, 261 (86%) were eligible for 24-month follow-up. Patients undergoing aTSA, those of younger age, those of male sex, and those who missed their 6-week and 6-month follow-up were significantly more likely to miss the 12-month follow-up visit. Following multivariable analysis, a missed 6-month follow-up (OR 10.10, 95% CI 5.32 to 19.16, P < 0.001) was associated with 12-month visit nonattendance, and increasing age (per year) (OR 0.96, 95% CI 0.93 to 0.99, P = 0.011) was associated with improved 12-month follow-up. Not having a surgical complication within 6 months postoperatively, not undergoing ipsilateral revision arthroplasty, and missing the 1-week and 12-month follow-up were significantly associated with missing the 24-month follow-up. After multivariable analysis, missing the 1-week (OR 3.07, 95% CI 1.12 to 8.41, P = 0.029) and 12-month (OR 3.84, 95% CI 2.11 to 6.99, P < 0.001) follow-ups was associated with missing the 24-month visit, whereas having a postoperative complication was associated with increased attendance at 24 months (OR 0.38, 95% CI 0.14 to 0.99, P = 0.047).

DISCUSSION

Strategies for preventing missed short-term follow-up should be focused on ensuring that patients undergoing TSA attend the 6-month and 12-month visit, particularly among younger patients and those with an uneventful postoperative course.

Patient reported outcomes do not correlate to functional knee recovery and range of motion in total knee arthroplasty

Background

Many total knee arthroplasty (TKA) patients exhibit continued pain and limited function following surgery. Determining TKA outcomes is typically reliant on post-operative evaluations and completing patient-reported outcomes (PROMs). Due to low compliance rates, it is essential to identify new strategies for monitoring patients. The purpose of this analysis was to assess the correlations between gait kinematics, PROMs, and knee range of motion (ROM).

Methods

130 patients (75 female) received Persona IQ TKA (Zimmer Biomet, Warsaw, IN, USA) which includes a stem extension with embedded accelerometer and gyroscope. PROM scores were compared at baseline and 6 weeks post-TKA using a paired t-test. Gait kinematics were recorded daily via the Persona IQ stem extension. Pearson's correlation coefficients were derived between PROMs and average gait kinematics.

Results

Knee Injury and Osteoarthritis Outcome Score (KOOS Jr.) and Veterans RAND 12 (VR-12) physical scores improved following surgery (p ≤ 0.001, p = 0.003, respectively). Weak statistically significant correlations were found between PROMS and gait kinematics.

Conclusion

Weak correlations between PROMs and gait kinematics indicate patient perception of improvement and objectively measured functional status may not be interchangeable. Further, compliance with Persona IQ data reached 95.4-97.7% (depending on the parameter) at 6 weeks following surgery, a 20% higher compliance rate over PROMs. Daily functional measurements provide insight into the patient's progression and may be useful in detecting poor outcomes.

The Utility of Routine Postoperative Radiographs in the Asymptomatic Total Hip Arthroplasty Patient

BACKGROUND

Total hip arthroplasty (THA) patients often receive routine radiographs in the year following their index surgery. This study sought to investigate the clinical and economic value of obtaining routine postoperative hip radiographs for asymptomatic patients following primary elective THA.

METHODS

A retrospective cohort study of consecutive patients who underwent primary elective THA from 2016 to 2019 was conducted. Patients undergoing nonelective or revision THA, radiographic follow-up <10 months, and patients aged <18 years were excluded. All radiographs were reviewed for abnormalities in the first postoperative year by an arthroplasty fellowship-trained orthopaedic surgeon, blinded to the symptoms of the patient.

RESULTS

Of the 327 patients (351 hips) included, 57.2% were women and 68.2% were White, with an average age of 65 years (range, 22-97 years) and average body mass index of 29.1 kg/m² (range, 16.2-49.8 kg/m²). Only four (0.4%) radiographic series revealed abnormalities with the potential to alter postoperative management. One patient experienced a change in management directly related to their abnormal finding (closed reduction for dislocation at 10.2 months postoperatively). The remaining three abnormal radiographic findings included femoral stem subsidence, progressive radiolucencies around an acetabular component, and cement mantle fracture. The average cost for each radiographic series was $155.27, resulting in total direct charges of $167,691.60.

CONCLUSION

Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. Consideration should be given to limit postoperative radiographs following standard elective THA, while reserving postoperative radiographic evaluation for patients who are symptomatic.

LEVEL OF EVIDENCE

Level III.

Poor Patient Compliance Limits the Attainability of Patient-Reported Outcome Measure Completion Thresholds for the Comprehensive Care for Joint Arthroplasty Model

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) links patient-reported outcome measures (PROMs) with hospital reimbursement in some value-based models for total joint arthroplasty (TJA). This study evaluates PROM reporting compliance and resource utilization using protocol-driven electronic collection of outcomes for commercial and CMS alternative payment models (APMs).

METHODS

We analyzed a consecutive series of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2016 and 2019. Compliance rates were obtained for reporting hip disability and osteoarthritis outcome score for joint replacement (HOOS-JR.), knee disability and osteoarthritis outcome score for joint replacement (KOOS-JR.), and 12-item short form survey (SF-12) surveys preoperatively and postoperatively at 6-months, 1 year, and 2- years. Of 43,252 THA and TKA patients, 25,315 (58%) were Medicare-only. Direct supply and staff labor costs for PROM collection were obtained. Chi-square testing compared compliance rates between Medicare-only and all-arthroplasty groups. Time-driven activity-based costing (TDABC) estimated resource utilization for PROM collection.

RESULTS

In the Medicare-only cohort, preoperative HOOS-JR./KOOS-JR. compliance was 66.6%. Postoperative HOOS-JR./KOOS-JR. compliance was 29.9%, 46.1%, and 27.8% at 6 months, 1 year, and 2 years, respectively. Preoperative SF-12 compliance was 70%. Postoperative SF-12 compliance was 35.9%, 49.6%, and 33.4% at 6 months, 1 year, and 2 years, respectively. Medicare patients had lower PROM compliance than the overall cohort (P < .05) at all time points except preoperative KOOS-JR., HOOS-JR., and SF-12 in TKA patients. The estimated annual cost for PROM collection was $273,682 and the total cost for the entire study period was $986,369.

CONCLUSION

Despite extensive experience with APMs and a total expenditure near $1,000,000, our center demonstrated low preoperative and postoperative PROM compliance rates. In order for practices to achieve satisfactory compliance, Comprehensive Care for Joint Replacement (CJR) compensation should be adjusted to reflect the costs associated with collecting these PROMs and CJR target compliance rates should be adjusted to reflect more attainable levels consistent with currently published literature.

The (un)necessity of regular postoperative follow-up of hemiarthroplasty for femoral neck fractures

BACKGROUND

Postoperative follow-up after hemiarthroplasty is part of routine based practice. However, these visits appear to be a significant burden since it concerns a frail population. The aim of this study was to confirm the current common practice regarding postoperative visits of patients treated with hemiarthroplasty and to evaluate the complication detection rate at these visits.

METHODS

A national short survey was conducted among orthopedic surgeons working in 26 large Dutch teaching hospitals to test the hypothesis that postoperative follow-up is indeed common practice. Furthermore, a retrospective patient review was performed in all hemiarthroplasties implanted between January 2014 and December 2019.

RESULTS

The response of the national survey was complete and showed that postoperative follow-up in patients treated with hemiarthroplasty is part of standard care according to 89% of respondents. A total of 1055 hips (1026 patients) were implanted with hemiarthroplasty during the studied period. Implant-related complications were identified in 68 hemiarthroplasties, with 31 of these hips going on to reoperation. Only 2 of these complications were picked up at standard planned follow-up leading to a complication detection rate of 0.3%. In contrast, complication detection rates of 47% and 16% were found at unplanned visits at the Emergency Department and the outpatient department, respectively.

CONCLUSIONS

Postoperative follow-up in patients treated with hemiarthroplasty is still the standard of care. However, this study revealed that the majority of implant-related complications are detected at unplanned visits and almost no at standard follow-up visits. Postoperative follow-up of patients treated with hemiarthroplasty could be abandoned in this frail population.

Telemedicine for patients undergoing arthroplasty : access, ability, and preference

AIMS

The purpose of this study was to determine the access to and ability to use telemedicine technology in adult patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), and to determine associations with the socioeconomic characteristics of the patients, including age, sex, race, and education. We also sought to understand the patients' perceived benefits, risks, and preferences when dealing with telemedicine.

METHODS

We performed a cross-sectional survey involving patients awaiting primary THA and TKA by one of six surgeons at a single academic institution. Patients were included and called for a telephone-administered survey if their surgery was scheduled to be between 23 March and 2 June 2020, and were aged > 18 years.

RESULTS

The response rate was 52% (189 of 363 patients). A total of 170 patients (90.4%) reported using the internet, 177 (94.1%) reported owning a device capable of videoconferencing, and 143 (76.1%) had participated in a video call in the past year. When asked for their preferred method for a consultation, 155 (82.8%) and 26 (13.9%) ranked in-person and a videoconference as their first choice, respectively. The perceived benefits of telemedicine consultations included reduced travel to appointments (165 (88.2%) agreed) and reduced cost of attending appointments (123 (65.8%) agreed). However, patients were concerned that they would not establish the same patient-physician connection (100 (53.8%) agreed), and would not receive the same level of care (52 (33.2%) agreed) using telemedicine consultations compared with in-person consultations.

CONCLUSION

Most patients undergoing arthroplasty have access to and are capable of using the technology required for telemedicine consultations. However, they still prefer in-person consultations due to concerns that they will not establish the same patient-physician connection and will not receive the same level of care, despite the benefits of reducing the time spent in travelling and the cost of attending appointments, and the appointments being easier to attend. Cite this article: Bone Joint J 2021;103-B(7 Supple B):98-102.

Techniques and Strategies to Optimize Efficiencies in the Office and Operating Room: Getting Through the Patient Backlog and Preserving Hospital Resources

The effects of the coronavirus disease 2019 pandemic are pervasive and have decreased the volume of hip and knee arthroplasty procedures since the mandated cessation of elective surgical procedures at the height of the pandemic in early 2020. Therefore, a backlog of patients in need of these elective procedures is a probable consequence and increased productivity and efficiency in patient care delivery is essential now and into the future. This article outlines multiple strategies and techniques to develop and optimize efficiency in the hip and knee arthroplasty practice. Techniques for increasing surgical efficiency are detailed, along with perioperative strategies in the hospital, ambulatory surgery center, and office settings are outlined and discussed.