Does Implant Selection Affect Patient-Reported Outcome Measures After Primary Total Hip Arthroplasty?

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.

Lower 90-day inpatient readmission and 1-year reoperation in patients undergoing robotic versus manual total hip arthroplasty through an anterior approach

BACKGROUND

The value of robotic-assisted total hip arthroplasty (rTHA) has yet to be determined compared to conventional manual THA (mTHA).

OBJECTIVE

Evaluate 90-day inpatient readmission rates, rates of reoperation, and clinically significant improvement of patient-reported outcome measures (PROMs) at 1-year in a cohort of patients who underwent mTHA or rTHA through a direct anterior (DA) approach.

METHODS

A single-surgeon, prospective institutional cohort of 362 patients who underwent primary THA for osteoarthritis via the DA approach between February 2019 and November 2020 were included. Patient demographics, surgical time, discharge disposition, length of stay, acetabular cup size, 90-day inpatient readmission, 1-year reoperation, and 1-year PROMs were collected for 148 manual and 214 robotic THAs, respectively.

RESULTS

Patients undergoing rTHA had lower 90-day readmission (3.74% vs 9.46%, p= 0.04) and lower 1-year reoperation (0.93% vs 4.73% mTHA, p= 0.04). rTHA acetabular cup sizes were smaller (rTHA median 52, interquartile range [IQR] 50; 54, mTHA median 54, IQR 52; 58, p< 0.001). Surgical time was longer for rTHA (114 minutes vs 101 minutes, p< 0.001). At 1-year post-operatively, there was no difference in any of the PROMs evaluated.

CONCLUSION

Robotic THA demonstrated lower 90-day readmissions and 1-year reoperation rates than manual THA via the DA approach. PROMs were not significantly different between the two groups at one year.

Patient-Reported Outcomes Following Revision Total Hip Arthroplasty Demonstrate Less Improvement and Significantly Higher Rates of Worsening Compared to Primaries

BACKGROUND

Patient-reported outcome measures (PROMs) provide the patient's perspective following total hip arthroplasty (THA), although differences between primary THA (pTHA) and revision THA (rTHA) remain unclear. Thus, we compared the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in pTHA and rTHA patients.

METHODS

Data from 2,159 patients (1,995 pTHAs/164 rTHAs) who had completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, or PROMIS Global-Physical questionnaires were analyzed. The PROMs and MCID-I/MCID-W rates were compared using statistical tests and multivariate logistic regressions.

RESULTS

Compared to the pTHA group, the rTHA group had lower rates of improvement and higher rates of worsening for almost all PROMs, including HOOS-PS (MCID-I: 54 versus 84%, P < .001; MCID-W: 24 versus 4.4%, P < .001), PF10a (MCID-I: 44 versus 73%, P < .001; MCID-W: 22 versus 5.9%, P < .001), PROMIS Global-Mental (MCID-W: 42 versus 28%, P < .001), and PROMIS Global-Physical (MCID-I: 41 versus 68%, P < .001; MCID-W: 26 versus 11%, P < .001). Odds ratios supported rates of worsening following revision for the HOOS-PS (Odds Ratio (OR): 8.25, 95% Confidence Interval (CI): 5.62 to 12.4, P < .001), PF10a (OR: 8.34, 95% CI: 5.63 to 12.6, P < .001), PROMIS Global-Mental (OR: 2.16, 95% CI: 1.41 to 3.34, P < .001), and PROMIS Global-Physical (OR: 3.69, 95% CI: 2.46 to 5.62, P < .001).

CONCLUSION

Patients reported higher rates of worsening and lower rates of improvement following rTHA than pTHA, with significantly less score improvement and lower postoperative scores for all PROMs after revision. Most patients reported improvements following pTHA, with few worsening postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Systematic Review of Data Collection by National Joint Replacement Registries: What Opportunities Exist for Enhanced Data Collection and Analysis?

BACKGROUND

National joint replacement registries assist surgeons and hospitals with guiding decision making and quality of care. The data points collected are essential to interpret and analyze data and to understand confounding variables and other sources of bias, which can impair retrospective observational research. The aim of this study was to review all national joint replacement registries to assess what data points are recorded, and in what manner, for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) so that improvements can be made to enhance data collection, interpretation, and analysis.

METHODS

All national registries were identified through Internet and publication search and contacted to invite participation. Data collection forms for both primary and revision THA and TKA were requested. Data collected were entered into an Excel spreadsheet.

RESULTS

The study group for primary and revision THA consisted of 28 national registries, with 26 agreeing to participate. The study group for primary TKA consisted of 27 national registries, with 24 agreeing to participate. Patient identification details were recorded uniformly. Only a minority recorded patient details beyond American Society of Anesthesiologists and body mass index. Most registries did not record surgeon variables: who actually performed or assisted the procedure and their level of training. There was variation in the degree of detail recorded for diagnosis, mostly regarding secondary causes of osteoarthritis and fracture. The details regarding case complexity were limited. Half recorded previous operations, and fewer recorded bone defects. The location of knee arthritis, preoperative limb alignment, and deformities were rarely recorded. Surgical approach and technological adjuncts were routinely collected, but few other details on the surgical technique were recorded. Implant details and fixation were uniformly collected, although a minority recorded specific details, including cement antibiotic or cementing technique. It was uncommon to record whether additional or adjunctive procedures were concurrently performed. Approximately half the registries lacked a revision specific form. The majority recorded reoperations in addition to revision procedures. Patient, surgeon, case, and postoperative details were recorded similar to primary procedures. There was variation in the degree of details recorded for the reasons underlying the revision +/- reoperation, with most recording greater detail for infection and fracture. Many included details on case complexity and bone defects, including the severity, classification, and how the defect was managed. The majority recorded the specific revision procedure that was performed (total or partial), the fixation used, and the components removed or revised. Other specific aspects of fixation including acetabular screws, cone or sleeve use, stems, and augments were less commonly recorded.

CONCLUSION

Substantial data are recorded by all registries, although each one is different. Data solicited lack many patient factors, surgeon variables, case complexity, and surgical techniques. Separate revision forms are not universal, and many registries do not record reoperation procedures, specific causes of revision, and the revision construct.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Veteran RAND-12 Mental Composite Score of >60 Associated With Increased Likelihood of Patient Satisfaction After Total Hip Arthroplasty

BACKGROUND

The present study aimed to determine the distribution of Veterans RAND 12-Item health survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher health care utilizations and 1-year patient-reported outcome measures (PROMs).

METHODS

A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (nonhome discharge, prolonged length of stay [LOS](ie, ≥3 days), all-cause readmission), attainment of patient acceptable symptom state (PASS) at 1-year postoperative and substantial clinical benefit (SCB) in the hip disability osteoarthritis outcome score (HOOS)-pain and HOOS-physical short form.

RESULTS

Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all P < .001). Preoperative VR-12 MCS<20 was associated with more than twice the odds of nonhome discharge (odds ratio [OR]:2.31) and prolonged LOS (OR: 3.46). VR-12 MCS >60 was associated with higher odds of achieving PASS (OR: 2.00) and SCB in HOOS-joint related (JR) (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes.

CONCLUSION

Low preoperative VR-12 MCS, specifically less than 40, may predict increased health care utilization. Furthermore, preoperative VR-12 MCS>60 predicts greater satisfaction at 1 year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared decision-making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA.

LEVEL OF EVIDENCE

II.

Demographic and Socioeconomic Determinants Are Associated with Poor Preoperative Patient-Reported Pain and Function in Primary TKA: A Cohort Study of 14,079 Patients

BACKGROUND

Pain and function, as reflected by patient-reported outcome measures (PROMs), can influence improvement after total knee arthroplasty (TKA) and can reflect the extent of patient access to orthopaedic surgical care. We aimed to (1) categorize patients according to pain and function PROM phenotypes, (2) identify patient characteristics associated with poor preoperative pain and function, and (3) assess relationships between baseline characteristics and PROM phenotypes.

METHODS

A prospective cohort of 14,079 TKAs was enrolled. Demographics, comorbidities, surgical details, and preoperative PROMs were collected. Outcomes included preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (P) and Physical Function (PS) subscores, stratified by demographics. Patients were then categorized into 4 PROM phenotypes defined on the basis of the cohort medians: above or equal to the median for both pain and function scores (P+PS+), below the median for both pain and function (P-PS-), above or equal to the median for pain but below the median for function (P+PS-), and below the median for pain but above or equal to the median for function (P-PS+). Descriptive statistics and multivariable regression analyses were calculated.

RESULTS

The largest PROM phenotype was P-PS- (39.4%), followed by P+PS+ (38.9%). The cohort with discordantly poor function but high pain scores (less pain) was the smallest cohort (9.9%). Preoperative KOOS-Pain and KOOS-PS scores at or below the 25th percentile were independently associated with younger age, female sex, higher body mass index (BMI), non-White race, current smoking, lower education, non-commercial insurance, and higher Charlson Comorbidity Index (CCI). Multivariate logistic regression showed that patients in the P+PS+ category were older (odds ratio [OR] = 1.56), were more likely to be male (OR = 2.00), had a lower BMI (OR = 0.67), had more education (OR = 1.63), had a lower CCI, and were less likely to be Black (OR = 0.80) or Other (OR = 0.62) race, be a current smoker (OR = 0.62), and have commercial insurance (OR = 0.74), compared with the P-PS- phenotype.

CONCLUSIONS

Younger age, obesity, non-White race, female sex, current or recent smoking, non-commercial insurance, and higher CCI were associated with worse pre-TKA PROMs and poor pain-function phenotype combinations. Such a pattern may indicate barriers to TKA access among these patient populations leading to advanced levels of impairment at the time of treatment.

LEVEL OF EVIDENCE

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

Should We Aim to Help Patients "Feel Better" or "Feel Good" After Total Hip Arthroplasty? Determining Factors Affecting the Achievement of the Minimal Clinically Important Difference and Patient Acceptable Symptom State

BACKGROUND

Recent attempts have been made to use preoperative patient-reported outcome measure (PROM) thresholds as prior authorization criteria based on the assumption that patients who have higher baseline scores are less likely to achieve the minimal clinically important difference (MCID). This study aimed to identify factors affecting the achievement of MCID and patient acceptable symptom state (PASS) after total hip arthroplasty (THA), and to determine the overlap between the two outcomes.

METHODS

We identified 3,581 primary, unilateral THAs performed at a single practice in 2015-2019. PROMs including Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-item Short Form Health Survey were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS according to attainment of MCID was assessed. Multivariable regression was used to identify independent predictors of MCID and PASS.

RESULTS

In total, 79.8% achieved MCID and 73.6% achieved PASS for HOOS-JR. Approximately 1 in 7 patients who achieved MCID did not eventually achieve PASS. Worse preoperative HOOS-JR (odd ratio 0.933) was associated with MCID attainment. Better preoperative HOOS-JR (odd ratio 1.015) was associated with PASS attainment. Men, lower body mass index, better American Society of Anesthesiologists score, and better preoperative 12-item Short Form Health Survey mental score were predictors of MCID and PASS. Age, race, ethnicity, Charlson Comorbidity Index, and smoking status were not significant predictors.

CONCLUSION

Preoperative PROMs were associated with achieving MCID and PASS after THA, albeit in opposite directions. Clinicians should strive to help patients "feel better" and "feel good" after surgery. Preoperative PROMs should not solely be used to prioritize access to care.

Opioid and Sedative NarxCare Scores Greater Than 300 Are Associated With Adverse Outcomes After Nonemergent Spine Surgery

STUDY DESIGN

This was a prospectively captured cohort study.

OBJECTIVE

To explore associations between the preoperative opioid-specific NarxCare Scores (NCS) (NCS-opioids) as well as sedative-specific NCS (NCS-sedatives) as measures of patients' prescription drug use and (1) 90-day postoperative readmission; (2) ED visits; (3) reoperation; (4) prolonged (>2 d) hospital length of stay (LOS); and (5) nonhome discharge. In addition, we sought to evaluate the previously suggested 300+ threshold as a cutoff for moderate/high-risk designation.

BACKGROUND

The association between preoperative opioids and sedative use and healthcare utilization after nonemergent spine surgery is not well quantified. The NCS is a weighted scalar measure of opioids and sedatives that accounts for the number of prescribing providers, dispensing pharmacies, milligram equivalence doses, and overlapping prescription days.

METHODS

A total of 4680 nonemergent spine surgery cases were included. Preoperative NCS-opioids/sedatives were captured. Bivariate and multivariable regression models were constructed to analyze associations between NCS-opioids/sedatives ranges and outcomes while accounting for baseline differences. Spline regression and propensity score matching (PSM) analyses were also implemented.

RESULTS

For NCS-opioid, multivariable regression demonstrated higher odds of prolonged LOS starting in the 400 to 499 NCS-opioids category [odds ratio (OR): 1.44; 95% confidence interval (CI): 1.05-1.97; P =0.026] going into the 500+ category (OR: 1.94; 95% CI: 1.29-2.93; P =0.002]. The 500+ categories exhibited higher odds of 90-day readmission (OR: 1.77; 95% CI: 1.01-3.09; P =0.045). PSM comparison demonstrated that patients within the 300+ category had higher incidence of prolonged LOS [n=455 (44%) vs . n=537 (52%); P <0.001], 90-day readmission [n=118 (11%) vs . n=155 (15%); P =0.019] and 90-day reoperation [n=51 (4.9%) vs . n=74 (7.2%); P =0.042]. For NCS-sedative; there was higher odds of prolonged LOS (OR: 1.73; 95% CI: 1.14-2.63; P =0.010) and nonhome discharge(OR: 2.09; 95%CI: 1.22-3.63; P =0.008) within the 400 to 499 NCS-sedatives category. PSM comparison demonstrated significantly higher rates of prolonged LOS within the 300+ NCS-sedative cohort ( vs . scores <300), [n=277 (44%) vs. 319 (50%); P =0.021].

CONCLUSION

Spine surgery continues to advance toward patient-specific care. Higher NCS-opioids/sedatives values may predict up to a twofold increase in postoperative healthcare utilization. High values should prompt an interdisciplinary approach to mitigate deleterious prescription drug use.

Differences in peri-hip articular pain after total hip arthroplasty between taper wedge stem and fit-and-fill stem

Background

Total hip arthroplasty (THA) for hip disorders helps to alleviate pain and improve active daily life. When determining the effects of medical therapy and the subsequent clinical results, patient quality of life (QOL) also needs to be assessed. Recently, patient-reported outcomes (PRO) have become important as evaluation criteria. This study aimed to evaluate patient QOL and various PRO between different types of cementless stems and to clarify the relationship between PRO and stem-cortical bone contact.

Methods

The study comprised 138 consecutive patients undergoing cementless THA for hip osteoarthritis. We assessed three different types of PRO: the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), patient's joint perception, and peri-hip articular joint pain (PHAP). We measured the state of contact between femur and implant by density mapping.

Results

No significant difference was noted in PRO between stem types based on the JHEQ and patient's joint perception. PHAP occurred more frequently in the patients with a taper wedge stem versus a fit-and-fill stem. In both groups, distal contact was associated with PHAP but not with JHEQ results and patient's joint perception.

Conclusion

The difference in PHAP between the two stem types groups was significant, with postoperative PHAP being higher with the taper wedge stem because of the more distal contact between the taper wedge stem and femur cortical bone.

Substantial clinical benefit values demonstrate a high degree of variability when stratified by time and geographic region

Background

A Substantial Clinical Benefit (SCB) value is the amount of change in a patient-reported outcome measure required for a patient to feel they significantly improved from an intervention. Previously published SCB values are often cited by researchers when publishing outcomes data. Where these SCB values are set can have a large impact on the conclusions drawn from a study citing them. As such, the goal of this study was to determine the generalizability of SCB values for a procedure when stratified by time from surgery and geographic region.

Methods

A nationwide outcomes database was utilized to obtain preoperative, one-year, and two-year postoperative outcome measurements for patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse TSA. The data were divided into three geographic regions: the South, the Midwest, and the West. An East region was not included due to its limited number of patients. SCB values were calculated for four outcomes measures: Single Assessment Numeric Evaluation score, American Shoulder Elbow Surgeons score, Visual Analog Scale, and Western Ontario Osteoarthritis of the Shoulder score. SCB values were calculated for each region, for each procedure, and at both one and two years postoperatively. To determine the variability of potential SCBs within each region, simulated datasets were created to determine a distribution of possible calculated SCBs.

Results

A total of 380 anatomic TSA patients and 543 reverse TSA patients were included for analysis. There was a high degree of variability of SCB values when stratified by procedure, time, and region. While some simulated datasets did produce homogenous SCB distributions among regions, some outcome measures demonstrated a large heterogeneity in distribution among regions, with concomitant large distributions of values within individual regions.

Conclusions

There is notable heterogeneity of SCB values when stratified by region or time. The current method of citing previously published SCB values for determining the efficacy of an intervention may be inappropriate. It is likely that this variability holds true in other areas of orthopedics.

Combinations of Preoperative Patient-Reported Outcome Measure Phenotype (Pain, Function, and Mental Health) Predict Outcome After Total Knee Arthroplasty

BACKGROUND

Value-driven healthcare models prioritize patient-perceived benefits to quantify the quality of care through patient-reported outcome measures (PROMs). The Patient Acceptable Symptom State (PASS) is the highest level of symptom beyond which a patient considers his/her condition satisfactory. We identified preoperative phenotypes of PROMs associated with not achieving PASS at 1 year following total knee arthroplasty (TKA) and explored the relationships between such phenotypes with hospital utilization parameters.

METHODS

A prospective institutional cohort of 5,274 primary TKAs for osteoarthritis from 2016 to 2019 with 1-year follow-up were included. Preoperative scores on Knee Disability and Osteoarthritis Outcome Score (KOOS) Pain, KOOS-Physical function Short form (PS), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were used to develop patient phenotypes. Associations between preoperative "phenotype" and 1-year PASS, discharge disposition, length of stay, 90-day readmission, and 1-year reoperation were evaluated using multivariate regression.

RESULTS

In total, 16.3% (n = 862) of patients reported their state as "not acceptable" at 1 year. A combination of low scores in each of the presently examined PROMs was associated with the highest odds of 1-year dissatisfaction (odds ratio 2.18, 95% confidence interval 1.74-2.74). The PROM phenotypes were the greatest drivers compared to sociodemographic variables in predicting satisfaction. Combinations of low scores in VR-12 MCS and KOOS-PS were significantly associated with both non-home discharge status and prolonged length of stay.

CONCLUSION

Patients with combined lower preoperative scores across multiple PROMs (KOOS-Pain <41.7, KOOS-PS <51.5, and VR-12 MCS <52.8) have increased odds of dissatisfaction after TKA. Measuring pain, function, and mental health concurrently as phenotypes may help identify TKA patients at risk for not achieving a satisfactory outcome at 1 year.