Beyond Joint Implant Registries A Patient-Centered Research Consortium for Comparative Effectiveness in Total Joint Replacement

Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 09/2012; 308(12):1217-8. DOI: 10.1001/jama.2012.12568
Source: PubMed
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    ABSTRACT: The move toward adoption and implementation of electronic health records (EHR) provides an opportunity in the United States to use electronic clinical data (ECD) to better understand patient outcomes and to improve the quality and efficiency of medical care. Within the field of orthopedics, national joint replacement registries have been shown in other countries to improve clinical decision-making and outcomes after joint arthroplasty. Thus, there is increasing interest among U.S. clinical investigators and policymakers to utilize ECD to develop national and regional joint replacement registries. We discuss our experience with integrating electronic data capture and reporting methodology into the California Joint Replacement Registry and American Joint Replacement Registry initiatives. The use of ECD for joint replacement registries will better facilitate multi-stakeholder collaboration, improve the quality of care, reduce medical spending, and foster customized evidence-based clinical decision-making.
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    ABSTRACT: Current approaches to quantifying total posthospital complications and readmissions following surgical procedures are limited because the United States does not have a single health care payer. Patients seek posthospital care in varied locations, yet hospitals can only quantify those returning to the same facility. Seeking information directly from patients about health care utilization following hospital discharge holds promise to provide data that is missing for surgeons and health care systems. Because total joint replacement (TJR) is the most common and costly elective surgical hospitalization, we examined the concordance between patients' self-report of potential short-term complications and their readmissions and our review of medical records in the initial hospital and surrounding facilities. Patients undergoing primary total hip or knee replacement from July 1, 2011, through December 3, 2012, at a large site participating in a national cohort of TJR patients were identified. Patients completed a six-month postoperative survey regarding emergency department (ED), day surgery (DS), or inpatient care for possible medical or mechanical post-TJR complications. We reviewed inpatient and outpatient medical records from all regional facilities and examined the sensitivity, specificity, and positive- and negative predictive values for patient self-report and medical records. There were 413 patients who had 431 surgeries and completed the six-month questionnaire. Patients reported 40 medical encounters (9 percent) including ED, DS or inpatient care, of which 20 percent occurred at hospitals different from the initial surgery. Review of medical records revealed 9 additional medical encounters that patients had not mentioned including five hospitalizations following surgery and four ED visits. Overall patient self-report of ED, DS, and inpatient care for possible complications was both sensitive (82 percent) and specific (100 percent). The positive predictive value was 100 percent and negative predictive value 98 percent. Patient self-report of posthospital events was accurate. Substantial numbers of patients required care at outlying hospitals (not where the TJR occurred). Methods that directly engage patients can augment current posthospital utilization surveillance to assure complete data.
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    ABSTRACT: In the U.S. and abroad, the use of patient-reported outcome measures to evaluate the impact of total joint replacement surgery on patient quality of life is increasingly common. Analyses of patient-reported outcomes have documented substantial pain relief and functional gain among the vast majority of patients managed with total joint replacement. In addition, postoperative patient-reported outcomes are useful to identify persistent pain and suboptimal outcomes in the minority of patients who have them. The leaders of five U.S. total joint replacement registries report the rationale, current status, and vision for the use of patient-reported outcome measures in U.S. total joint replacement registries. Surgeon leaders of the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry, American Joint Replacement Registry, California Joint Replacement Registry, Michigan Arthroplasty Registry Collaborative Quality Initiative, and Virginia Joint Registry report the rationale supporting the adoption of patient-reported outcome measures, factors associated with the selection and successful implementation of patient-reported outcome measures, and barriers to complete and valid data. U.S. registries are at varied stages of implementation of preoperative surveys and postoperative total joint replacement outcome measures. Surgeon leaders report unified rationales for adopting patient-reported outcome measures: to capture data on pain relief and functional gain following total joint replacement as well as to identify suboptimal implant performance. Key considerations in the selection of a patient-reported outcome measure include its ability to measure both joint pain and physical function while limiting any burden on patients and surgeons related to its use. Complete patient-reported outcomes data will be associated with varied modes of survey completion, including options for home-based completion, to ensure consistent timing and data capture. The current stage of implementation of patient-reported outcome measures varies widely among U.S. registries. Nonetheless, evidence from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry supports the feasibility of successful implementation of patient-reported outcome measures with careful attention to the selection of the outcome measure, mode and timing of postoperative administration, and minimization of any burden on the patient and surgeon. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
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