The AAOS Performance Measurement Committee (PMC) has observed that a dizzying array of patient-reported outcome performance measures (PRO-PMs) related to hip and knee joint replacement care were being developed by other stakeholders. The committee recognized that the PMs—developed by a variety of other organizations, including The Joint Commission, American Association of Hip and Knee Surgeons, Optum, Focus on Therapeutic Outcomes, and Minnesota Community Measurement—would lead to frustrating implementation challenges for frontline surgeons attempting to comply.
As part of the effort to guide PRO-PMs from use as research tools to widespread implementation as part of the routine practice of orthopaedic surgery, AAOS created the Performance Measurement Committee (PMC) in March 2014. The committee’s goals are to monitor, influence, and create PMs related to the care of orthopaedic patients.
As highlighted in the article “The Evolving State of TJA Performance Measures” (AAOS Now, September 2016), the PMC observed a wide array of conflicting PRO-PMs not only related to hip and knee joint replacement but also across other care settings and procedures.
Based on their observations, the PMC identified a need to guide the early development of PRO-PMs. The PMC developed a position statement to be utilized by workgroups developing new measures to facilitate patient centeredness and engagement, eventual uniform implementation of PRO-PMs across diagnoses and treatments, and future research efforts. After review by the PMC and the AAOS Committee on Evidence-based Quality and Value, the AAOS Board of Directors approved the AAOS Position Statement 1188 on Principles for Musculoskeletal-based Patient Reported Outcome-performance Measurement Development in March 2018.
AAOS and those who developed the position statement intend that the document be utilized by researchers, PRO-PM developers, payers, and healthcare change advocates. They hope the position statement provides predictable guidance and recommendations for the development cycle of PRO-PMs.
The following summaries are from the position statement’s “recommendations and guidance related to PRO-PM development” section.
Recommendation No. 1: Staged PRO-PM development and implementation
AAOS recognizes and acknowledges that the infrastructure and clinical processes currently do not exist in such a manner to facilitate widespread adoption of PRO-PMs. The Academy recommends a logical and staged development/implementation cycle for PRO-PMs. AAOS envisions that this recommendation will result in a given PRO-PM evolving over the maintenance cycle of the measure, which could take several years to complete. The decision to move to the next stage would be at the discretion of the developing organization and based on feedback/data from the previous stage. The following is recommended:
- Stage 1: Routine PRO use in clinical practice—a process measure. Outcome-based PRO-PM development should begin as a process measure, answering the question: “Are providers collecting PRO data on their patients?” This process measure would reflect the percentage of practices collecting PRO data on their patients and would be reported as a percentage of total patients treated for a given condition.
- Stage 2: Pre- and post-treatment comparison—a process measure. Once stage 1 is successfully implemented, the PRO-PM would be redesigned through its routine maintenance cycle, with the designers comparing the results of pre– and post–patient-reported outcome measure (PROM) findings. This PM would report a change score for an individual patient and document that the change score was shared with the patient. Although the change score is reported as part of the measure, at this stage the change score is not averaged or published for practice comparison. Instead, it is used at the individual patient/provider level for real-time care assessment and at a national level for data analysis and assessment of impact on clinical care.
- Stage 3: Outcome-based PRO-PM assessment. Following completion of stage 2, the measure would be redesigned to focus on reporting the PRO-PM comparison outcome data with the appropriate risk stratification and presented to the public in a manner to allow practice comparison.
Recommendation No. 2: Timeframes for administering PROMs in performance measurement
The Academy recommends pre- and post-treatment timeframes for assessing a PRO, allowing frontline providers the ability to utilize the same timeframes across diagnoses and treatments regardless of who develops the PRO-PM. PRO-PMs should have a preintervention collection period and a single postintervention collection period. The postintervention time period depends on the intervention being measured. For example, total joint arthroplasty postintervention PROM collection is at one year.
- preintervention: PROMs administered 90 days prior to the planned intervention (a timeframe that coincides with current requirements for a history and physical and operative consent completion needs)
- early postintervention: four months ± 30 days (ensures a data point three months post-procedure)
- mid postintervention: 13 months ± 30 days (ensures a data point 12 months post-procedure)
- late postintervention: 25 months ± 30 days (ensures a data point 24 months post-procedure)
Recommendation No. 3: Utilization of consistent PROM tools
The Academy recommends consistent PROM tools for use within a given PRO-PM. It recommends that workgroups:
- develop PRO-PMs that recommend use of both a general health instrument and a disease-specific health instrument
- identify appropriate PROMs within each category for utilization and not be restrictive or prescriptive with their use/
selection within each category
- strive to include PROMs that engage patients to identify outcomes important to individual patients, such as the Single Assessment Numeric Evaluation or Patient Generated Index–Health Quality of Life (PGI-HQOL)
- use standardized PROMs for activity level or pain pre- and postintervention. Measurement of patient expectations assists in the shared decision-making process.
Recommendation No. 4: Guidelines for future PROM development
The Academy provides guidance and recommendations for the future development of a currently nonexistent single PROM tool that can be adapted to or developed for different care settings and can be utilized across differing musculoskeletal diagnoses or treatments. The ideal PROM should be:
- nonproprietary (public domain, no licensing fees)
- usable across different diagnoses (cross-cutting)
- patient centered (includes function/activities/domains important to patients, engaging patients with their care)
- responsive to the measured intervention
Moving forward, AAOS believes that future PROM development should focus on creating a foundation for uniform scoring of patient-selected outcome traits. One example of this type of PROM is the PGI-HQOL. This “future” PROM could guide patients in selecting appropriate traits related to musculoskeletal care (such as pain, activity, sensation, etc.) and general health traits. By empowering patients to select the outcomes important to them as individuals, this approach to PROM development could result in simplifying the burden associated with PRO-PM development and implementation by having one cross-cutting PROM for multiple musculoskeletal diagnoses.
Visit https://bit.ly/2PYw6hv for additional details and information about this position statement.
Kent Jason Lowry, MD, is a member of the AAOS Committee on Evidence-based Quality and Value.