Editor’s note: This article is part of an ongoing “PROMs in Practice” series presented by the AAOS Patient-Reported Outcome Measures (PROMs) Workgroup. Each month, a workgroup member will address the impact of PROMs on their subspecialty, patient care, the future of musculoskeletal healthcare, and more.

The AAOS 2024 Annual Meeting in San Francisco marked the 1-year anniversary of the PROMs Workgroup. In recognition of the growing interest in and support of the utilization of PROMs in clinical care, along with the policy and reimbursement implications announced by the Centers for Medicare & Medicaid Services (CMS), the workgroup was formed under the direction of the AAOS Board of Directors with the goal of working toward an idealized future state of PROM utilization by equipping AAOS members with user-friendly resources to increase awareness and understanding of the benefits of PROMs and PROM utilization at the point of clinical care. This article details the current status of PROM collection and utilization in orthopaedics, barriers to utilization in clinical care, resources the PROMs Workgroup has developed, and where the field needs to go next.

What is the current landscape?
PROMs are utilized to obtain an understanding of a patient’s symptom burden, health status, and quality of life. Although these tools are not new, their utilization has evolved over time. Once primarily a research tool to understand outcomes of investigations, there is growing evidence that their utilization in clinical care (from utilization in shared decision-making models to methods for tracking outcomes) has benefits for patients. Recognizing these benefits, the workgroup set forth to understand the sentiment, collection, and utilization of PROMs in clinical care. It conducted a survey of AAOS members in April 2023 and found that 52 percent of respondents felt that it is important to collect PROMs, 46 percent collected these data in practice, and 35 percent utilized them in practice.

These data are important going forward, particularly in light of the recent CMS total hip and total knee arthroplasty Patient-Reported Outcome-Based Performance Measure (PRO-PM). Under this measure, CMS requires the submission of complete demographic and PROM data (preoperatively and at 1 year postoperatively) for 50 percent of all patients aged 65 years or above who are undergoing a primary total hip or total knee replacement. For more information on the PRO-PM, view the PROMs Workgroup Fact Sheet. The preoperative data-collection period for this mandatory submission began on April 2, 2024, for procedures performed on or after July 1, 2024. There will be notable financial penalties for those not submitting complete data on 50 percent of all eligible patients, including a reduction of 25 percent of the Annual Payment Update (usually 2 to 4 percent) for all of the hospital’s Medicare Fee-for-Service Part A claims (including non-orthopaedic claims).

What are the barriers?
The PROMs Workgroup was convened, in part, to help elucidate and mitigate the barriers to this CMS policy for AAOS members. Complete data collection from 50 percent of all eligible patients with 1-year follow-up may be a challenge. For example, the 2022 American Joint Replacement Registry Annual Report, which represents more than 2.5 million primary and revision hip and knee arthroplasty procedures performed between 2012 to 2021, reports a 22 to 28 percent 1-year PROM response rate from patients 55 years and older undergoing primary knee arthroplasty.

AAOS has conducted stakeholder interviews and demonstrated barriers to implementation of this policy, including lack of an ability to access and display PROMs, the time-consuming nature of utilization, and the fact that PROMs may be viewed as complex by many stakeholders (e.g., patients, surgeons). In addition to evaluating the sentiment and collection and utilization rates of PROMs, the AAOS PROMs survey also queried barriers to PROM utilization in clinic. Respondents noted that the greatest barriers to PROM adoption included concerns about staff burden (72 percent), challenges with patients completing PROMs (69 percent), and PROMs being too costly to implement (47 percent). At the PROMs symposium at the AAOS 2024 Annual Meeting, questions from the audience noted several additional barriers to implementation, including challenges in getting PROM utilization initiatives started and discussing the value of PROMs with hospital leadership and patients.

What resources are available?
To address these barriers, the PROMs Workgroup has developed several tools and partnerships. For example, a PROMs User Guide has been developed, based on multiple stakeholder interviews, to help organizations understand and address their barriers. Accompanying the User Guide is a PROMs Utilization Scoring Tool, which can help inform improvement initiatives and track changes in PROM implementation over time. To address the potential complexity of PROM collection and utilization, the workgroup collaborated with subspecialty societies to develop a preferred set of orthopaedic PROMs by specialty area.

The PROMs Workgroup has further delineated best practices for third-party vendor collection and utilization of PROMs, such as encouraging integration with electronic health records and availability in multiple languages. Lastly, the workgroup has continued to build the “burning platform” to promote the importance of PROM utilization to initiate the culture change needed to improve practice and patient care.

Where do we go next?
During the AAOS 2024 Annual Meeting, members of the PROMs Workgroup hosted a symposium to provide strategies to implement PROMs collection, maintain compliance, and use these measures to improve shared decision making and communication. Many attendees at the symposium had questions about how to get PROM utilization initiatives started and how to discuss PROMs with hospital leadership and patients. The PROMs Workgroup is working to create white papers to inform discussions with hospital leadership and patients that highlight the value of PROM utilization. As the reimbursement penalties associated with the new CMS policy impact hospitals, the workgroup aims to collaborate with the American Hospital Association to not only inform hospital leaders of policy changes but also equip them with tools to aid in compliance.

Furthermore, the workgroup is surveying the capabilities of numerous third-party vendors to address barriers to PROM collection and utilization by way of integrating best-practice guidelines into workflows as well as creating a comparative vendor list of capabilities to ease implementation. The workgroup believes this will help mitigate challenges to the time-consuming nature of PROMs for surgeons and patients, the difficulties in access and display of these tools, and ultimately the cost of collection and utilization.

The workgroup will continue to advocate for and educate the membership on PROM-related policies and improved compliance to mitigate financial loss. It also plans to develop implementation guides to accompany the User Guide to assist members in PROM deployment. Ultimately, the workgroup strives to provide stakeholder- and context-specific guidance for the membership to assist in aligning with policy to improve patient care and mitigate financial risk.

Resources developed by the PROMs Workgroup will be announced to AAOS membership as they are released and can be found via aaos.org/proms. For more information or to get involved, email proms@aaos.org.

Lauren Shapiro, MD, MS, FAAOS, is an assistant professor of orthopaedic hand and upper-extremity surgery at the University of California, San Francisco; affiliate faculty at the Philip R. Lee Institute for Health Policy Studies; and co-chair of the AAOS PROMs Workgroup.

Kurt P. Spindler, MD, FAAOS, is the director of research and outcomes at Cleveland Clinic Florida, professor of surgery at Cleveland Clinic Lerner College of Medicine, and co-chair of the AAOS PROMs Workgroup.