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Patient-reported Outcomes

Value-based Purchasing for

Osteoarthritis and Total Knee
Arthroplasty: What Role for
Patient-reported Outcomes?

Catherine MacLean, MD, PhD Prompted by the aims to improve the patient experience of care (including quality and
satisfaction), improve the health of populations, and reduce the per capita cost of
health care, the US healthcare system is embarking upon a new era in care delivery
that seeks to optimize healthcare value. Value, the consideration of quality relative to
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cost, can be increased by improving quality, reducing cost, or doing both. Given that
patient-reported outcomes related to pain, function, and quality of life underlay both the
reason patients seek care for and the benchmarks by which treatment success is
measured for osteoarthritis, measures of these patient-reported outcomes figure
prominently in understanding the quality and hence value. Directed attention to patient-
reported outcomes has the potential to drive quality and efficiency improvements, but
only if the quality measures that are developed from them are clinically important,
scientifically acceptable, usable, and feasible.

the health care we purchase to treat OA. What

Background improvements are achieved for the $73 billion
spent to treat OA and for the $28.5 billion spent
Osteoarthritis (OA) is a common and costly on TKA? Did patients achieve reductions in pain
disease affecting 27 million adults in the and improvements in function? If so, how much?
United States.1 In 2013, OA accounted for Were the improvements achieved big enough to
$73 billion, or 2.5% of US healthcare justify the money spent to achieve them?
spending.2,3 Total knee arthroplasty (TKA), Prompted by the following aims to improve
which is performed predominantly to treat the patient experience of care (including qual-
OA, accounted for $28.5 billion, or 1.1% of ity and satisfaction), improve the health of
all healthcare spending and (along with total populations, and reduce the per capita cost of
hip arthroplasty) was the single largest health care,8 the US healthcare system is em-
expenditure for the Centers for Medicare and barking upon a new era in care delivery that
Medicaid Services (CMS).4 As a result of an seeks to optimize healthcare value. “Value,”
increasingly large cohort of increasingly which is the consideration of quality relative
overweight/obese senior citizens, utilization to cost, can be increased by improving quality,
of TKA is expected to grow over the next 15 reducing cost, or doing both. For OA, patient-
years,5 with Medicare facing estimated costs reported outcomes, especially of pain and
of $50 billion.6 function, figure prominently in understanding
From the Hospital for Special Surgery, Viewed within the context of the US health- the quality and hence value.
New York, New York.
care system, which is generally recognized as
Dr. MacLean or an immediate family spending more money than other developed
member serves as board member, nations,7 treatment for OA generally, and Healthcare Quality Defined
owner, officer, or committee member TKA specifically, is a bright target for cost-
of the American College of reduction initiatives. Given the many docu- Healthcare quality has been defined by the
Physicians. mented opportunities to reduce healthcare Institute of Medicine as “the degree to which
J Am Acad Orthop Surg 2017;25 costs in the United States generally, opportu- health services for individuals and populations
(suppl 1):S55-S59 nities certainly exist to reduce the cost of care increase the likelihood of desired health
delivered for OA by working to eliminate outcomes and are consistent with current
DOI: 10.5435/JAAOS-D-16-00638 unsafe, unnecessary, and duplicative care. professional knowledge.”9 Donabedian10
Copyright 2016 by the American The narrative surrounding cost reduction for describes quality of care as the application of
Academy of Orthopaedic Surgeons. OA, however, is incomplete without consider- medical science and technology in such a way
ation of the impact on health that is achieved by as to maximize health benefits without

February 2017, Vol 25, Supplement 1 S55

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Value-based Purchasing for Osteoarthritis and Total Knee Arthroplasty

increasing health risks.10 It is important to tion in OA, use of any such PROMs to assess
note that in both definitions, quality is defined Measuring Healthcare Quality quality would require risk adjustment.
not by absolute health outcomes or changes in Usability refers to whether the results of a
health outcomes, but rather in terms of the We measure quality to drive improvements in measure can be used by healthcare providers,
probability of achieving maximal health ben- health. Measurement and reporting of quality patients, or purchasers to impact the quality of
efit as a result of the medical care provided. drives population’s health improvement in the care delivered to populations or individuals.
The quality of health care can be assessed by following two ways: it identifies for providers’ Good measures should be actionable by
measuring the structures, processes, and out- areas of deficiency or “care gaps” that can be healthcare providers to improve the care they
comes of health care. Structure refers to the addressed to produce better health outcomes, and deliver, to patients to inform therapeutic choices
tools, resources, organization, and financing it identifies for patients and other purchasers of including provider, and to purchasers to drive
used in the provision of health care. Structural health care the quality of different providers, al- quality for their beneficiary population through
measures assess whether infrastructure ele- lowing them to choose ones who have the highest quality-based incentives and network design.
ments are in place that are likely to increase or likelihood of maximizing their personal health Feasibility refers to the practicality of mea-
decrease the probability of good health out- outcomes or the health outcomes of populations. surement. Currently in the United States, most
comes. Structures relevant to OA include Quality measures quantify quality concepts. quality measures being used by health plans and
qualified staffing to manage OA, hospital They do this by precisely defining the following: accreditation and other quality-reporting organi-
programs to track and report surgical compli- the structure, process, or outcome of interest; the zations are based on administrative data because
cations, and participation in quality- population to which they are relevant; and the these data are readily available and far less costly
improvement activities such as registries. specific clinical circumstances in which they to obtain than measures based on clinical data
Quality structures related to patient-reported matter. Quality measures facilitate quantitative that require medical record abstraction or mea-
outcome measures (PROMs) might include measurement of quality within a defined pop- sures based on data from patient’s self-reporting.
having the infrastructure to collect PROMs or ulation and allow for comparison over time and Quality measures based on patient-reported
participation in a registry or another quality across measured units. For example, does qual- outcomes have been largely regarded as not
activity into which PROMs are reported and ity differ across geographies, insurance compa- feasible because they are not routinely collected
feedback on performance is provided. nies, or healthcare providers? in clinical practice, and the infrastructure to
Process of care describes what healthcare collect PROM data for quality measurement
providers do for patients and includes taking a largely does not currently exist. Increasing rec-
health history, prescribing medications, and Characteristics of Good ognition of the importance of PROMs in
performing tests or procedures. Care processes Quality Measures understanding health outcomes and quality,
relevant to OA include treating pain and especially for musculoskeletal disease, has led to
functional limitations with appropriate thera- The National Quality Forum standards for mea- the development of quality measures based on
pies, including TKA, and the use of therapies to sure endorsement12 lay out at a high level the PROMs.
prevent complications, such as prophylaxis to characteristics of good healthcare quality mea-
prevent venous thromboembolism. Quality sures (Table 1). These standards require mea-
processes related to PROMs include collection sures to be important, scientifically acceptable, Characteristics of Good
of data on pain, functional status, and/or usable, and feasible. As a foundation, good Quality Measurement
quality of life using validated tools. measures should address something important to
Health outcomes include both health status health that can be meaningfully impacted by To promote health improvement and value, we
and discrete events such as recovery from an health care. The primary health effects of OA not only need good quality measures but also to
illness, death, and complications of medical that matter to patients are pain, functional lim- make sure those measures are used well. Specifi-
care. Patient-reported outcomes are health itation, and impacts on quality of life, each of cally, the scoring of quality measures needs to
outcomes that patients can feel for themselves which can be meaningfully impacted by health reflect meaningful clinical standards, report sta-
and are best reported by the patient because (1) care. Hence, measures of these outcomes or of tistically valid estimates, and be transparent in the
only the patients know whether they experi- structures and processes that lead to these out- methods used to calculate reported point esti-
ence it, or (2) only the individual patients can comes would be meaningful. mates and thresholds. Clinical standards should
provide details about the level of difficulty that Good measures must also be scientifically inform determination of the level of performance
they experience or assign context/importance acceptable such that they produce valid and reli- that represents good quality or a meaningful care
to the activity. Outcomes relevant to OA able results. Valid measures actually measure what gap. However, this is not the way quality is scored
include patient-reported pain and functional they are intended to measure. Reliable measures for many programs. Rather, quality is often
status and complications of care, such as gas- will produce the same result with repeated mea- defined based on performance relative to the
trointestinal bleeding, infections, and venous surement. The validity and reliability of numerous population mean, regardless of whether it is a
thromboembolic events. PROMs for OA have been demonstrated.13–18 clinically rational quality threshold.
As discussed elsewhere in this issue,11 a Scientific acceptability also requires appropri- Given that the only reason TKA is performed is
number of validated instruments are available ate risk adjustment. Measures for which perfor- to improve either pain or function, PROMs that
to assess patient-reported outcomes for OA, mance would vary based on factors other than the measure these are logical candidates for quality
generally, and for knee OA, specifically. The health care delivered need to be risk-adjusted to assessment. However, to use such measures to
two main constructs assessed by these understand the magnitude of quality and/or to drive quality and value, the translation of the
instruments are pain and functional status. compare it across measured populations that results into meaningful levels of quality perfor-
Several instruments also assess the ability to might be differentially affected by those factors. mance must be determined. Is there a certain
work and quality of life, both of which can be Given the known impacts of baseline functional absolute threshold or a change score for pain and
impacted by pain and functional status, and status, contralateral joint disease, psychosocial, function that should be achieved to define a
by the health effects (positive and negative) of and socioeconomic status19–22 on patient- high-quality result? Meaningful scores will no
therapies for OA. reported outcomes of pain and physical func- doubt require risk adjustment. In addition, given

S56 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Catherine MacLean, MD, PhD

Table 1
Characteristics of Good Quality Measures
Applications/Considerations for Patient-Reported
Outcome Measures (PROMs) for Knee
Domains Characteristics Osteoarthritis (OA)

Importance Measure addresses clinically important health issue. Pain, functional status, and quality of life are important
health issues for patients with OA.
Health care can have a meaningful impact Health care for OA is centered around improving these
on the health issue. outcomes.
The measure is focused on an important Meaningful quality thresholds have not been established
health outcome or the clinical care that for PROMs for OA.
leads to that health outcome.
Scientifically Measure is valid—measures what is Numerous PROMs for OA have demonstrated reliability
acceptability intended to measure. and validity.
Measure is reliable—produces the same Few PROMs have been used as measures of quality and
result when remeasured. require validation in that context.
Measure is risk-adjusted, if appropriate. PROMs for OA are influenced by numerous factors and
require risk adjustment to be used as quality measures;
little work has been done in this area.
Usability Measure is understandable to stakeholders Different stakeholders require different reporting of
interested in healthcare quality. performance on quality measures for actionability.
Measure is actionable to drive quality improvement Useful provider reports will include detailed information
by one or more stakeholders. on population characteristics (eg, age, risk strata, and
services utilized), and drill-downs to the patient level.
Useful patient/consumer reports will be specific enough
to individual patients (eg, performance stratified by the
age of the patient) to guide choice of procedure and
choice of provider (hospital and surgeon).
Useful payer reports will differentiate high- versus low-
quality providers to inform quality-based incentives and
determine of which providers will be included in networks.

OA = osteoarthritis, PROMs = patient-reported outcome measures

Table 2
Patient-reported Outcome Measures for Total Knee Arthroplasty Eligible for Voluntary Reporting in the Centers for Medicare and
Medicaid Services Comprehensive Care for Joint Replacement Modela
Type of PROM Eligible Tools Required Collection Period

Generic PROM instrument for TKA VR-12 or PROMIS-global 90–0 d before and 270–365 d after TKA
procedures procedure
Knee-specific PROM instrument for TKA KOOS Jr. Only, or KOOS Stiffness Subscale 90–0 d before and 270–365 d after TKA
procedures and KOOS Pain Subscale and KOOS procedure

KOOS = Knee Injury and Osteoarthritis Outcome Score, PROM = Patient-reported Outcome Measure, PROMIS = Patient-reported Outcomes Measurement Information
System; TKA = total knee arthroplasty; VR-12 = Veterans RAND 12-Item Health Survey

the range of clinical scenarios and patient goals Patient-Reported Outcome Measures Initiative of proportion of patients who had an OKS collected
that drive decisions to perform TKA, it is unlikely England’s National Health Service (NHS), which both preoperatively and postoperatively; the
that percentiles of change scores or simple reports, collects, and publicly reports hospital- statewide average is 24%. Similarly, the appli-
observed expected ratios will identify high versus level risk-adjusted Oxford Knee Scores (OKSs).23 cation for the Blue Distinction Centers for Knee
low quality. In this program, preoperative, postoperative, and and Hip Replacement and the Spine Surgery
change scores are reported relative to the Program requests information on the percentage
national average. A similar program recently of patients with knee or hip replacement who
Current Uses of launched by MN Community Measurement have undergone both preoperative and post-
Patient-Reported Outcome likewise publicly reports hospital-level OKSs for operative functional assessment at least 6 months
Measures to Assess Quality patients who have undergone TKA as an after surgery but does not report it publicly.25
for Total Knee Arthroplasty observed rate relative to an expected rate that is Working in conjunction with a multi-
adjusted for presurgical score and the type of stakeholder group, CMS has defined a specific set
Probably, the most robust effort to use PROMs health insurance.24 MN Community Measure- of PROMs for collection as part of their com-
to assess the quality surrounding TKA is the ment also deploys a process measure to assess the prehensive care for joint replacement (CJR)

February 2017, Vol 25, Supplement 1 S57

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Value-based Purchasing for Osteoarthritis and Total Knee Arthroplasty

the 90 days after the procedure. If the actual epi-

Figure 1
sode cost comes in below the set target price, the
hospital can keep the difference within specified
rules if it meets the program quality standards.26
Hospitals that report specified preoperative and
postoperative PROMs to CMS can earn two
points on the program scorecard. For hospitals
near a threshold, those points could boost the
hospital to the next quality tier. Depending on
which threshold is crossed and the year of the
program, the hospital could become eligible for a
reconciliation or quality incentive payment, or
see a 0.5% to 1.0% reduction in the effective
discount for reconciliation payment or
repayment amount. It is anticipated that CMS
will eventually publicly report facility-level
performance on PROMs. The manner in
which these will be reported, used to define
quality, and/or incorporated into quality-
based payments remains unknown.

Future of Patient-Reported
Model for value-creation opportunities for different levels of care aggregation. AEs = Outcome Measures in Value-
adverse events, DRG = diagnostic-related group, ER = emergency room, OR = operating Based Purchasing
room, pmpm = per member per month, THA = total hip arthroplasty, TKA = total knee
arthroplasty. Realization of the full potential of PROMs as
tools to create value in the United States will
require the following: implementation of infra-
model (Table 2).26 Reporting of these PROMs Because the primary treatment objectives for
structure to routinely collect and report them,
to CMS is voluntary, although hospitals that OA are improvement of pain, functional status,
analytics to develop appropriate risk adjustment,
report earn points for their overall quality and quality of life, PROMs have an important
thoughtful consideration to develop clinically
scorecard. Hence, these PROMs are being role in determining whether the care delivered
meaningful quality thresholds, and financial
used as process measures, that is, the hos- creates the health we seek to create and direct care
incentives that promote quality improvement
pital passes the measure if it completes pre- processes to achieve those goals. In a value-driven
within individual hospitals and collaboration
and postsurgical PROMs for a specified marketplace, PROMs can serve as benchmarks
across hospitals.
number or proportion of patients who against which reimbursements can be determined
undergo total joint replacement. and providers of specific procedures such as TKA
can be selected by patients or payers. Perhaps,
more importantly, they can be used as guideposts References
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S58 Journal of the American Academy of Orthopaedic Surgeons

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Catherine MacLean, MD, PhD

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