Tools for High-Value Orthopaedic Care Delivery
Elizabeth Duckworth, MD, MBA
Eugenia Lin, MD
Olivia Manickas-Hill, BA
Prakash Jayakumar, MD, PhD
None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Duckworth, Dr. Lin, Olivia Manickas-Hill, and Dr. Jayakumar.
INTRODUCTION
The shift toward value-based health care in the United States, since the enactment of the Patient Protection and Affordable Care Act (ACA) in 2010, has sparked a demand for tools and technologies to support stakeholders engaged in realizing this goal. Government agencies, regulatory bodies, professional groups, commercial insurers, pharmaceutical and biomedical device companies, and health care provider organizations are increasingly recognizing the need for such tools to better prepare them for delivering a range of value-oriented functions. This chapter defines concepts and unmet needs that provide the inspiration for tools and technologies enabling value-based health care delivery. A description of current state-of-the-art and future patient-facing, surgeon-facing, and systems-level tools contributing to an essential toolkit for high-value orthopaedic practices is also provided.
OVERVIEW OF HIGH-VALUE MODELS OF CARE DELIVERY
In orthopaedics, the largest transformation toward value-based reimbursement to date has been the Centers for Medicare & Medicaid Services (CMS) implementation of the Comprehensive Care for Joint Replacement (CJR) model in April 2016. Mandating hospitals across the country to accept bundled payment for a surgical episode of care around total hip and total knee arthroplasty, the CJR model places a greater emphasis on accountability for quality and costs of care by promoting coordination between hospitals, physicians, and postacute care providers. The CJR model and other value-oriented initiatives signal the requirement for tools and technologies, such as robust electronic health records and outcome measurement platforms, to deliver optimal care while also offering a lens on performance and benchmarking fit for value.1 Accountability for quality and costs of care for Medicare patient populations has also been realized in the engagement of groups of hospitals, practices, and clinicians within accountable care organizations.2
Value-based practice and payment reform in orthopaedics is now expanding beyond surgical procedures toward management of the condition over a full cycle of care, the original vision in the seminal work, Redefining Health Care.3 With this in mind, tools for high-value care can be key drivers for the development of alternative condition-based bundled payment models across orthopaedic care (Figure 1).
Value-based practice and payment reform in orthopaedics is now expanding beyond surgical procedures toward management of the condition over a full cycle of care, the original vision in the seminal work, Redefining Health Care.3 With this in mind, tools for high-value care can be key drivers for the development of alternative condition-based bundled payment models across orthopaedic care (Figure 1).
CONCEPTS AND UNMET NEEDS FOR DEVELOPING HIGH-VALUE TOOLS
Value-Based Health Care
Value-based health care is defined as care that achieves health outcomes benefiting patients relative to the costs of care.4 Importantly, this definition relies on the direct measurement of outcomes that matter to the individual over a full cycle of care. These outcomes should include a range of quality metrics from patients’ perspectives of their physical, emotional, and social health and well-being to clinically
effective outcomes including those related to hospitalization, complications, rehabilitation, and recurrences.5 The denominator includes the total cost of care for managing a patient’s condition and should incorporate direct and indirect costs spanning the gamut of inpatient, outpatient, rehabilitation, drugs and devices, physician services, equipment, and facility costs, as well societal costs through loss of productivity.5 Considering the costs of a full cycle of care may also support increased spending on higher value preventive services while disincentivizing the shift in costs from one type of service or provider of services to another.4
effective outcomes including those related to hospitalization, complications, rehabilitation, and recurrences.5 The denominator includes the total cost of care for managing a patient’s condition and should incorporate direct and indirect costs spanning the gamut of inpatient, outpatient, rehabilitation, drugs and devices, physician services, equipment, and facility costs, as well societal costs through loss of productivity.5 Considering the costs of a full cycle of care may also support increased spending on higher value preventive services while disincentivizing the shift in costs from one type of service or provider of services to another.4
 FIGURE 1 Tools for high-value orthopaedic care delivery. |
Patient-Centered Care
Patient-centered care is defined as care that respects and responds to individual patient preferences, values, and needs, while ensuring patients remain at the center of their care and clinical decision making.6 This concept includes the effect of care on patient-specific factors (physical, psychological, and social health and well-being) alongside the individual’s experience of care.7 Communication, trust, and empathy form some of the cornerstones of patient-centered care and enable patients to more effectively engage in their health care ecosystem. Shared decision making (SDM) is the expert communication of clinical information including management options to help clinicians and patients arrive at informed treatment decisions aligned with the patient’s preferences, values, and needs. This concept combines several patient-centered elements and is increasingly being adopted in orthopaedics.8 Patient-centered care has been embraced by the American Academy of Orthopaedic Surgeons via its appropriate use criteria, which utilize validated tools to extrapolate the appropriateness of an intervention within different patient and treatment combinations.9
Integrated Care
Integrated care is defined as care that is coordinated across professionals, facilities and support systems; continuous over time and between visits; tailored to patients’ needs and preferences; and based on shared responsibility between patients and caregivers while systematically measuring outcomes.10 In this regard, there has been growing interest in comprehensive, team-based, condition-focused approaches to orthopaedic care in the form of integrated practice units (IPUs).11 IPUs are structurally and functionally organized around conditions (rather than specific providers or procedures) over a full care cycle, involving a range of treatment strategies.11 The full range of treatments (including surgical and nonsurgical care) are delivered by a dedicated multidisciplinary team working within a common organizational unit, accountable for outcomes and costs of care under a bundled payment arrangement.12 Relatively few IPUs exist in current clinical practice; however, several institutions have adopted integrated care pathways (ICPs) that offer a specific, time-dependent regimen used to standardize care during a course of treatment.11 Vertically integrated institutions such as Geisinger Health and Kaiser Permanente have embraced ICPs for joint replacement surgery and seen reductions in length of hospital stay, complications, redundancy in ancillary services, and waste through enhanced interdisciplinary coordination.12,13 ICPs
have also been applied extensively in geriatric and nongeriatric fracture management and resulted in decreased complications, length of stay, time to surgery, and costs of care.14 Integrated care may also be considered comprehensive care by design because it aims to provide for the holistic needs of patients; one common example is the combined medical, surgical, and rehabilitation care provided by orthogeriatric teams in managing geriatric trauma patients.15 The benefits of a more complete integrated, biopsychosocial approach is increasingly being recognized in orthopaedics, especially in relation to the comprehensive management of osteoarthritis.16 The concepts of value-based health care, patient-centered care, and integrated care demand the development of practical, safe, and effective tools and technologies for delivering high-value orthopaedic care.
have also been applied extensively in geriatric and nongeriatric fracture management and resulted in decreased complications, length of stay, time to surgery, and costs of care.14 Integrated care may also be considered comprehensive care by design because it aims to provide for the holistic needs of patients; one common example is the combined medical, surgical, and rehabilitation care provided by orthogeriatric teams in managing geriatric trauma patients.15 The benefits of a more complete integrated, biopsychosocial approach is increasingly being recognized in orthopaedics, especially in relation to the comprehensive management of osteoarthritis.16 The concepts of value-based health care, patient-centered care, and integrated care demand the development of practical, safe, and effective tools and technologies for delivering high-value orthopaedic care.
PATIENT-FACING TOOLS DESIGNED FOR HIGH-VALUE ORTHOPAEDIC CARE
Tools enabling the capture of patient-generated health data are integral to valuebased health care. Patient-generated health data is defined as health-related data created, recorded, and gathered from patients (or family members or other caregivers) to help establish a patient’s health status.17 This type of information derived from patients is distinct from objectively reported data by clinicians or clinical systems.
Patient-Reported Outcome Measures
Patient-reported outcome measures (PROMs) are validated measures of physical, psychological, and social health and well-being reported by the patient that have revolutionized orthopaedic clinical research and are now being increasingly used in clinical practices across orthopaedic subspecialties.18 PROMs enable quantification of a patient’s perceptions of their health and responses to medical interventions with respect to function, symptoms, and quality of life.19 The introduction of national registries incorporating PROMs has had a meaningful effect in several countries through the evaluation of patient outcomes for different surgical techniques, analysis of positive predictors of these outcomes, and comparison across orthopaedic and non-orthopaedic conditions.20,21 The American Board of Orthopaedic Surgery collects PROMs as part of the Part II Board Certification process and the CMS incentivizes PROMs collection through quality reporting and bonus payment initiatives.22,23 Effective PROMs should demonstrate reliability (how well the tool repeatedly assesses the same item), validity (whether the tool measures the content it intends to measure), and responsiveness (the tool’s sensitivity to change over time) while also being user-friendly and easy to interpret (the degree to which qualitative and clinical meaning can be assigned to a PROMs quantitative scores or change in scores).24,25 Measuring PROMs before and after a treatment intervention provides an opportunity to objectively measure the effect of an intervention on the patient’s health from their perspective. This effect has traditionally been quantified using fixed-scale measures developed from classic test theory. In recent decades, there has been increased use of computer adaptive tests (CATs), developed using item response theory, which enables follow-up questions to be administered based on the patient’s response to a prior question.26 Although
fixed-scale PROMs require patients to answer most, if not all, questions to arrive at a valid score, CATs generally involve fewer but more tailored questions, and therefore result in more precise and efficient capture of patient outcomes. The most commonly used CATs are the Patient Reported Outcome Measurement Information System (PROMIS) measures developed by the National Institutes of Health. Development of PROMIS was prompted by the need for a valid, reliable, and generalizable set of measures that could be applied across clinical conditions, providing comprehensive coverage of different levels of a relevant health domain, while maintaining efficiency and reducing burden on responders.18,27 The PROMIS instruments score health domains using a common metric, normalized to the US general population. Over a 5-year period from 2014 to 2018, the volume of orthopaedic studies leveraging PROMIS increased sixfold, with most studies examining the domains of physical function, pain interference, and depression.28
fixed-scale PROMs require patients to answer most, if not all, questions to arrive at a valid score, CATs generally involve fewer but more tailored questions, and therefore result in more precise and efficient capture of patient outcomes. The most commonly used CATs are the Patient Reported Outcome Measurement Information System (PROMIS) measures developed by the National Institutes of Health. Development of PROMIS was prompted by the need for a valid, reliable, and generalizable set of measures that could be applied across clinical conditions, providing comprehensive coverage of different levels of a relevant health domain, while maintaining efficiency and reducing burden on responders.18,27 The PROMIS instruments score health domains using a common metric, normalized to the US general population. Over a 5-year period from 2014 to 2018, the volume of orthopaedic studies leveraging PROMIS increased sixfold, with most studies examining the domains of physical function, pain interference, and depression.28
PROMs provide a range of functions from tracking, screening, and segmentation of patient phenotypes, to enabling decision support and SDM.29 For instance, PROMs have been used in anterior cruciate ligament reconstruction and total joint arthroplasty (TJA) to aid surgeons in determining whether surgical intervention will benefit the patient by comparing a patient’s individual recovery to an expected recovery curve.30,31 Some institutions have committed to gathering PROMs for all patients across the spectrum of orthopaedic care, with the goal of longitudinally tracking outcomes of their population.26 Broadly, within orthopaedics, PROMs fall under the categories of health, health-related quality of life, and quality of life. Under health, PROMs range from disease-specific, region-specific, or conditionspecific PROMs, as well as psychosocial PROMs.32,33 The American Academy of Orthopaedic Surgeons has compiled a list of approved, open-access PROMs from a 2015 Quality Outcomes Data Work Group to evaluate PROMS for general health and condition or PROMs specific to an anatomic region.34
Patient-Reported Experience Measures
Patient-reported experience measures (PREMs) broadly capture patient perceptions of their experience with health care.35 PREMs range from measures of patient satisfaction with various structural and functional aspects of health care such as waiting times, access to facilities, and ability to navigate services, to (perhaps more importantly) the quality of communication and interpersonal interactions with clinicians and clinical teams.36 PREMs capturing satisfaction with clinician-patient communications and trust in providers, alongside confidence with the level of information received and involvement in care, are shown to have a positive association with PROMs in patients undergoing hip and knee arthroplasty.37 In the United States, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) provide a suite of PREMs developed by the Agency for Healthcare Research and Quality, aiming to reflect key areas of overall patient experience related to structural, functional and interpersonal aspects of care. Since 2013, part of the value-based payment for hospitals initiated by CMS reflects the results of the hospital version of the Consumer Assessment of Healthcare Providers and Systems (known as H-CAPS).7
Patient Activation Measures
Patient activation measures (PAMs) are tools that measure an individual’s understanding, competence, and willingness to participate in care decisions and processes; rather, the knowledge, skills, and confidence a person has in engaging with their health and health care ecosystem.6 Active engagement of patients in their care has been demonstrated to improve health outcomes, patient experience, and lower health care costs.38 PAMs enable providers to understand both an individual patient’s level of activation and, more broadly, the levels of activation among various segments of their population. In particular, the Patient Activation Measure-13 (PAM-13) and the shorter PAM-10 have been used in orthopaedic care.39
Patient Decision Aids
SDM empowers patients to become active participants in their health and care by enabling both physician and patient to contribute to medical decision making. This approach depends on expert communication and education delivered by physicians that encourages patients to comfortably disclose their preferences, needs, and values to make informed treatment decisions.8,40 Studies have shown SDM leads to better patient satisfaction, improved decision quality, more appropriate use of health care resources by patients, and better outcomes.41,42,43 Based on a Cochrane review, SDM does not have a significant effect on the duration of the clinician-patient encounter, nor does it place additional burden on an already busy clinic schedule, adding only 2.55 minutes per encounter. Studies also suggest that these additional few minutes need not involve the physician but can be managed by midlevel health professionals.44
Patient decision aids (PDAs) are tools designed to facilitate SDM by helping patients understand relevant evidence-based information, empowering patients to better understand potential benefits and harms, and to aid communication between patients and clinicians.45 Importantly, PDAs are distinct from patient education materials (which are also useful tools) in that they more actively direct patients toward making an informed choice among multiple treatment options. Some PDAs also help align treatment options with patient preferences rather than providing information about specific treatments or treatment plans after they have already been set in place.46 In orthopaedic care, PDAs have been studied most frequently in patients with persistently painful preference-sensitive conditions (ie, where multiple valid treatment options exist) such as degenerative disease of the spine and osteoarthritis of the hip and knee.47 PDAs can take multiple forms, including written booklets, videos, and interactive online tools and can be provided to patients before, during, or after an initial encounter with an orthopaedic practitioner. PDAs may also be effective in empowering patients to make informed decisions at a given point in time as well as providing ongoing guidance along different phases of a care pathway. Evidence suggests that orthopaedic patients with hip osteoarthritis and degenerative disease of the spine recall only 38% and 45% of verbal information respectively, after outpatient clinic visits with a provider, and as little as 18% of information 6 weeks after surgery.48,49 PDAs could help address this knowledge and retention gap by providing patients with supportive resources on demand.
SDM-Related Outcome Metrics
SDM-related outcome measures (SROMs) can be used as part of an orthopaedic service’s SDM initiative alongside implementation of PDAs. Somewhat similar to PROMs, these tools provide a measure of effect from the patient’s perspective in relation to various elements of the decision-making process (eg, preparation for decisionmaking [Preparation for Decision-Making Scale], Decision Quality and level of SDM [Decision Quality Index, CollaboRATE survey], decisional conflict [Decision Conflict Scale, SURE 4-item screener], decisional regret [Decision Regret Scale], and decision support [Decision Support Analysis Tool, DSAT-10]), as well as numerical rating scales for various aspects of satisfaction with the consultation such as clinician-patient interaction.50 Further validated tools (eg, OPTION) have also been developed to independently observe, measure, and score the extent and quality of SDM delivered by clinicians. Tools and checklists for the development and application of PDAs are also provided by the International Patient Decision Aids Standards (IPDAS) initiative.51
CLINICAL APPLICATIONS FOR VALUE AND PERFORMANCE MEASUREMENT
A key component of these patient-facing tools, aside from their psychometric characteristics (validity, reliability, responsiveness), is the capability for users to interpret and apply them in real-world clinical settings and the potential for utilization as performance measures in gauging value. The ability to understand how the scores are generated by such tools is crucial to apply these metrics at the clinical and systems levels. The minimal clinically important difference (MCID) is the smallest change in a treatment outcome (eg, PROM scores) that a patient would identify as important and that would indicate a change in the patient’s management or health status.52 MCID thresholds of many commonly used PROMs are available in the orthopaedic literature and can be used to benchmark performance and assess clinically meaningful improvement.53 Differences smaller than the MCID are unlikely to matter to patients. MCID can be calculated using statistical methods (eg, the distribution method) based on typically selecting a threshold at 0.5 standard deviation within the distribution of outcome scores, or a subjective approach (eg, the anchor method), aligning scores to anchor questions reflecting patient satisfaction and patient perceptions around functional improvement.54 The anchor method is generally preferred, given that it more closely reflects patient perceptions of improvement, aligns with expectations, and helps to better define substantial clinical benefit (SCB) thresholds. SCB reflects an improvement in outcomes thought by the patient to be considerable. This may be particularly relevant in assessing the effect of interventions, such as TJA, which has a strong record in improving symptoms and function, and for which minimal clinical improvement should really be the standard outcome.55 SCB may also be useful in the treatment of sports injuries involving high-performing athletes and those with functional expectations on the higher end of the spectrum.56 Another tool for enabling clinically meaningful interpretation of patient-generated outcomes data is the patient acceptable symptom state, defined as an absolute threshold for symptoms experienced with a specific condition beyond which patients consider themselves well and therefore satisfied with treatment.57 Although MCID and SCB
can be defined using an existing PROMs dataset or with the simple addition of a single anchor question, these thresholds do not account for the fact that it is easier to achieve a larger magnitude of change in patients who have extreme baseline values, nor do they provide an indication of a patient’s successful return to activities of daily living, work, and recreation, or satisfaction with their level of improvement.58 Although the patient acceptable symptom state requires additional scoring, it can be used to determine success of an intervention in patients who do not have preoperative PROMs, is less sensitive to baseline symptom levels, and provides a useful tool for setting expectations around the potential outcomes of treatment.59 The use of these thresholds is gaining interest along with the development of PROMs as performance measures, defined as standardized tools, administered at designated time points, with an established risk-adjusted scoring methodology.60
can be defined using an existing PROMs dataset or with the simple addition of a single anchor question, these thresholds do not account for the fact that it is easier to achieve a larger magnitude of change in patients who have extreme baseline values, nor do they provide an indication of a patient’s successful return to activities of daily living, work, and recreation, or satisfaction with their level of improvement.58 Although the patient acceptable symptom state requires additional scoring, it can be used to determine success of an intervention in patients who do not have preoperative PROMs, is less sensitive to baseline symptom levels, and provides a useful tool for setting expectations around the potential outcomes of treatment.59 The use of these thresholds is gaining interest along with the development of PROMs as performance measures, defined as standardized tools, administered at designated time points, with an established risk-adjusted scoring methodology.60
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