Transforming Healthcare to Value: The Orthopaedic Solution

By Kurt P. Spindler, MD

With our nation’s aging population, orthopaedics now accounts for 20 to 30 percent of all healthcare dollars spent in the United States. This has clearly accelerated the motivation to move reimbursement away from a volume based model toward a value-based model. It has also provided the impetus for Cleveland Clinic’s Department of Orthopaedic Surgery to develop its own robust system for accurately measuring outcomes.

A history of metrics

Fortunately, the goal (desired outcome) of the vast majority of treatments for musculoskeletal injuries and disease is measurable: to relieve pain or restore function. Measuring pain and function has a scientific history spanning more than three decades. It began with the 36-item Short Form Health Survey and Western Ontario and McMaster Universities Arthritis Index (WOMAC®) in the 1980s. In the late 1990s and early 2000s, joint-specific measurement tools focusing on the knee, hip and shoulder were psychometrically developed and validated. These patient-reported outcome measures (PROMs), self-administered by patients either on paper or electronically, can be easily completed at designated preoperative and postoperative times, when the patient is at home.

Experience spawns innovative measurement tool

Cleveland Clinic orthopaedists have been national leaders in outcome measurement for over a decade. Joseph P. Iannotti, MD, PhD, Orthopaedic & Rheumatologic Institute Chairman, was instrumental in the design of the widely used Penn Shoulder PROM. I was the principal investigator of the NIH-funded Multicenter Orthopaedic Outcomes Network (MOON) anterior cruciate ligament reconstruction prospective longitudinal cohort that involved following over 3,500 patients at two, six and 10 years. Primary outgrowths of this project were sports-specific knee PROMs. Richard Parker, MD, former Chairman, Department of Orthopaedic Surgery, now Cleveland Clinic Hillcrest Hospital President, was an original member and executive leader in the MOON group. With this experience behind us, in 2014, our team began designing a new clinical outcome measurement tool to transform orthopaedic surgery into a value-based model of care. We named our resulting tool OrthoMiDaS Episode of Care (OME).

Research-grade evaluation system

The intent of OME is to accurately capture patient-reported outcome measures (relief of pain and restoration of function) in a cost-effective, scientifically valid and scalable manner. OME is a research-grade clinical outcomes evaluation system that builds on 14 years of experience (NIH-funded MOON and Cleveland Clinic outcomes tracking in orthopaedics), the expertise of over 20 orthopaedic surgeons, the skills of expert statisticians and database/web programmers, and the robustness of a customized REDCap1 database system.

The program collects three separate data sets to effectively measure, track and, most importantly, scientifically evaluate a patient’s pain and/or functional changes after an episode of care. We measure outcomes of orthopaedic surgeries ranging from arthroscopy to every knee, hip and shoulder arthroplasty at several Cleveland Clinic facilities in Northeast Ohio and Florida.

Data sets collected:

• PROMs for pain, function, and quality-of-life status prior to surgery (Figure 1)
• Surgeon capture of procedures performed, including disease severity and proven risk factors, immediately following surgery (Figure 2)
• Same PROMs one year postsurgery OME implementation at five Cleveland Clinic hospitals began Jan. 1, 2016.

Results thus far have been exceptional, with no additional cost.

Cost-effective, scientifically valid and scalable

Cost-effective: The majority of data collection is done electronically using existing technical infrastructure and commodity hardware, and is integrated into the operational workflow so that no additional employees are required and no operating room schedules are delayed.

Scientifically valid: OME has captured baseline data on over 97 percent of 10,095 elective orthopaedic surgeries over the course of 13 months in all knee, hip and shoulder surgeries, from joint replacement to arthroscopic procedures. Thus, initial sampling bias is avoided by having less than 5 percent failure-to-collect outcomes at the outset. Our goal is to collect follow-up data on a minimum of 70 percent of these surgeries, thus reducing follow-up bias.

Scalable: The OME platform currently collects data on orthopaedic surgeries at five high-volume Cleveland Clinic locations, and is slated to expand to other hospitals and ambulatory surgical centers in the future. We also plan to scale to episode-based procedures outside of orthopaedics and use OME as the platform by which large-scale multicenter orthopaedic studies can be performed.

Rich data capture

The rich data capture in OME can accurately adjust a hospital’s performance on publicly reported metrics. For example, hospitals are rated for arthroplasty (total hip or total knee) based on lengths of stay, readmissions and infections. The scientific literature has shown that elective revision arthroplasty has longer lengths of stay, higher readmissions and higher infection rates. This should be self-evident given the more complicated and longer surgeries. Public reporting does not separate primary total knee or hip arthroplasty from revisions, nor does it adjust for revisions. Thus, the publicly reported metric is severely biased against arthroplasty centers of excellence that are referral centers and that perform a high percentage of complicated revision cases.

Prognosis and modifiable predictors

These high-quality data determine both prognostic and modifiable predictors for a patient’s clinically relevant outcome of pain and function, the primary reason that they underwent surgery. Using the data we have collected, we are developing risk-adjusted multivariate modeling that will help guide patient and physician decision-making.

We view OME as the “Framingham” cohort of ALL orthopaedic surgeries of the knee, hip and shoulder, and believe it has the potential to transform our nation’s healthcare system.

Note

1. REDCap (Research Electronic Data Capture) is a secure web application for building and managing online surveys and databases. It is available free of charge.

Dr. Spindler is Vice Chairman of Research for the Orthopaedic & Rheumatologic Institute.