Adding the Patient’s Perspective to Joint Registry Data

    FORCE-TJR is a national database that combines surgical results of hip and knee arthroplasty with patient-reported outcomes in pain and functioning.

    By Susan Doan-Johnson

    Joint implant registries are critical to the orthopaedic community’s understanding of the characteristics, performance, and longevity of various implants used in hip and knee arthroplasty. They also help identify problems with specific implants that need to be addressed.

    They are so important, in fact, that orthopaedic registries from around the world were showcased in a special forum at the 2014 Annual Meeting of the American Academy of Orthopaedic (AAOS)

    As valuable as these registries are, however, something is missing: the patient’s perspective on the total joint replacement experience.

    Outcomes, as Reported by Patients

    That is the void being filled by FORCE-TJR registry (Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement), which was launched in 2011 with $12 million in funding to the University of Massachusetts Department of Orthopedics and Physical Rehabilitation from the Agency for Healthcare Research and Quality. This funding runs through 2015, and after that, expenses will be covered through paid memberships and supplemental grants.

    FORCE-TJR is intended to be a national database of surgical results and patient-reported outcomes (PROs). The PROs come from the surveys that participating joint replacement patients complete before and after their surgery. The surveys include questions about pain and activity, take about 15 minutes to complete, and can be done on a computer or on paper.  Patients are followed by the registry after surgery – with a survey 6 months after surgery and then every year after that – to continue gathering long-term outcomes data.

    Thus far, more than 125 orthopedic surgeons from across the United States are participating, with data on 15,000 hip and knee replacement patients added to FORCE-TJR. Eventually, the registry will have data on at least 30,000 patients.

    The goal is to use the data – particularly the patient assessments on the success or failure of their surgeries – to guide and improve clinical best practices, health care policy, and the overall health and quality of life for millions of people suffering from osteoarthritis of the knee or hip.

    Gathering Patient Attributes and Clinical Variables

    David C. Ayers, MD, the Arthur M. Pappas, MD, Chair in Orthopedics and Chair and Professor of Orthopedics and Physical Rehabilitation at the University of Massachusetts in Worcester, is one of the leaders of the FORCE-TJR project.

    David C. Ayers, MD

    “FORCE -TJR is unique because of the depth and range of data being collected,” he said. By collecting the PROs, “FORCE-TJR addresses what is important to patients: pain relief, functional gain, and absence of complications.”

    More than 120 patient attributes (such as obesity, work status, activity level) and clinical variables (comorbidities, surgical approach, perioperative complications) are entered into the FORCE-TJR via a proprietary computerized system using standardized, validated questionnaires.

    In addition, FORCE-TJR assesses implant features and longevity in parallel with the American Joint Replacement Registry.

    Significantly, Dr. Ayers said, FORCE-TJR has a 95% response rate in collecting data from participants, “higher than any other registry of its kind.”

    The data collected by FORCE-TJR represent a nationwide sample of patients and providers. The participating orthopaedic practices and hospitals are from a variety of settings – urban, rural, low-volume offices, and high-volume offices – in all regions of the United States.

    This is one of the strengths of FORCE-TJR. According to the registry’s website, “this diversity will ensure that analyses and research reflect typical clinical practice thereby providing optimal guidance for patients, clinicians, and national healthcare policymakers.”

    The data from FORCE-TJR represent “the next step in the value process,” Dr. Ayers said.

    “Using PROs allows us to better track, predict and avoid complications. That means fewer readmissions and revision surgeries, which ultimately means lower costs,” he said. “The PROs are what make FORCE unique and empower us moving forward. We envision our method being important to negotiating rates from payers in the future. “

    Early Findings from FORCE-TJR

    The hope, Dr. Ayers said is that data from FORCE-TJR will help patients understand what to expect from hip and knee replacement, including pain, disability, and typical outcomes, and help surgeons understand optimum timing for surgery, possible postoperative complications based on patient risks, expected gains, and implant longevity.

    Among the early findings from the FORCE-TJR data are the following:

    • On average, knee arthroplasty patients are older than hip arthroplasty patients (66.5 vs. 64.3 years) and have a higher body mass index (BMI).
    • Today’s knee arthroplasty patients are younger and their presurgical physical function represents significant levels of disability.
    • Pain in the muscles and joints of the nonoperative knee and low back is significantly associated with poorer physical function in patients undergoing knee arthroplasty or hip arthroplasty.
    • Women undergoing knee or hip arthroplasty have more severe arthritis, poorer physical function, and more problems related to their muscles and joints than men undergoing these procedures.
    • Younger (less than 65 year old) patients undergoing knee or hip arthroplasty do not have as many health problems, in addition to osteoarthritis, than older patients undergoing these procedures. However, they have a higher BMI, smoke more, and are more likely to have emotional/mental health challenges.
    • At the time of knee or hip arthroplasty, younger patients (less than 65 years old) have greater physical function impairment compared with older patients undergoing these procedures.
    • Very overweight patients undergoing knee or hip arthroplasty are likely to have more pain in their muscles and joints and poorer physical function

    Pinpointing the Right Time for Surgery

    At the AAOS meeting, Dr. Ayers and his colleagues presented data from the FORCE-TJR registry in a number of posters and podium presentations. One study evaluated the timing of joint replacement surgery based on patient pain and function scores. (Pre-Op THR Pain and Functional Limitation Profiles are Consistent Across U.S. Surgeons)

    “This is the first time we’ve been able to quantify the point at which most patients and surgeons together make the decision to proceed with a total knee or hip replacement,” Dr. Ayers said.

    “We studied the typical orthopedic practice in the United States and found that we were able to statistically identify a point, based on a national sample of patients’ reported levels of pain and functional impairment, that surgeons offer surgery and patients decide to move forward.”

    The uniformity of pain and function scores across such a wide population offers, for the first time, possible national benchmarks patients and surgeons can use in shared decision-making and in determining whether the patient meets national “norms” for the timing of surgery.

    Within FORCE-TJR, patient-report pain and stiffness are scored independently and then combined for a physical composite score (PCS) of the patient’s level of pain and physical function.  The nationally recognized mean PCS score for an individual with no hip and knee pain or functional difficulty is 50.

    In the FORCE-TJR study across 15,000 patients, the typical PCS score for a patient at the point when they decided to have joint replacement surgery was 32 – nearly two standard deviations below the norm, representing significant pain and disability.