Will Orthopedic Registries Improve Joint Surgery Outcomes?

Laird Harrison


February 04, 2016

In This Article

Growth of Orthopedic Registries

AJRR isn't the only orthopedic registry in the United States.[3] Statewide joint replacement registries have been started in California and Virginia, though one in California, the California Joint Replacement Registry, merged into AJRR last year.

In 2010, the University of Massachusetts Medical School established the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) registry with $12 million from the Agency for Healthcare Research and Quality.[4] As of 2015, more than 25,000 patients were enrolled.[5] FORCE-TJR has taken steps to include a diverse population, particularly those treated in community settings, and follow them as they move from one practice to another. FORCE-TJR collects data from patient-satisfaction questionnaires, along with adverse events and radiographs.

In Michigan, Blue Cross Blue Shield and Blue Care Network have funded the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) through multiple hospitals.[6]

Orthopedics faces some unique challenges, Dr Lewallen points out. One is that problems with a prosthesis may not emerge for several years. So the data in the registry have less immediate value than the data in registries for other specialties. Another is that orthopedic surgeons perform diverse types of procedures. Different datasets might be more useful for a knee replacement than for an anterior cruciate ligament reconstruction. In some cases, such as spine surgery, other medical specialties are closely involved.

Consequently, the North American Spine Society is launching a registry of its own.[7] And some orthopedic spine surgeons already participate in the American Association of Neurological Surgeons' National Neurosurgery Quality and Outcomes Database.[8]

How Will the Data Be Used?

With its sharp focus on hip and knee replacements, AJRR soon hopes to produce some data that can be useful in improving outcomes. In its 2015 annual report, it provided some preliminary results on the 210,000 procedures it has tracked.[1]

For example, it found that the mean age of patients undergoing arthroplasty in the United States was 67.7 years for hips and 66.1 for knees, indicating that nearly half of these procedures are performed in people under 65, and who are therefore not likely to be covered by Medicare.[1]

Also in its sample, surface replacement arthroplasty, "which was once widely performed," the annual report notes, had fallen to 0.5% of hip procedures and was concentrated in a handful of hospitals and surgeons.[1]

The registry will not release information on individual physicians, but it will provide useful benchmarks to which physicians can compare themselves, Dr Lewallen says. "There may be some surgeon with a dislocation rate three times higher than normal, and he doesn't even know it. If you provide him with credible data, he's forced to confront it, and that's the first step forward," Dr Lewallen observes.

Payers have not waited for the AJRR to develop quality data before ranking orthopedists, says Kevin Bozic, MD, MBA, professor of orthopaedic surgery at the Dell Medical School at the University of Texas in Austin, chair of the Council on Research and Quality at AAOS, and co-chair of AJRR. "Payers are developing their own networks based on a variety of criteria, which I would describe as rudimentary measures of quality, cost, and utilization," he says.

Payers steer patients to the doctors they perceive as providing the best outcomes at the lowest cost. One approach is to sort physicians into tiers, with lower copays or deductibles for the higher-ranked doctors.

Another approach is to pay a fixed price for care—for example, offering $30,000 for a total hip replacement—and then let the patient choose the provider.


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