Total joint replacement surgery is among the most commonly performed inpatient procedures in the United States. More than 1,000,000 hip and knee replacements are performed each year, and, with the aging of our population, that number is expected to grow quickly.
Despite the general success of such replacements, approximately 20 percent of recipients of well-done replacements are unsatisfied with their surgery, and unmet patient expectations for the procedure are typically an important cause of such dissatisfaction. In fact, one study found that the most important contributing factor to dissatisfaction following total knee arthroplasty was not meeting patients’ expectations.
Furthermore, rates of replacement surgery continue to vary across geographic regions and by race, and these differences cannot be explained solely by differences in the prevalence of hip and knee disease. Research suggests the decision to proceed with joint replacement surgery may at times be more reliant on provider preferences than on objective criteria and patient preferences. A large 2014 study showed that when validated appropriateness criteria were applied to actual cases of knee replacement surgery, over one third of those procedures done in the U.S. were inappropriate.
To address the issue of surgical appropriateness and to ensure that patients and surgeons engage in shared decision making that explicitly acknowledges patient goals and preferences, Blue Shield of California has developed an innovative joint replacement program. This program was developed with considerable input from The Society for Patient Centered Orthopedics and the California Orthopedic Association.
The program requires objective assessment of the indication for surgery, including the use of patient-centered assessment tools and documentation of a completed CollaboRATE shared decision making survey by the patient as a component of the pre-authorization process. Blue Shield will also collect a nine-item Shared Decision Making questionnaire (SDM-Q-9) directly from patients and will provide prospective surgical candidates with decision aids. Finally, the success of the joint replacement from the patient’s perspective will be measured by obtaining pre- and post-operative PROMIS (Patient Reported Outcomes Measurement Information System) scores directly from surgical patients.
Patient-Centered Assessment Tools
There are a number of tools available for soliciting patients’ perspective on the need for, and outcomes of, joint surgery. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) assess both short- and long-term consequences of knee/hip osteoarthritis and injury.
Both have a validated short form available that takes patients only a minute or two to complete. Both are non-proprietary and free. These surveys ask patients to assess their level of pain and physical function. KOOS scores are valid, reliable, and responsive to changes in knee arthritis symptomatology and joint replacement. HOOS scores have been recommended for studying both non-surgical care of patients with hip arthritis as well as those undergoing total hip replacement, due to their reliability, validity, and responsiveness. We hope that the required use of these tools will help ensure that all decisions to proceed with joint replacement are based on patient-centered evidence.
We will collect each surgeon’s patients’ KOOS or HOOS results and share them back with surgeons, along with aggregate results from all other participating orthopedists. Thus, each individual surgeon will have the opportunity to analyze his/her treatment decisions in light of those of his peers.
Finally, both pre-operatively and at one year post-op, we will capture health related quality-of-life data using the PROMIS-Global 10 tool. The PROMIS system is funded by the National Institutes of Health and backed by extensive research. The score incorporates physical, emotional, and social well being. The measures have been shown to be valid, reliable, and inclusive. The PROMIS tool will help in understanding the patient-perceived benefit of the procedure and will, therefore, be useful in understanding such factors as the appropriateness of different surgeons’ patient selection for surgery. These results, too, will be shared with providers.
Improved Patient Satisfaction And Surgical Outcomes
Shared decision making between patients and their surgeons is important not only in making treatment decisions, but also in achieving good outcomes in the eyes of both doctors and patients — who can have very different opinions of the outcome of the same episode of care. This is particularly true because American doctors have a long history of poor communication with our patients.
According to the National Academy of Medicine, fewer than half of all patients think their doctor asks the necessary questions and takes the time to understand their goals and concerns. Researchers in Seattle studied over 1,000 patient encounters, including many involving orthopedists, and concluded that fully informed consent for treatment only occurred in 9 percent of studied encounters.
The Informed Medical Decisions Foundation and other organizations have advocated for formal shared decision making, often using decision aids, as a means to address this problem — and it works. Patients report that after making shared decisions, that they feel empowered, experience less decisional conflict, and make what they perceive as better decisions with more realistic expectations of likely treatment outcome. In joint replacement surgery, the use of decision aids can also impact outcomes by ensuring that only the best candidates for the procedure proceed with it.
Shared decision making is also critical for patients who are good candidates for joint replacement surgery—from a clinical perspective—but who may not want the procedure for other reasons. Many patients with severe hip and knee arthritis will choose non-operative management when they are well informed about their options.
In a Canadian study, no more than 15 percent of candidates with severe arthritis were definitely willing to undergo arthroplasty. Furthermore, a recent randomized controlled trial of conservative medical care versus knee replacement published in The New England Journal of Medicine revealed that three fourths of the patients assigned to receive non-surgical care did not elect to proceed to knee replacement during the following year.
These and other data make abundantly clear that while joint replacement surgery can be highly effective, it is not for everyone, including some patients who seem to be good candidates for the procedure. Thus, we need adequate shared decision making strategies to ensure that patients receive the care they prefer.
CollaboRATE
We have chosen CollaboRATE as our tool for measuring shared decision making for its efficacy and ease of use. Elwyn and colleagues have described it as “a fast and frugal patient-reported measure of shared decision making.” Users can complete it in 30 seconds or less, making it ideal for routine use in daily clinical practice. It has demonstrated discriminative validity, concurrent validity with other measures of shared decision making, intrarater reliability, and sensitivity to change.
Patients score their providers on three questions on a scale from 0 to 9, allowing providers to obtain a good sense of their patient-perceived shared decision making ability and effort. CollaboRATE also allows for measuring provider improvement over time. As noted, we will also collect Shared Decision Making questionnaire (SDM-Q-9) scores directly from patients, comparing these to surgeons’ CollaboRATE scores to help ensure that the latter are not subtly biased by having been obtained through the surgical office.
We believe the requirement for obtaining CollaboRATE scores as part of the total joint preathorization process will encourage providers to focus more strongly on shared decision making. Like the HOOS and KOOS scores, providers will receive back reports from Blue Shield of California with their aggregate CollaboRATE scores, along with data from other providers that allows them to understand how well their patients rate them and how well they are doing compared to their peers. We believe that those performing poorly will quickly focus on improvement.
Looking Forward
Blue Shield of California and its physician partners have put in place a unique, patient-focused process for evaluating joint replacement surgery, both pre- and post-operatively. Blue Shield will share all data with participating surgeons to drive quality improvement and build a patient-centered knowledge database regarding this surgery.
Furthermore, as data on the efficacy of this program accumulates, we intend to publish it in peer-reviewed journals. Our program incorporates both an important element of data collection—similar to that of joint registries—and also puts in place a robust patient-centered preauthorization process.
We hope that similar programs will rapidly spread, both geographically and across specialties and for different procedures. Such programs are a crucial component of moving toward a patient-centered medical system, achieving the Triple Aim, and paying for value. We believe that our effort offers a model of insurer-physician cooperation toward improving health care quality. Current medical literature supports the use of our patient-centered processes — all that remains is the drive to widely implement them.
from Health Affairs Blog http://ift.tt/1SrcPOr
No comments:
Post a Comment