Advertisement

The Appropriateness of Preoperative Patient Reported Outcome Measures as an Indication for Total Hip Arthroplasty

Published:November 08, 2022DOI:https://doi.org/10.1016/j.arth.2022.09.004

      Abstract

      Background

      While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers have begun requiring preoperative PROMs when determining patient eligibility for total hip arthroplasty (THA). Concerns exist these data may be used to deny THA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate outcomes following THA based on theoretical PROM thresholds.

      Methods

      We retrospectively analyzed 18,006 consecutive primary THA patients from 2016-2019. Hypothesized preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR) cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered “approved” surgery. Preoperative scores above each threshold were considered “denied” surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. HOOS-JR scores were collected preoperatively and 1-year postoperatively. Minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.

      Results

      Using preoperative HOOS-JR thresholds of 40, 50, 60, and 70 points, the percentage of patients who would have been denied surgery was 70.4%, 43.2%, 20.3%, and 8.3%, respectively. For these denied patients, 1-year MCID achievement was 75.9%, 69.0%, 59.1%, and 42.1%, respectively. In-hospital complication rates for approved patients were 3.3%, 3.0%, 2.8%, and 2.7%, while 90-day readmission rates were 5.1%, 4.4%, 4.2%, and 4.1%, respectively. Approved patients had higher MCID achievement (P < .001) but higher nonhome discharge (P = .01) and 90-day readmissions rates (P = .036) than denied patients.

      Conclusion

      Most patients achieved MCID at all theoretical PROM thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • MN Community Measurement
        New measures help quantify improvement experienced by patients following knee and spine surgery.
        ([accessed 1.9.22])
        • National Health Service
        Finalised patient reported outcome measures (PROMs) in England, April 2015 to March 2016.
        ([accessed 1.9.22])
        • Ryan A.
        • Tompkins C.
        Efficiency and value in healthcare: linking cost and quality measures.
        National Quality Forum, Washington DC2014: 1-64
      1. “Comprehensive Care for Joint Replacement Model.” CMS.gov.
        ([accessed 1.9.22])
      2. “UnitedHealthcare Commerical Medical Policy.” Uhcprovider.com.
        ([accessed 1.9.22])
        • Menz H.B.
        • Roddy E.
        • Thomas E.
        • Croft P.R.
        Impact of hallux valgus severity on general and foot-specific health-related quality of life.
        Arthritis Care Res. 2011; 63: 396-404
        • Berliner J.L.
        • Brodke D.J.
        • Chan V.
        • SooHoo N.F.
        • Bozic K.J.
        John Charnley Award: preoperative patient-reported outcome measures predict clinically meaningful improvement in function after THA.
        Clin Orthop Relat Res. 2016; 474: 321-329
        • Stratford P.W.
        • Binkley J.M.
        • Riddle D.L.
        • Guyatt G.H.
        Sensitivity to change of the roland-morris back pain questionnaire: part 1.
        Phys Ther. 1998; 78: 1186-1196
        • Copay A.G.
        • Subach B.R.
        • Glassman S.D.
        • Polly D.W.
        • Schuler T.C.
        Understanding the minimum clinically important difference: a review of concepts and methods.
        Spine J. 2007; 7: 541-546
        • Wyrwich K.W.
        • Bullinger M.
        • Aaronson N.
        • Hays R.D.
        • Patrick D.L.
        • Symonds T.
        Estimating clinically significant differences in quality of life outcomes.
        Qual Life Res. 2005; 14: 285-295
        • Paulsen A.
        • Roos E.M.
        • Pedersen A.B.
        • Overgaard S.
        Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively.
        Acta Orthop. 2014; 85: 39-48
        • Maredupaka S.
        • Meshram P.
        • Chatte M.
        • Kim W.H.
        • Kim T.K.
        Minimal clinically important difference of commonly used patient-reported outcome measures in total knee arthroplasty: review of terminologies, methods and proposed values.
        Knee Surg Relat Res. 2020; 32: 19
        • Ramkumar P.N.
        • Navarro S.M.
        • Haeberle H.S.
        • Ng M.
        • Piuzzi N.S.
        • Spindler K.P.
        No difference in outcomes 12 and 24 Months after lower Extremity total joint arthroplasty: a systematic review and meta-analysis.
        J Arthroplasty. 2018; 33: 2322-2329
        • Neuprez A.
        • Neuprez A.H.
        • Kaux J.F.
        • Kurth W.
        • Daniel C.
        • Thirion T.
        • et al.
        Total joint replacement improves pain, functional quality of life, and health utilities in patients with late-stage knee and hip osteoarthritis for up to 5 years.
        Clin Rheumatol. 2020; 39: 861-871
        • Lyman S.
        • Lee Y.Y.
        • McLawhorn A.S.
        • Islam W.
        • MacLean C.H.
        What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement?.
        Clin Orthop Relat Res. 2018; 476: 2432-2441
        • Lyman S.
        • Lee Y.Y.
        • Franklin P.D.
        • Li W.
        • Mayman D.J.
        • Padgett D.E.
        Validation of the HOOS, JR: a short-form hip replacement survey.
        Clin Orthop Relat Res. 2016; 474: 1472-1482
        • Roth A.
        • Anis H.K.
        • Emara A.K.
        • Klika A.K.
        • Barsoum W.K.
        • Bloomfield M.R.
        • et al.
        • Cleveland Clinic OME Arthroplasty Group
        The potential effects of imposing a body mass index threshold on patient-reported outcomes after total knee arthroplasty.
        J Arthroplasty. 2021; 36: S198-S208
        • Baker P.
        • Deehan D.
        • Lees D.
        • Jameson S.
        • Avery P.J.
        • Gregg P.J.
        • et al.
        The effect of surgical factors on early patient-reported outcome measures (PROMS) following total knee replacement.
        J Bone Joint Surg Br. 2012; 94-B: 1058-1066
        • Ko H.
        • Martin B.I.
        • Nelson R.E.
        • Pelt C.E.
        Patient selection in the comprehensive care for joint replacement model.
        Health Serv Res. 2022; 57: 72-90