The current literature about revision total knee arthroplasty (rTKA) for aseptic causes is focused mainly on “doctorly” data such as complication rates and implant survivorship. Taking a different tack in the October 21, 2020 issue of JBJS, Siddiqi et al. report findings from a comprehensive evaluation of patient-reported outcome measures (PROMs) at baseline and 1 year following rTKA. The PROMs evaluated included KOOS-Pain, KOOS-Physical Function, KOOS-QOL, and Veterans Rand-12.
Here is a general summary of the findings:
- Patients undergoing aseptic rTKA had overall improvements in pain and function scores at 1 year postoperatively.
- Knee-related QOL improved nearly 30 points, but >50% of patients did not report improvement in their overall global health at 1 year.
- Predictors of improved 1-year pain scores were older age, baseline arthrofibrosis, lower baseline pain, and non-Medicare/Medicaid insurance.
- Predictors of improved 1-year function scores were baseline arthrofibrosis and female sex.
- Larger mean pain-score improvements occurred in patients undergoing rTKA for implant failure and aseptic loosening; pain-score improvements were lower in patients undergoing rTKA for instability.
Although 31% of the 246 eligible patients were lost to follow-up and excluded from the final analysis, the authors say their findings “corroborate the overall quality and, most importantly, the value that aseptic rTKA provides to patients.” Perhaps the findings’ greatest value is their potential application in the shared decision-making process between surgeons and patients pondering an aseptic rTKA, and in helping set realistic patient expectations if the surgery is undertaken.
Physician groups and hospitals have come to rely on electronic patient portals (EPPs) for many things, including appointment scheduling and reminders, delivery of test results, and pre- and post-visit information gathering from patients. Most of the research into the clinical efficacy and cost-effectiveness of EPPs has taken place in primary care and internal medicine settings. But in the August 5, 2020 issue of The Journal of Bone & Joint Surgery, Varady et al. examine the benefits of EPP use among patients undergoing orthopaedic procedures of various types. In the process, they also uncover racial and socioeconomic disparities in the use of EPPs.
The retrospective review of >18,000 patients (average age of 56.9 years) undergoing an orthopaedic procedure at 2 Boston-area academic hospitals found a veritable 50-50 split between those who used the EPP and those who did not. Relative to white patients, African-American and Hispanic patients were significantly less likely to use the EPP. Other demographic factors associated with portal nonuse were non-English speaking, male sex, low income, and having less than a college education.
Multivariable regression analysis demonstrated that, relative to EPP nonuse, EPP use was associated with significantly lower no-show rates, increased odds of completing one or more patient-reported outcome measures (PROMs), and improved overall patient satisfaction. The degree of after-surgery functional improvements measured with PROMs was the same among EPP users and nonusers.
The authors home in on the benefits of the 27% reduction in missed appointments this study divulged. First and foremost, missed appointments have been shown to negatively affect patient outcomes. On the provider side, no-shows increase staff frustration and cost time and money. (The 2 hospitals realized a combined estimated $200,000 in savings over 1 year from the reduction in no-shows.) Consequently, Varady et al. say that “the benefit of reducing missed appointments alone may be sufficiently strong to warrant efforts to increase EPP enrollment.”
Increased efforts among orthopaedic office staff and clinicians to enroll patients in portal usage during their hospital stay or during pre- or postoperative visits could also help address the disparity issue. “These results have important implications for the orthopaedic surgery community in…achieving more equitable care,” the authors conclude.
Patient-reported outcome measures (PROMs) have become increasingly important tools in the 30 years since the orthopaedic community began embracing the movement toward the “patient perspective.” Clinical findings such as range of motion and imaging results remain important, but we have come to understand that pain and function–as reported by the patient–are the most crucial data points. And we are not alone. Insurance companies, registries, scholarly publications, and research review panels now often require PROMs as part of their core evaluations.
But not all PROMs are created equal. For clinicians to trust the output from these instruments, validation of the measures is required. This entails reliability testing and assessment of face, construct, and criterion validity. Furthermore, translating PROMs validated in English into other languages involves not only linguistic translation, but also cultural components in order to capture the full patient perspective.
In the August 5, 2020 issue of The Journal, Bin Sheeha et al. report their work in evaluating the responsiveness, reliability, and validity of the Arabic-language version of the Oxford Knee Score (OKS-Ar). After painstaking statistical analysis of OKS-Ar questionnaires completed by 100 Arabic-speaking patients (80 of whom were female) before and after total knee arthroplasty (TKA), the authors concluded that the OKS-Ar is a valid, sensitive, and easy-to-use instrument to assess pain and function in TKA-treated individuals whose main language is Arabic.
To be truthful, this is not very glamorous research to conduct or very exciting to read about. However, it is absolutely fundamental to ensuring the validity of multicenter, international trials and registry studies. In essence, Bin Sheeha et al. have dug a conduit that facilitates the flow of reliable data and that will help improve future patient care worldwide. As such, it deserves our attention, understanding, and appreciation.
Marc Swiontkowski, MD
Patient-reported outcome measures (PROMs) for orthopaedic procedures have long been used in clinical research. In the last decade, the use of PROMs has expanded to include quality-of-care assessments and, in some healthcare systems, to help calculate costs and reimbursements. All this has made PROMs increasingly visible to patients.
There are several validated and widely used PROMs for hip and knee arthroplasty. One problem with those is that the data from one PROM are not interchangeable with data from another. That disconnect limits the opportunity for meaningful data aggregation and thwarts large-scale population research.
In the June 3, 2020 issue of The Journal, Polascik et al. tackle this problem head-on. They report on a “crosswalk” system that allows back-and-forth conversion between 4 of the most commonly used PROMS—the Oxford hip and knee scores and the HOOS and KOOS short-form scores. The authors developed this tool by applying sophisticated statistical methods to data from a large cohort of hip and knee arthroplasty patients. The accuracy of the 4 crosswalks Polascik et al. developed was substantiated when they found minimal differences between the means of the known and crosswalk-derived scores.
This practical tool for converting scores is a substantial advance in patient-reported outcomes research. It will further facilitate the pooling of data for use in future clinical research, quality-of-care initiatives, and reimbursement systems. Patients, surgeons, researchers, and health systems alike all stand to benefit greatly.
Marc Swiontkowski, MD