Faculty Bibliography

STUDY DESIGN/METHODS:Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. OBJECTIVE:To analyze the effects of the BPCI program on patient outcome metrics and cost data. SUMMARY OF BACKGROUND DATA/BACKGROUND:The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present two years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. METHODS:In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with MCC) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same DRGs from 2009 to 2012 from which the target price was established. RESULTS:350 patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared to the baseline cohort, length of stay decreased (4.58 +/- 2.51 vs 5.13 +/- 3.75; p = 0.009), readmission rate was unchanged, and discharges with HHA increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 +/- 27,028 vs $48,913 +/- 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 +/- 26,347 vs $45,934 +/- 19,638, p = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (p < 0.001), and the percentage of complex spines increased from 23% to 45% (p < 0.001). CONCLUSIONS:Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. LEVEL OF EVIDENCE/METHODS:3.

STUDY DESIGN/METHODS:A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017. OBJECTIVE:To validate the association of PROMIS with NDI in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain. SUMMARY OF BACKGROUND DATA/BACKGROUND:PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain. METHODS:Inclusion criteria were age>18years and a primary complaint of neck pain. The NDI, VAS Back, Neck, Arm and Leg, and PROMIS Physical Function, Pain Intensity, and Pain Interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain while controlling for neck pain. Bivariate correlations and independent samples t-tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS. RESULTS:130 patients were included. NDI correlated strongly to PROMIS Physical Function (r = -0.771, p < 0.001), Pain Intensity (r = 0.605, p < 0.001), and Pain Interference (r = 0.786, p < 0.001). VAS Neck and Arm Pain also correlated to the PROMIS Pain Intensity instrument (VAS Neck: r = 0.642, p < 0.001; VAS Arm: r = 0.376, p < 0.001).Following matching for neck pain, the high and low back pain groups each included 32 patients. There were significant differences in PROMIS Physical Function when high and low back pain groups were compared (39.07 vs 43.68, p = 0.031). No significant difference was found for any outcome metric for high and low arm pain groups. CONCLUSIONS:PROMIS instruments are capable of characterizing pain and disability in patients with neck pain and are sensitive to disability in regions adjacent to the neck. LEVEL OF EVIDENCE/METHODS:3.

OBJECTIVEThe Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden.METHODSA retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores.RESULTSA total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = -0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%).CONCLUSIONSPROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

BACKGROUND:Incorporating patient-reported outcomes (PROs) is paramount to the creation of a value-based healthcare system that prioritizes patient-centered care in total joint arthroplasty. The relationship between global assessment PROs such as Patient-Reported Outcome Measurement Information System (PROMIS) and joint-specific PROs for hip and knee, such as short form variations of Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) and Hip Injury and Osteoarthritis Outcome Score (HOOS-JR), has yet to be assessed. METHODS:A retrospective analysis was conducted to assess PRO measurements for knee-related and hip-related complaints. The KOOS-JR and HOOS-JR were compared to the PROMIS computerized adaptive test (CAT) short forms (physical function, pain interference, and pain intensity) to assess their relationship. RESULTS:A total of 3644 patients completed 4609 questionnaires. A modest to strong correlation was observed between the KOOS-JR and the PROMIS CAT (ranging from r = 0.56 to -0.71, P < .05). A modest to strong correlation was also found between the HOOS-JR and the PROMIS CAT (r = 0.59 to -0.79, P < .05). CONCLUSION/CONCLUSIONS:PROMIS CATs demonstrated a modest to strong correlation with KOOS-JR or HOOS-JR. Future studies should further investigate the limitations of global assessment health surveys in capturing disease-specific changes following total joint arthroplasty.

We integrated and optimized patient-reported outcome measures into the electronic health record to provide quantitative, objective data regarding patients' health status, which is important for patient care, payer contracts, and research. With a multidisciplinary team from information technology, clinical informatics, population health, and physician champions, we used formal human-computer interaction techniques and user-centered design to integrate several technology platforms and computerized adaptive testing for the National Institutes of Health Patient-Reported Outcomes Measurement Information System. The patient-reported outcome measure system leverages software frequently used by health systems and provides data for research and clinical care via a mobile-responsive web application using Symfony, with REDCap for configuring assessments and de-identified data storage. The system incorporates Oracle databases and Epic flowsheets. Patients complete patient-reported outcome measures, with data viewable in MyChart and Epic Synopsis Reports. Researchers can access data portals. The highly usable, successful patient-reported outcome measures platform is acceptable to patients and clinicians and achieved 73 percent overall completion rates.

BACKGROUND:Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation. OBJECTIVE:The purpose of this study was to assess resident perceptions of the purpose and use of the EMR. METHODS:An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY). RESULTS:Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians. CONCLUSIONS:Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.

BACKGROUND:The complication rate of locked plating for proximal humerus fractures remains stubbornly high. The purpose of this study was to determine if a learning curve exists with the operative treatment of proximal humerus fractures. METHODS:We prospectively followed 161 consecutive patients with proximal humerus fractures treated by a single surgeon with locked plates from 2005 to 2016. Radiographic data, functional outcomes, and complications from the surgeon's first 81 patients were compared to the subsequent 80 patients. RESULTS:There was no statistical difference in the rates of complications (p = 0.29) or screw penetration (p = 0.19). There were no differences in DASH scores (p = 0.64 to 0.79) or tip-apex distance (p = 0.40). Head shaft angles were slightly smaller in patients treated earlier in the surgeon's career (p = 0.02). DISCUSSION/CONCLUSIONS:While surgeon experience is certainly a favorable quality, there does not appear to be a significant "learning curve" in the treatment of proximal humerus fractures.

Technologies continue to shape the path of medical treatment. Orthopedic surgeons benefit from becoming more aware of how twenty-first century information technology (IT) can benefit patients. The percentage of orthopedic patients utilizing IT resources is increasing, and new IT tools are becoming utilized. These include disease-specific applications. This article highlights the opportunity for developing IT tools applicable to the growing population of patients with osteoarthritis (OA), and presents a potential solution that can facilitate the way OA education and treatment are delivered, and thereby maximize efficiency for the health care system, the physician, and the patient.

BACKGROUND:The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally reported survey of patients' perspectives of hospital care that is used for hospital comparison and reimbursement. Although the survey attempts to correct for many factors that may affect scoring, socioeconomic factors are not considered in score weighting. The purpose of this study was to analyze the effect of socioeconomic status on HCAHPS scores. PATIENTS AND METHODS/METHODS:HCAHPS scores from 15,789 patients were collected. All patients were seen at a single academic medical center from 2010 to 2014, thus controlling for quality of care. HCAHPS Top Box scores were then compared to patient socioeconomic status based on the median income of the ZIP Code for each patient. RESULTS:Median income was negatively associated with patients' overall hospital rating (p < 0.001) and willingness to recommend hospital (p < 0.001). When controlling for the current adjustment factors (age, education, primary language, health status, and emergency admission), living in a ZIP Code with a median household income above $100,000 per year was independently associated with worse Top Box Scores for the categories of "Overall Hospital Rating" (p = 0.042), "Recommend Hospital" (p = 0.007), "Pain Management" (0.048), "Communication about Medicine" (p = 0.007), "Cleanliness of Hospital Environment" (p = 0.002), and "Quietness of Hospital Environment" (p < 0.001). CONCLUSION/CONCLUSIONS:Socioeconomic status independently affects HCAHPS scores. Patients living in ZIP Codes with lower median incomes generally rated hospitals better than patients with higher incomes. Therefore, treatment of a disproportionate number of low income patients cannot be cited as a pretext for poor HCAHPS scores.