➢ The health-care quality landscape in the United States is rapidly changing due to sweeping health-care reform legislation and increased value-driven cost-control pressures on payers and providers.
➢ Quality of care will increasingly affect payment for health-care services by both governmental and private payers.
➢ Many potential pitfalls and challenges exist in developing methodologies to measure and report quality, specifically in orthopaedic surgery.
➢ The orthopaedic profession should strive to be at the forefront of these changes in health-care quality, in order to ensure that meaningful, fair, and transparent measures are used to improve the safety and efficacy of musculoskeletal care.
Passage of the Patient Protection and Affordable Care Act in 2010 mandated sweeping changes to the United States health-care system1. The Patient Protection and Affordable Care Act has vastly expanded the government’s involvement in tracking and reporting quality measures for physicians and hospitals, creating a dizzying array of stakeholders in this complex policy arena (Fig. 1). Quality measures are now increasingly tied to reimbursement, potentially redefining payment models for physicians and hospitals across the country. Medicare alone will base 9% of hospital payments on performance by 20172.
Quality measurement has caused confusion and consternation in the health-care community, in large part because stakeholders have many different definitions of quality. As this paper will show, the term “quality” is used in various contexts to refer to process compliance, low infection or mortality rates, patient satisfaction, or high scores on validated outcomes surveys. Moreover, quality as currently measured often has little or no connection to value, defined as outcome achieved for a given cost3. In seeking to build a health-care system that is more efficient and delivers better outcomes for patients, the concept of value should be at the center of efforts to define and measure quality.
Health-care stakeholders are far from reaching a consensus on the development, implementation, and reporting of quality measures or on defining their impact on modern health care. Orthopaedic surgery is likely to garner substantial focus in these debates because of the increasing volume and expense of musculoskeletal procedures4. Musculoskeletal procedures account for 36% of Medicare surgical discharges, and total joint replacements are the highest short-stay inpatient cost for Medicare5,6. Orthopaedic surgeons need to be highly informed to actively guide the development of fair and useful quality metrics for musculoskeletal care.
This article presents an overview of the key public and private stakeholders guiding the measurement and reporting of health-care quality, with particular emphasis on efforts related to orthopaedic surgery.
Physician Quality Reporting System (PQRS)
The PQRS (initially known as the Physician Quality Reporting Initiative, or PQRI) was created by the Centers for Medicare & Medicaid Services (CMS) in 2007. Physicians voluntarily report data on process measures for covered services furnished to Medicare Part B fee-for-service beneficiaries. For 2013, CMS published 328 different measures that physicians could choose to report; these can be selected and reported individually or, alternatively, measures groups based on common medical problems can be chosen. The measures group most pertinent to orthopaedics at this time is perioperative care, focusing on the appropriate use of prophylactic antibiotics and the prevention of venous thromboembolism7,8. The bonus payments were as high as 2% in 2009, but under the Patient Protection and Affordable Care Act they are gradually being reduced and will soon become payment penalties with reductions of 1.5% below the fee schedule in 2015 and 2% in 2016 for nonreporting physicians (Table I)9. The CMS generates annual Quality and Resource Use Reports as feedback for physicians, and those doctors meeting reporting requirements are publicly listed on the CMS Physician Compare web site10. CMS has proposed expanding this public reporting on Physician Compare in 2014 to include actual doctor-specific PQRS performance data11. Participation in the Maintenance of Certification program provides the opportunity for an additional annual incentive of 0.5% by maintaining board certification12.
Hospital Value-Based Purchasing Program
The Patient Protection and Affordable Care Act mandated that CMS create the Hospital Value-Based Purchasing Program, incorporating financial incentives for hospital compliance and performance beyond the hospital-acquired condition penalties described below. This program commenced in fiscal year 2013. In its first year, the Value-Based Purchasing Program effectively reduced all Medicare payments to hospitals by 1%. Hospitals can recapture a portion of that 1% on the basis of two types of outcomes: compliance with reporting process measures (70% of score), and performance on patient-experience surveys (30% of score). The score is calculated on a previous baseline period and is awarded annually. In 2014, the program will not only include compliance reporting and patient experience but also mortality outcomes, with a potential maximum reduction of 1.25%. The Value-Based Purchasing Program is projected to expand, with as much as 3% of Medicare payments being based on performance, patient-experience, outcomes, and efficiency metrics. Results are also published on the CMS Hospital Compare web site. Relevant to orthopaedics, the percentages of patients receiving appropriate perioperative antibiotics and deep vein thrombosis prophylaxis are reported13.
Patient experience is assessed with use of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a validated, thirty-two-item questionnaire that measures patients’ perceptions of their hospital experiences (Table II)14. The Deficit Reduction Act of 2005 mandated that hospitals collect and submit HCAHPS data in order to receive their full annual payment update; failure to make a public report results in an annual payment penalty of up to 2%15.
Physician Value-Based Payment Modifier
Similar to the Hospital Value-Based Purchasing Program, physicians will also see value-based payment modifiers enacted beginning in fiscal year 2015 based on PQRS data from 2013. For the first two years, only groups of 100 or more doctors will be included, but after 2017, all physicians accepting fee-for-service Medicare will be affected. Practice-specific PQRS data, as reported in the Quality and Resource Use Reports, will be used to calculate payment modifiers. In the initial phase, groups choosing to not report will be assessed a 1% penalty. Groups that do participate can choose a quality-tiered track that could potentially yield either bonuses or penalties on the basis of performance relative to the national mean. Alternatively, a no-risk track without penalties or bonuses can be selected by participating groups16.
Paralleling the use of the HCAHPS survey in the Hospital Value-Based Purchasing Program, the PQRS now includes a similar patient experience survey known as the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS). These survey results will begin to be published on the Physician Compare web site in 2014, and groups of at least twenty-five physicians can elect to have their 2014 CG-CAHPS scores included in their value-based payment modifier for 2016. The CMS has not specifically stated if CG-CAHPS scores will be a mandatory component for payment modifiers, but this remains a possibility11.
The Surgical Care Improvement Project
The Surgical Care Improvement Project was established in 2003 to create process measures for decreasing surgical complications and morbidity in hospitals. The CMS and the Centers for Disease Control and Prevention (CDC) combined efforts to create a public-private partnership that now includes eight other major national organizations, including the American College of Surgeons (ACS), the American Hospital Association, the Veterans Affairs (VA), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now known as The Joint Commission)17. The Surgical Care Improvement Project measures focus on preventing perioperative surgical site infections, venous thromboembolism, cardiac events, and respiratory complications (Table III)18. Specific evidence-based guidelines in each of these categories are published and promoted by the Surgical Care Improvement Project collaborative19. Currently there is a 2% reduction in the CMS annual payment update if hospitals fail to successfully report their Surgical Care Improvement Project measures. Additionally, the Surgical Care Improvement Project is now part of the hospital Value-Based Purchasing Program, affecting pay for performance. Compliance data are publicly reported on the CMS Hospital Compare web site20.
The Surgical Care Improvement Project has been one of the more successful large-scale implementations of process-improvement programs in terms of improving compliance with hospital process measures, but research investigating the outcomes of these measures has raised a question regarding the correlation between compliance with Surgical Care Improvement Project measures and improved patient outcomes21-23. When Surgical Care Improvement Project measures were followed, several individual hospitals showed improvement in the occurrence of perioperative surgical site infections in small patient samples and with low initial guideline compliance24,25. However, a number of recent large, multicenter studies have shown no orrelation of guideline compliance to reduced rates of perioperative surgical site infections20,21. In the orthopaedic literature, Wang et al. reviewed 17,714 total hip arthroplasties at 128 state hospitals in New York during 2008, when hospitals were first at risk of losing payments from CMS if there were reasonably preventable events (such as perioperative surgical site infections and venous thromboembolism) after arthroplasty26. Hospital compliance with Surgical Care Improvement Project guidelines increased from 93% to 96% for the measure of infection prevention and from 91% to 97% for the measure of preventing venous thromboembolism. Increased compliance with the infection prevention guidelines of the Surgical Care Improvement Project did not lead to reductions in infection outcomes following hip replacement. In fact, increased compliance with venous thromboembolism prophylaxis was associated with a higher risk of surgical site infection, an effect possibly caused by an increased risk of postoperative hematoma formation associated with aggressive venous thromboembolism prophylaxis, thereby heightening the risk of perioperative surgical site infection. This study provides an example of how measuring compliance with process measures may not improve the value of care delivered to patients.
The Deficit Reduction Act of 2005 required a quality adjustment in Medicare payments for certain hospital-acquired conditions. As of 2013, there are fourteen categories of complications for which treatment will not be reimbursed by the CMS if the complications occur during hospitalization27. Particularly relevant to orthopaedic care on this list are perioperative surgical site infections, retained foreign bodies, falls, pressure ulcers, urinary tract infections, and venous thromboembolism or pulmonary embolism after orthopaedic procedures. While some of these complications are also listed by the National Quality Forum (see below) as serious reportable events, or “never events,” other complications, such as venous thromboembolism and hospital falls, have less evidence supporting their unavoidability28,29.
Agency for Healthcare Research and Quality (AHRQ)
The AHRQ administers the National Guideline Clearinghouse, a public web-based listing of evidence-based clinical practice guidelines. Guidelines can be submitted for inclusion by a number of organizations, including governmental agencies and medical associations. More than 220 orthopaedic guidelines appear, covering diagnosis and management of a wide array of musculoskeletal conditions30. Current criteria for inclusion in the National Guideline Clearinghouse are relatively lax; however, beginning in June 2014 the inclusion criteria will be made more selective on the basis of the Institute of Medicine’s 2011 report, Clinical Practice Guidelines We Can Trust. New guidelines must then be based on systematic evidence review and must contain risk-to-benefit assessments of recommended treatments31.
The AHRQ also created quality indicators that hospitals can track using commonly collected inpatient administrative data to identify adverse events and assess complications. Existing orthopaedic quality indicators track the mortality associated with hip replacement and hip fracture32.
National Quality Forum
The National Quality Forum is a private, nonprofit consortium that is a central stakeholder in national health-care quality efforts, often functioning as the bridge between the governmental and private spheres. Membership includes the American Academy of Orthopaedic Surgeons (AAOS) and other physician organizations, nursing organizations, allied health organizations, and hospital systems. Currently, the National Quality Forum web site lists more than 600 endorsed quality standards33. Endorsement requires a nine-step Consensus Development Process, integrating the input of member organizations as well as the general public34.
The National Quality Forum has been central to several major developments in the health-care quality arena in recent years. One accomplishment has been to publish the report “Safe Practices for Better Healthcare,” last updated in 2010. This is a collection of thirty-four measures that provide a broad framework for improving outcomes and patient safety and that are applicable in nearly any hospital (Table IV). These measures have been viewed as a benchmark and are often integrated into industry quality-measurement algorithms35.
The National Quality Forum is a core member of the National Priorities Partnership, a collaboration of fifty-two major national organizations whose shared objective is the creation and implementation of a unified National Quality Strategy, as mandated by the Patient Protection and Affordable Care Act. The National Priorities Partnership provides regular consensus input to the Department of Health and Human Services regarding the National Quality Strategy36. Other members of the National Priorities Partnership include the American Medical Association, the American Nurses Association, the Leapfrog Group, the Pacific Business Group on Health, and The Joint Commission. Ex-officio governmental members include the AHRQ, the CDC, the CMS, the National Institutes of Health (NIH), the U.S. Food and Drug Administration, and the Veterans Health Administration37.
The National Quality Forum has been contracted by the U.S. Department of Health & Human Services (HHS) to convene the Measure Applications Partnership, a large-scale public-private effort to advise the U.S. government regarding performance measures that are most suitable for pay-for-performance programs and public health-care quality reporting. The goal is to create alignment in quality measurement and reporting between the public and private sectors. Within the Measure Applications Partnership, there are both hospital and physician workgroups that advise the coordinating committee of the Measure Applications Partnership, which in turn reports to HHS38. Playing a central role in shaping federal quality measurement programs, the Measure Applications Partnership has already reviewed more than 500 measures submitted by HHS, and it has provided extensive recommendations on how to better design the federal quality programs39.
The National Surgical Quality Improvement Project (NSQIP) of the American College of Surgeons (ACS)
The NSQIP began in the Veterans Health Administration hospitals in 1991 as an effort to track and improve mortality rates in surgical patients. After the program achieved a nearly 50% reduction in mortality, non-Veterans Health Administration hospitals became increasingly interested in adopting the program, and pilot efforts were initiated in 1999. In 2001, the ACS, with funding from the AHRQ, began to package the NSQIP program as a surgical quality improvement tool for use by private hospitals40.
Now known as the ACS NSQIP, the program oversees collection of perioperative data on randomly assigned patients, and complications through the thirtieth day after surgery are also monitored in a highly standardized abstraction and validation process. A procedure-targeted program has seen the expansion of this general surgery-based program to include all surgical subspecialties, including orthopaedics. Also, a pediatric-focused NSQIP has shown success in a pilot program and likely will be expanded in the near future41. A recent study involving 118 ACS NSQIP hospitals concluded that the program helped each hospital prevent between 250 and 500 complications per year. Using risk adjustment, 66% of participating hospitals recorded an improvement in mortality levels40. As of 2013, NSQIP offers voluntary public reporting of hospital outcomes on the CMS Hospital Compare web site.
The NSQIP and the Surgical Care Improvement Project were outgrowths of similar efforts for quality improvement within the federal government in the 1990s and 2000s. It should be emphasized that NSQIP now functions as a data-gathering and reporting tool for hospitals, while the Surgical Care Improvement Project publishes practice guidelines and monitors the adherence of hospitals to these protocols. In their effort to combine data from both of these programs, Ingraham et al. used the NSQIP database and found that only one of the sixteen Surgical Care Improvement Project infection guidelines was associated with a significant reduction in perioperative surgical site infections. This suggests that adherence to and enforcement of the Surgical Care Improvement Project guidelines may not be accounting for real reductions in perioperative surgical site infections23.
The National Database of the Society of Thoracic Surgeons
In 1989, the Society of Thoracic Surgeons established a database (called the STS database) to improve quality and patient safety in cardiothoracic surgery. This effort is considered to be a successful example of a self-reported nationwide outcomes database operated by a physician association. Nearly 95% of U.S. adult cardiac surgery centers now report to the database. Moreover, the CMS has allowed contribution to the STS database to qualify as PQRS participation42. Recent external audits of the STS database have validated the accuracy and completeness of reporting by participating surgeons, further strengthening the credibility of the program43.
Since 2011, hospitals participating in the STS database have had the option of publishing their outcomes for the general public. In addition, since the year 2009, the Society of Thoracic Surgeons has partnered with Consumer Reports for the purpose of featuring outcomes data within the magazine and on that publication’s web site. The program has also proven to be a powerful tool for research, as more than 100 peer-reviewed articles in which the database was used have been published44.
In 2008, the American Association of Neurological Surgeons established the NeuroPoint Alliance to create a national clinical outcomes database for neurosurgery. Several other neurosurgical associations have now joined this partnership, and the National Neurosurgery Quality and Outcomes Database (N2QOD) has been established. As of 2013, lumbar and cervical surgery modules are online, and additional programs for spine deformity, cerebrovascular, and tumor surgeries are being developed. Data will be gathered for the thirty-day perioperative period as well as at three and twelve months after surgery. Goals for the project include establishing national morbidity and mortality benchmarks, stimulating continuous quality improvement, and producing quality and comparative effectiveness data to support claims made to insurers45.
UnitedHealth Premium Designation
UnitedHealth Group is the largest health insurer in the U.S., and it grants a “Premium” designation to certain physicians within their network. A physician can earn up to two “stars,” the initial one for quality of care and another for cost-effective care, with the goal of influencing patients’ selection of higher-performing in-network physicians46.
National Quality Forum-endorsed standards are used as benchmarks to evaluate claims-based data and generate the quality score, which is risk-adjusted based on illness severity. More than twenty orthopaedic procedures are tracked with use of specific outcomes measures. The cost-effective care designation takes into account not only a physician’s direct fee for providing a service, but also the facility and ancillary costs associated with the treatment they provide for an episode of care. In order to achieve the cost-effectiveness star, a physician must meet or exceed the median cost-effectiveness compared with other same-specialty doctors within the region47. By coupling these two designations for quality and cost-efficiency, the UnitedHealth model aims to improve health-care value. In addition to UnitedHealth, other large health plans and health-care purchasers have similar specialty-specific quality recognition programs; orthopaedic surgeons should investigate whether their primary payers have these designations, which can improve referrals and reimbursements48.
Pacific Business Group on Health
Founded in 1989, the Pacific Business Group on Health, a driving force in the health-care quality landscape, consists of sixty large health-care payers who have at least 2000 beneficiaries in California. Members are large national employers, including Boeing, Chevron, and General Electric49. The California Healthcare Performance Information system debuted in 2012 as a partnership of the Pacific Business Group on Health and three large insurers to create the largest health-care outcomes database in California. Data from private payers and Medicare are aggregated, generating quality data on the care of 10 million patients. Performance reports on approximately 10,000 California physicians are now available, and hospital rankings are also being published50. Patients and payers alike are able to take advantage of these rankings to select high-performing providers. The California Healthcare Performance Information system also conducts annual patient-assessment surveys regarding the quality of care given by physicians, and the resulting scores are used to determine performance-based physician payments. For specialist physicians, patients complete a four-page survey including ratings of wait time and availability, office staff, care coordination, health maintenance, and emotional health51. The Pacific Business Group on Health is also a key stakeholder in the California Joint Replacement Registry (CJRR), which seeks to be a model for tracking and improving patient outcomes following lower-extremity total joint arthroplasty procedures.
The Leapfrog Group
In 2000, The Leapfrog Group was formed as a consortium of large employers seeking to use their combined purchasing power to improve health-care quality and value, primarily by focusing on hospital safety. Today, Leapfrog members provide health insurance to 34 million Americans. Leapfrog advocates for four key quality improvements in hospitals: computerized physician order entry, evidence-based hospital referral for consumers, intensive care unit staffing by intensivist physicians, and scoring of hospitals based on adherence to the National Quality Forum’s Safe Practices52.
The core initiative of The Leapfrog Group has been the Leapfrog Hospital Survey, a voluntary survey that hospitals can choose to complete in order to receive a quality designation from Leapfrog. The survey evaluates the performance of each hospital on the key improvements listed above, as well as compliance with ten of the thirty-four National Quality Forum Safe Practices. In addition, four high-risk surgical procedures are surveyed (none of which are orthopaedic)53. The survey results are readily available to the public on the Leapfrog web site; more than 1200 hospitals complete the survey. Recently, the usefulness of the Leapfrog survey has been questioned by the Association of American Medical Colleges due to its voluntary and nonvalidated nature; the indicators are not true quality metrics but rather process measures that may no longer be evidence-based.
Leapfrog also generates the Hospital Safety Score. This score utilizes twenty-eight publicly available measurements of hospital safety and performance to grade more than 2600 hospitals in the U.S. Within the Hospital Safety Score, there are seven metrics that apply to orthopaedic procedures54: (1) appropriate perioperative antibiotics, (2) timely urinary catheter removal, (3) appropriate prophylaxis against venous thromboembolism, (4) falls and trauma, (5) death among surgical inpatients, (6) postoperative deep vein thrombosis or pulmonary embolism, and (7) postoperative wound dehiscence.
Consumer Reports, long known for publishing information on manufactured product quality, has begun rating hospitals. They currently provide scores for more than 4000 U.S. hospitals. Publicly reported data from CMS and state health regulators as well as the American Hospital Association are used as the basis for the scores. Orthopaedic procedures factor prominently into these rankings; high-volume index surgical procedures include hip replacement, knee replacement, and back surgery55.
Consumer Reports is seeking to expand its reporting of physician-specific data, and its partnership with the Society of Thoracic Surgeons described above is the current paradigm. Consumer Reports has also published scores for physicians in Massachusetts, Minnesota, and Wisconsin on a range of quality metrics56-58. Focus thus far has been on cardiac, diabetes, geriatric, and preventative care, but publishing surgical data remains as a stated goal.
U.S. News & World Report
U.S. News & World Report annually issues rankings of the top hospitals for sixteen medical specialties, including orthopaedic surgery. Whereas 4800 hospitals were assessed in 2013, only 147 hospitals ranked in even one specialty. To qualify, hospitals must meet volume thresholds that vary by specialty; for orthopaedics, a hospital needs a minimum of 320 annual admissions. Hospitals then receive a four-part score based on reputation (32.5%), mortality rate (32.5%), care-related indicators such as nursing staff (30%), and patient safety (5%)59. Other private-sector quality measurement systems discussed in this report do not emphasize reputation; moreover, the source data for U.S. News & World Report are administrative, nonclinically validated data, which are at least two years old when the scores are released.
Quality Roadmap for Orthopaedic Surgery
Measuring and reporting treatment outcomes are rapidly becoming major focal points for health plans, health-care purchasers, and government regulatory bodies—a policy change that has been accomplished largely without direct physician involvement. Efforts thus far have often been a so-called one size fits all approach to measuring quality, engendering considerable and often justifiable frustration within medical professional associations. Some of these so-called quality metrics do not provide accurate and equitable assessments of quality, particularly with regard to individual physicians. Due to the substantial inconsistency surrounding the calculation and reporting of quality data, the meaningfulness of the data is often confusing to both physicians and patients. Moreover, many of the current quality-reporting programs, particularly those focused on compliance with process measures, are of questionable usefulness in improving the value of care60,61. More research is needed to evaluate the true effect of the major quality reporting efforts on the overall value of care delivered.
Orthopaedic surgeons have a unique opportunity to define clinically relevant, actionable quality measures in their field (Table V). First and foremost, physicians must take ownership of the entire process and be leaders whose objective is maximizing the value of care delivered3,62. Orthopaedics is well positioned to be at the forefront of the medical community in providing value-driven, evidence-based care; musculoskeletal treatments are some of the most successful in restoring function and quality of life to patients.
Since 2007, the AAOS has developed evidence-based clinical practice guidelines that synthesize existing research into recommendations based on the strength and quality of the evidence. Clinical practice guidelines are a critical step forward in evidence-based care; the most recent guidelines developed by the AAOS incorporated the findings of more than 200 high-level research studies. AAOS clinical practice guidelines meet the eight standards of the Institute of Medicine as stated in their guidelines, “Clinical Practice Guidelines We Can Trust” (Table VI)63. However, clinical practice guidelines are not without disadvantages, including the time and expense required to develop them, the limited number of specific medical conditions that can be addressed, and controversy over how clinical practice guidelines should be applied in everyday practice64. In addition, more high-quality research that addresses clinically relevant problems is needed to inform new and updated guidelines.
The AAOS has also published appropriate use criteria for specific orthopaedic treatments, such as rotator cuff repair, distal radial fracture fixation, and nonarthroplasty management of osteoarthritis of the knee65. Whereas clinical practice guidelines summarize the effectiveness of various treatments for a specific clinical problem (such as knee osteoarthritis), appropriate use criteria use the existing literature and expert opinion to guide surgeons as to which patients would most benefit from a given treatment. Downsides of appropriate use criteria are similar to clinical practice guidelines and may include lack of applicability to less common clinical scenarios and the fact that expert opinion can play a prominent role in their development. Both clinical practice guidelines and appropriate use criteria suffer from difficulties in practical implementation, as well as appropriate measurement of the effects of their utilization on the overall quality of care that is delivered.
Orthopaedic surgeons must also accelerate development and use of patient-reported outcomes tools for common musculoskeletal conditions4. Government and private payers are more likely to welcome the input of the orthopaedic profession if validated and clinically useful patient-reported outcomes instruments are brought to the table. Orthopaedic specialty societies face a challenge in focusing and narrowing the breadth of available patient-reported outcomes from the large array available. The NIH has developed the Patient-Reported Outcomes Measurement Information System (PROMIS) as an instrument that is applicable across medical specialties and chronic conditions. Recently, investigators have begun to adopt PROMIS for orthopaedic patients, taking advantage of the huge investment already made by the NIH66-68. In addition to the NIH-sponsored development of PROMIS, the Patient Protection and Affordable Care Act established the Patient-Centered Outcomes Research Institute, which is providing more than $400 million in grants to help fund the development of new quality metrics2,69.
The Patient-Centered Outcomes Research Institute has also accelerated adoption of electronic health records through financial incentives for hospitals and medical practices. As information technology platforms include the capability to collect and analyze outcomes data, implementation of packaged programs such as the ACS NSQIP, the AHRQ Quality Indicators, or Bridges to Excellence70 can help a hospital or practice begin a quality tracking effort. In addition, efforts such as the American Joint Replacement Registry allow electronic submission of quality data; the American Joint Replacement Registry can be a foundation for quality measurement and improvement in the field of total joint arthroplasty. Finally, the AAOS should consider following the model established by the cardiothoracic surgeons and neurosurgeons for using registries to measure and improve quality in orthopaedic surgery.
Importantly, orthopaedic surgery professional associations, including the AAOS and subspecialty societies, should seek active roles in influencing quality reporting policy at the federal level4. Constant dialog and advocacy with the CMS are necessary to make improvements in measures reported to the PQRS, which will play an increasingly important role in determining physician payment and public reporting of outcomes. Alliances should be sought and nurtured with strategic partners, like the National Quality Forum, the National Priorities Partnership, the Measure Applications Partnership, and private payers.
The health-care quality landscape is complex, rapidly changing, and daunting. A greatly expanded federal influence increases the possibility of further reductions in reimbursements along with increased administrative burdens for physicians. Development of clinical practice guidelines, appropriate use criteria, quality measures, reporting systems, and advocacy agendas will require significant effort and expense. However, they provide a unique opportunity for orthopaedic surgeons to lead efforts that improve the quality and efficiency of the care we provide to our patients.
Source of Funding: None.
Investigation performed at Washington University, St. Louis, Missouri, and Ohio State University, Columbus, Ohio
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated