David Ayers and Patricia Franklin on Quality in Joint Replacement

This article originally appeared in Pathways, a magazine published for physicians and the community by UMass Memorial Medical Center.

Practice makes perfect. This is the conclusion of an estimated two dozen studies published in peer-reviewed literature over the past decade documenting an association between hospital and surgeon procedure volume, and complication rates in total joint replacement. The bottom line: Patients treated at hospitals and by surgeons with greater volumes of total joint replacements have lower rates of mortality and complications than patients treated at lower-volume centers.

Further, when it comes to total knee replacement, a 2003 National Institutes of Health
Consensus Development Conference statement affirms these findings, saying, "One of the clearest associations with better outcomes appears to be the procedure volume of the individual surgeon and the procedure volume of the hospital."

The UMass Memorial Arthritis and Joint Replacement Center performs more than 1,100 total joint replacements annually, putting it in the top tenth percentile of joint replacement centers in the United States in terms of procedure volume. And, like other high-volume centers, UMass Memorial can point to an extremely low rate of complications among its total joint replacement patients.

"But there is a difference between complication rates and functional outcomes," pointed out David Ayers, MD, chair of orthopedics and rehabilitation at UMass Memorial. Dr. Ayers knows whereof he speaks: he and colleague Patricia Franklin, MD, MPH, MBA, director of clinical research for orthopedics, are leading experts on outcomes in joint replacement, in demand as speakers at national and regional conferences, and widely published on the topic.

"A complication is an untoward event or bad occurrence," he added. "We're looking to measure how patients function after surgery, and how much their pain level has improved."

"After all, improved function and pain relief are the reasons patients choose joint replacement," continued Dr. Franklin. "Surgeons have always asked their patients how they're doing after surgery, but we've never had an objective way to trend this data and use it to more fully inform clinical decision-making. Until now."

Earlier this year, UMass Memorial launched a Patient Decision Center, which gathers and tracks data on patients pain levels and functional status prior to and for three years after joint replacement surgery. What distinguishes this initiative is that patients themselves provide the data using a standardized, self-administered questionnaire.

"We use the patient's time in the waiting room to do the assessment," said Dr. Franklin, who explained that the user-friendly, computer-based questionnaire takes only five to seven minutes to complete, and has already been integrated into the workflow in the Arthritis and Joint Replacement Center. The assessment is scored immediately, printed out and given to the patient to review along with his or her surgeon during the scheduled office visit.
"It's similar to a blood glucose test given to patients with diabetes before their doctor appointment," she continued. "But with these scores, patients can see if their pain level and physical functioning are trending up or down, and it can provide objective information with which to frame discussions about self-care, activity levels and other treatment options.

"The ultimate goal is to deliver more evidence-based care recommendations for patients as well as referring physicians," Dr. Franklin added. "For example, when is the right time to refer a patient for joint replacement surgery? Our vision is to have patients do a preassessment with their referring physician. This would enable doctors to say to their patients, ‘Patients with your pain level and functional scores have seen these outcomes from surgery.' And with ongoing measurement, patients themselves can see how they're doing over time."

"This initiative also tracks a patient's mental and physical well-being," Dr. Ayers noted.
"We know from previous research that patients with heightened anxiety levels before joint replacement surgery have more difficulty recovering from the procedure. Their anxiety contributes to fear of stepping on their leg or fully participating in physical therapy and, as a result, this patient group is at risk for lower functional outcomes.

"We've learned - and have helped surgeons understand - that these patients need more comprehensive pre-op education, and postsurgical physical therapy and support," he added. "This is an example of how our research can change the way patients are treated to improve outcomes."

It is also an integral component of the comprehensive resources offered at the UMass Memorial Arthritis and Joint Replacement Center.

"Regardless of how simple or how serious a patient's condition, we offer the full spectrum of care," Dr. Ayers pointed out. "Here we have all types of specialists under one roof - orthopedic surgeons, rheumatologists, physiatrists, nutritionists, physical therapists - so the referring physician doesn't have to make an ‘orthopedist or rheumatologist' decision.

"At the same time, the care is focused on the patient," he continued. "This is evidenced by our investment in state-of-the-art technology and its application to outcomes research. The access to this technology is an undeniable advantage of being an academic institution," he added.

Another key advantage is the access it affords patients to cutting-edge clinical protocols, such as a prospective randomized study now underway at UMass Medical School that compares hip replacements made of tantalum - a newer, FDA-approved metal – to titanium, the current gold standard. Early access to technologic advances in orthopedics, such as gender-specific knee replacement joints (see sidebar) and radiostereometric analysis (RSA), an x-ray modality that gives patients individualized feedback on how their joint replacement is functioning in vivo, are other examples of the depth and breadth of resources available at UMass Memorial.

"Four years ago, UMass Memorial was performing fewer than 400 total joint replacements a year," Dr. Ayer noted. "But since then (which, coincidentally, was when
Dr. Ayers came on board and spearheaded the opening of the Arthritis and Joint
Replacement Center), the program has experienced enormous success, bringing a resource to the Central New England community that didn't exist before.

"Our typical patient is performing on par with the best outcomes at the best joint replacement centers in the United States," he continued. "Going forward, patients will be defining their own outcomes." And he is confident that they will continue to be at the upper end of the national spectrum.