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Commentary and Perspective   |    
Joint Arthroplasty: The Climate Has Made It Ripe for Quality Assessment, but How Do We Compare Apples to Apples?Commentary on an article by Gary J. Hooper, FRACS, et al.: “The Relationship Between the American Society of Anesthesiologists Physical Rating and Outcome Following Total Hip and Knee Arthroplasty. An Analysis of the New Zealand Joint Registry”
Edward Y. Cheng, MD
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The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his 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. The author has not had any other relationships, or 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 © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jun 20;94(12):e91 1-2. doi: 10.2106/JBJS.L.00351
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Increasingly, efforts are being directed at measuring quality in the delivery of health care. Given the economic burden of providing health care in the U.S., high-volume procedures are being targeted for assessing the quality and benefits of the intervention. Hip and knee arthroplasty are procedures that are ripe for analysis. A common proxy for quality has been volume. However, true quality measures, unlike volume, are exceedingly difficult to measure because of numerous confounding factors. Therefore, risk adjustment becomes paramount so that valid comparisons can be made, thereby leading to accurate conclusions. However, in the rush to measure quality, risk adjustment frequently falls by the wayside. One major problem in performing risk adjustment has been a dearth of information regarding factors that independently predict outcome. This problem is especially true for hip and knee arthroplasty. For this reason, this article by Hooper and his associates that analyzes preoperative medical status and outcomes following hip or knee arthroplasty could not be timelier.
The paradigm shift of paying for performance is in its infancy. To date, initial attempts to implement this strategy have used adherence to process guidelines (e.g., timing of antibiotic prophylaxis) instead of evidence-based performance measures1. Although it is intuitive that baseline medical status and patient comorbidities would impact procedural outcomes, the data to support this hypothesis have been lacking. The study by Hooper et al. provides some data analyzing the relationship between the American Society of Anesthesiologists (ASA) physical status classification system and three end points (mortality, physical function, and implant survivorship). As expected, patients with a higher complexity of comorbidities (i.e., higher ASA class, independent of age and sex) had higher six-month mortality rates. Somewhat surprisingly, a higher ASA class was found to predict lower Oxford scores. Higher ASA class did correlate with a higher implant revision rate for hips but not for knees. These findings would suggest that worse baseline physical status, a non-surgeon-related factor, is not only related to worse outcomes, but may play a greater role in predicting poorer function than has been traditionally believed. It would be valuable to analyze the ASA class relative to change in function over baseline preoperative score, rather than absolute functional score, as this may be a purer measure of the benefit of arthroplasty; however, the authors did not have these data and could not study this end point.
The choice to study ASA class undoubtedly is related to its availability in the New Zealand Joint Registry. ASA class has been criticized for its mediocre validity2 and other comorbidity indexes may be preferable3, especially when functional outcomes are the end point4. Moreover, comorbidity indexes are a compilation of variables, and individual variables instead of a compilation of variables may be preferable for risk adjustment purposes.
As the push for quality measurement and reporting evolves, orthopaedic surgeons need to be engaged in their development and implementation as pay-for-performance initiatives are rolled out in health policy initiatives. The experience with public reporting of cardiac surgery outcome data has shown that there may be unintended consequences such as risk avoidance behaviors by surgeons and decreased access for minority patients5-7. In order to avoid these inadvertent effects, risk adjustment must be performed and is dependent on the identification of independent factors, both surgeon and non-surgeon-related, that are predictive of functional outcome. The study by Hooper et al. represents a small but important step forward in this effort.
Bozic  KJ;  Chiu  V. Quality measurement and public reporting in total joint arthroplasty. J Arthroplasty.  2008  Sep;23 (  6 Suppl 1):146-9.  Epub 2008 Jun 13.[PubMed][CrossRef]
 
Mak  PH;  Campbell  RC;  Irwin  MG; American Society of Anesthesiologists. The ASA Physical Status Classification: inter-observer consistency. American Society of Anesthesiologists. Anaesth Intensive Care.  2002  Oct;30(  5):633-40.[PubMed]
 
Dunbar  MJ;  Robertsson  O;  Ryd  L. What’s all that noise? The effect of co-morbidity on health outcome questionnaire results after knee arthroplasty. Acta Orthop Scand.  2004  Apr;75(  2):119-26.[PubMed][CrossRef]
 
Groll  DL;  To  T;  Bombardier  C;  Wright  JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol.  2005  Jun;58(  6):595-602.[PubMed][CrossRef]
 
Ryan  AM. Has pay-for-performance decreased access for minority patients?Health Serv Res.  2010  Feb;45(  1):6-23.  Epub 2009 Oct 15.[PubMed][CrossRef]
 
Resnic  FS;  Welt  FG. The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention. J Am Coll Cardiol.  2009  Mar 10;53(  10):825-30.[PubMed][CrossRef]
 
Narins  CR;  Dozier  AM;  Ling  FS;  Zareba  W. The influence of public reporting of outcome data on medical decision making by physicians. Arch Intern Med.  2005  Jan 10;165(  1):83-7.[PubMed][CrossRef]
 

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References

Bozic  KJ;  Chiu  V. Quality measurement and public reporting in total joint arthroplasty. J Arthroplasty.  2008  Sep;23 (  6 Suppl 1):146-9.  Epub 2008 Jun 13.[PubMed][CrossRef]
 
Mak  PH;  Campbell  RC;  Irwin  MG; American Society of Anesthesiologists. The ASA Physical Status Classification: inter-observer consistency. American Society of Anesthesiologists. Anaesth Intensive Care.  2002  Oct;30(  5):633-40.[PubMed]
 
Dunbar  MJ;  Robertsson  O;  Ryd  L. What’s all that noise? The effect of co-morbidity on health outcome questionnaire results after knee arthroplasty. Acta Orthop Scand.  2004  Apr;75(  2):119-26.[PubMed][CrossRef]
 
Groll  DL;  To  T;  Bombardier  C;  Wright  JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol.  2005  Jun;58(  6):595-602.[PubMed][CrossRef]
 
Ryan  AM. Has pay-for-performance decreased access for minority patients?Health Serv Res.  2010  Feb;45(  1):6-23.  Epub 2009 Oct 15.[PubMed][CrossRef]
 
Resnic  FS;  Welt  FG. The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention. J Am Coll Cardiol.  2009  Mar 10;53(  10):825-30.[PubMed][CrossRef]
 
Narins  CR;  Dozier  AM;  Ling  FS;  Zareba  W. The influence of public reporting of outcome data on medical decision making by physicians. Arch Intern Med.  2005  Jan 10;165(  1):83-7.[PubMed][CrossRef]
 
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