Joint Replacement Outcomes a Bit Better With Patient Reports Post-Surgery

Patient-reported outcome measures (PROMs) following knee and hip replacement procedures showed "a small improvement" over usual post-surgery care when patients were asked to submit them regularly for a year after their procedures, researchers found from a randomized trial.

Scores on the 100-point European Quality of Life Visual Analogue Scale (EQ-VAS) were better among hip replacement patients assigned to the electronic PROM reporting system by 2.10 points compared with a control group for whom PROMs were evaluated only at discharge and at month 12 (P=0.004), according to Viktoria Steinbeck, MSc, of Technical University Berlin in Germany, and colleagues.

For patients undergoing knee replacement, a mean 1.24-point improvement in EQ-VAS score was seen with the intervention, which failed to reach statistical significance. However, fatigue scores from the Patient-Reported Outcomes Measurement Information System (PROMIS) were significantly lower (-0.84 points, 95% CI -1.48 to -0.22), the researchers reported in JAMA Network Open.

Other PROMs, including those specific for each type of procedure, also showed patterns of small improvements with the regular patient self-assessments, many of which were statistically significant but of questionable clinical meaning. Steinbeck and colleagues noted that the approach used in the trial could potentially be tweaked to achieve greater gains.

They emphasized that their main goal was to do something about the near-total lack of standardization in how patients' recovery is tracked following joint replacement.

"In many countries, joint replacements are common procedures that lack a standardized postsurgery pathway with regular consultations, bearing the risk of inadvertent postsurgery adverse effects remaining undetected," Steinbeck's group wrote. This is exacerbated in Germany, they added, "where inpatient care and outpatient care are separate care silos, hindering seamless follow-up care" -- a charge that could be leveled at many other countries including the U.S.

It therefore stands to reason that "identifying and responding earlier to suboptimal outcome developments can improve patients' well-being and recovery time," the group continued. They cited oncology as a field that has already embraced proactive PROM collection with proven benefits; whether the same can be achieved in orthopedics, however, remains an open question.

To try to answer it, the researchers enrolled 3,697 patients undergoing hip replacement and 3,110 having knee arthroplasty procedures, all from nine German hospitals. Participants were randomized 1:1 to the PROM intervention or to usual care. The latter has PROMs assessed prior to surgery, at hospital discharge, and at a follow-up exam at month 12. The intervention group also completed these evaluations at months 1, 3, and 6. Patients in this group were given digital versions of each PROM that they completed online. Moreover, these intermediate assessments could trigger alerts to nurses who then could follow up with patients; alerts were sent when a prespecified PROM score threshold was exceeded or if certain measures showed worsening of 10% or more from a previous score. Patients could choose whether to get their inpatient or outpatient physician involved for further evaluation and perhaps treatment.

The trial's primary goal was to assess the strategy's cost-effectiveness; that was not reported in the current study. Rather, it focused on the secondary outcomes of change from baseline in PROM scores and differences in such changes between the intervention and control groups.

Both groups appeared to benefit from their procedures, with improved scores at month 12 relative to baseline. As previously noted, between-group differences in outcomes were quite small. However, alerts were generated for substantial numbers of patients in the intervention group: 25% of those having hip procedures and 32% of knee replacement patients at month 6, for example.

And these alerts appeared clinically useful, with about 40% of hip replacement patients with alerts having their physical therapy program altered. It wasn't clear why that failed to translate to more clearly favorable outcomes with the intervention versus control, but the trial was unblinded and, as Steinbeck and colleagues observed, the mere solicitation of PROMs "can change the way in which patients think about their condition."

Another potential limitation was that study locations could have differed in how they implemented the protocol (for example, study nurses had discretion about whether to call patients after receiving an alert, and in many cases they decided it wasn't necessary).

In general, the researchers concluded, more research is needed on "the ideal time intervals, the timeframe, and effects of the different intervention steps."

Comment