Medical Registry Costs Cut Both Ways

Participating in an orthopedic registry reduces some costs, but the expense associated with building and maintaining the technology a registry requires can be huge.

The orthopedic community got its first glance at a four-year data collection effort that, for the first time, marries the national clinical outcomes of a total joint replacement registry with patients' post-operative functionality.

The American Joint Replacement Registry (AJRR) is the primary orthopedic registry that surgeons have been relying on since 2009. That's when the AJRR began collecting information on hip and knee implant devices, and whether or not the surgery was successful.

The newest orthopedic registry, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) registry, expands the AJRR's definition of success to include the patient's perspective, says David Ayers, MD, chair of the Department of Orthopedics and Physical Rehabilitation at University of Massachusetts Medical School, who is leading the FORCE-TJR registry.

"As long as the implant is in the body, it's considered a success," says Ayers. "We changed that. We can't say that if a joint replacement hasn't been removed then that's a success because what if the patient (still) has incredible pain? We said it needs to be about the patient and not the implant."

The FORCE-TJR registry also measures the same implant information that the AJRR does. In fact, the two registries share information. Hospitals that participate in both the AJRR and FORCE-TJR can streamline the data collection process and submit it once to FORCE-TJR.

"They're not competitive," says Kate Chenok, former executive director of California's Joint Replacement Registry (CJRR), of the AJRR and the FORCE-TJR registry. "They were both started for slightly different reasons. The commonality of all the registries is that they are passionate about patient care."

Multiple joint registries exist besides the AJRR, FORCE-TJR registry, and CJRR. There is a state registry in Michigan, Kaiser Permanente, as well as others that are hospital or practice-specific.

Registry Benefits
It's hard to come up with any drawbacks for these types of registries. They exist in other countries and have driven down medical costs; in other specialties, and registries can offer participating providers with a high-level or microscopic view of comparative clinical outcomes.

For example, the FORCE-TJR registry, which has collected data on 30,000 procedures from organizations in 22 states, found that despite younger patients accounting for more hip and knee replacements, their pain was comparable to what older patients prior to surgery. That's data that destroys assumptions about age.

Ayers says providers can also get practice-to-practice information to compare patients and outcomes, which can prompt changes in protocols that reduce cost and or improve quality.

"It's a very powerful tool because surgeons always want to get better; they always want to improve," says Ayers.

And evidence shows that participating in an orthopedic registry reduces some costs. The CJRR, in its most recent report shows that hospitals that are part of its registry do not have to keep its patients in the hospital as long.

When compared to U.S. average and California averages, the length of stay at a CJRR participating hospital, was shorter for both hip replacements and knee replacements – in some cases by almost two days. The average LOS for a hip replacement in the U.S. was more than four (4.2) days in 2010; in California, it was exactly four days; at a CJRR hospital, it was 2.3 days.

"The benchmarking data that physicians get back isn't information they can get anywhere else," says Chenok. "They're able to see opportunities for improvement."
 
Barriers to Registries
Despite the importance of the data collected, whether it is specific to implants, patients, or both, funding medical registries has historically been a challenge. The infrastructure costs to building and maintaining the technology a registry requires can be huge.

The FORCE-TJR registry is funded by a $12 million grant from the Agency for Healthcare Research and Quality (AHRQ). The CJRR is funded mainly through the California HealthCare Foundation, but also has financial support from business groups, professional associations, and payers.

"There are a lot of competing resources," says Chenok, who says initial reluctance to join because of potential HIPAA violations, has diminished because the patient's identifying information is not shared.

Another potential barrier that the FORCE-TJR registry has overcome is getting responses from patients, for their outcomes. Ayers says it has an 86% response rate from patients in terms of data completeness. FORCE-TJR registry is patient-centric, and has patients sign a release that allows the registry to follow up with them on pain and functionality at 6 months, 1 year, then annually.

"We don't give up," says Ayers. "Spending time at the front end to educate the patients is key; [we] get not only their home telephone, but also their email address, their cell phone number, their best friend's number, their family's number. We don't give up."

Following the patient also alleviates some of the technology fatigue that causes physicians to complain.

Defining Value vs. Cost
The cost of developing and maintaining a medical registry for orthopedics could also be eventually diminished if value-based reimbursement overtook fee-for-service as the primary way physicians get paid.

Most organizations have their feet in both FFS and some value-based contracts, but the movement away from FFS is not strong enough yet for some organizations to invest in another way to track outcomes, value, and pre- and post-operative patient functionality. But, it's coming, says Ayers.

"The data we collect, which directly measures patient outcome and measures quality, is measuring the numerator of the value equation," says Ayers. "If you don't do this, you can't measure value. This is a toolset that most astute practice leaders understand is going to be essential to thrive."