Editorial Comment: Symposium: ABJS Carl T. Brighton Workshop on Outcome Measures

Abstract

Why should we be interested in outcome measures in 2013? In 1934, E. A. Codman MD gave us his “End Result Idea,” which was “The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future.” [2]. For orthopaedic surgeons, early outcome measures mostly derived from the physician’s input. However, a patient’s definition of success can be drastically different than a physician’s definition [1]. Today, interest in measuring outcomes has expanded from the confines of the patient/physician relationship to include many other stakeholders in the healthcare arena, including policy makers, prospective patients, other clinicians, payors, device and drug makers, and researchers. Guest edited by Drs. Philip C. Noble (Fig. 1) and Michael J. Grecula (Fig. 2), this symposium brought together multiple stakeholders in healthcare to present and debate the issues and potential solutions concerning the current state of outcome measures in orthopaedics. Based on the ABJS Carl T. Brighton Workshop of the same topic, the workshop addressed each issue from the perspective of three questions: (1) Where are we now? (2) Where do we need to go? (3) How do we get there? Fig. 1 Dr. Philip C. Noble Fig. 2 Dr. Michael J. Grecula One of the central challenges in orthopaedic care is how to overcome the extra burden of collecting outcome measures, while still reaping the benefits of the collected data. To many surgeons, the collection of outcomes data is a useful way of benchmarking how a patient is functioning in general terms and for documenting progress in recovery. Few would dispute that this information could provide much greater relevance to patient care if it were available prospectively, in a fashion that could inform clinical decisions relating to individual patients. However, in most clinical settings, such a system remains the work of science fiction, due to problems related to implementation and expense. As we move forward to embrace the adoption of outcomes assessment in orthopaedics, several fundamental questions must be kept at the forefront. First, what do existing outcome instruments really measure, and to what extent are those measurements aligned with the expectations of all stakeholders? Second, to what extent should outcome measures be based on the patient’s quality of life and satisfaction with outcome versus their functional ability? These questions were tackled by several of our contributors. A final issue confronting the application of outcomes in orthopaedic practice is the tension between the interests of individual patients and those of healthcare payors. This symposium emphasizes the need for outcomes data assessing the clinical effectiveness of interventions competing for limited resources, and measuring the value of the interventions that we provide. Administrative and funding agencies seek to capture the outcome of medical intervention using the simplest of metrics, including some that are only process measures. In orthopaedics, a number of decisions relating to treatments and clinical pathways have been formulated in the absence of high quality data with limited attention to the confounding effects of risk factors and comorbidities. Although policies formulated on the basis of this limited information may approximate the needs of whole populations, the detrimental effects at the clinical level can be substantial. In clinical practice, decisions must be made, and evaluated, one patient at a time. If outcomes data are to be of prognostic value in the clinical setting, treatment recommendations must have sufficient granularity to incorporate the effects of modifying factors as they relate to each individual patient. Just as the accuracy of outcome-based decisions is likely to critically affect the acceptance of outcomes in clinical orthopaedics in the years ahead, the same dilemma may influence the future of orthopedic registries. This issue is the driving force of a study in our symposium that combines administrative data with patient-reported outcomes collected directly from patients. As the provisions of the Patient Protection and Affordable Care Act have authorized the creation of the Patient Centered Outcomes Research Institute, the amalgamation of the outcomes and registries movements may come sooner than anticipated. Therefore, it is time for the orthopaedic community to take charge and become involved in solving issues related to the validity and reliability of patient-centered outcome measures, making them clinically useful with a minimum burden to both patients and clinical practices.