Patient Acceptable Symptom State Score Research Articles

Total Ankle Arthroplasty in the Alternative Payment Model Era

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Ankle arthritis often results in functional decline and decreased quality of life. Total ankle arthroplasty (TAA) is an acceptable option for end-stage disease. With a growing active and aging population, there’s increasing demand for total joint arthroplasty (TJA). In response, the Centers for Medicare and Medicaid Services (CMS) implemented the Comprehensive Care for Joint Replacement (CJR) program to curb costs and optimize outcomes associated with TJA. TAA is included in CJR; however, little is known about episode of care costs and quality of care delivered to patients within a bundled- payment model. This study provides an analysis of quality and cost across an episode of care for primary TAA performed under the CJR model and a commercial bundled-payment health plan.Methods:At a large hybrid academic institution, CJR and bundled-payment health plan data was queried for TAA discharges at 7 affiliate hospitals within Metropolitan Service Areas (MSAs). Patient-reported outcomes (PROs) between April 2016 and August 2018 were assessed pre-operatively, 0-3 months post-operatively and >3 months post-operatively. Foot and Ankle Ability Measure (FAAM), Global Rate of Change (GRC), and Patient Acceptable Symptom State (PASS) were analyzed. Episode of care cost and associated cost domains were assessed between April 2016 and March 2018. Statistical analysis was performed using Stata® 15.1. Pre-operative and post-operative FAAM scores were analyzed using two-tailed t-tests. Pre-operative and post-operative GRC and PASS scores were analyzed using likelihood ratio tests. Associations between cost and FAAM scores were analyzed using Spearman correlations. Comparisons between cost and GRC or PASS were analyzed by Kruskal-Wallis tests and Wilcoxon rank- sum tests, respectively. Statistical significance was defined as a p-value <0.05.Results:155 (55% male, mean 66.1 years) patients were identified. There was no difference between pre-operative and 0-3 months post-operative function (p=0.4943). However, there was significant improvement in functional outcomes at >3 months post-operatively (p=0.0113). Patients reported significant improvement in perceived change in ankle status (p<0.001, p<0.001) and satisfaction of ankle status (p<0.001, p<0.001) at both 0-3 months and >3 months post-operatively when compared to pre- operative assessments. The average TAA episode of care cost was $24,398. Average contracted diagnosis-related group (DRG) costs accounted for the majority (67.58%) of the average total cost. The average readmission cost was $9,440. Costs for skilled nursing facilities (SNF) and inpatient rehabilitation were on average $7,462 and $19,635, respectively. There were no significant correlations observed between outcomes and cost (p>0.05).Conclusion:Primary TAA within a bundled-payment model demonstrates that alternative payment models can reasonably maintain quality of care standards while concurrently promoting cost-efficient utilization of medical resources. Significant functional improvement and increases in patient satisfaction were observed following primary TAA in the bundled-payment system. With the progressive shift from fee-for-service to value-driven reimbursement, continued evaluation of the relationship between quality and cost for TJA within an alternative payment model is necessary.

A Prescriptively Selected Nonthrust Manipulation Versus a Therapist-Selected Nonthrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial

Randomized controlled trial. Several studies that have investigated the effects of a therapist-selected versus a randomly assigned segmental approach have looked at immediate effects only for pain-related outcomes. To examine differences in outcomes following a therapist-selected nonthrust manipulation versus a prescriptively selected nonthrust manipulation in subjects with low back pain. Subjects with mechanically producible low back pain were randomly treated with nonthrust manipulation in a therapist-selected approach or a prescriptively selected approach. All subjects received a standardized home exercise program. Outcome measures included pain, disability, global rating of change, and patient acceptable symptom state. Analyses of covariance, chi-square tests, and Mann-Whitney U tests were used to determine differences between groups. Sixty-three subjects were tracked for 6 months, during which subjects in both groups significantly improved. There were no differences between groups in pain, disability, or patient acceptable symptom state scores at 6 months. There was a significant difference in global rating of change scores favoring the therapist-selected manipulation group at 6 months. This study measured long-term differences between a prescriptively selected nonthrust manipulation and a therapist-selected approach to nonthrust manipulation. In pain, disability, and patient acceptable symptom state there were no differences in outcomes, findings similar to studies of immediate effects. After 6 months, perceived well-being was significantly higher for those in the therapist-selected treatment group. The study was registered at ClinicalTrials.gov (NCT01940744). Therapy, level 1b.

The Influence of the Contralateral Knee Prior to Knee Arthroplasty on Post-Arthroplasty Function: The Multicenter Osteoarthritis Study

Some of the poor functional outcomes of knee arthroplasty may be due to pain in the contralateral, unreplaced knee. We investigated the relationship between the preoperative pain status of the contralateral knee and the risk of a poor postoperative functional outcome in patients who underwent knee arthroplasty. We analyzed data on 271 patients in the Multicenter Osteoarthritis Study who had undergone knee arthroplasty since the time of enrollment. Eighty-six percent of these patients were white, 72% were female, and the mean age was sixty-seven years. The severity of pain in the knee contralateral to the one that was replaced was measured before the knee arthroplasty with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale, with the scores being grouped into four categories (0, 1 to 4, 5 to 9, and 10 to 20). Poor post-arthroplasty function six months or more after surgery was determined with use of the Patient Acceptable Symptom State (PASS) outcome tool and a clinical performance measure of walking speed. We evaluated the relationship between contralateral pain severity and the functional outcomes with use of Poisson regression. Seventy-two (27%) of 264 patients demonstrated poor post-arthroplasty function by failing to attain the threshold PASS score, and seventy-six (30%) of 250 subjects had a slow walking speed. As the pre-arthroplasty pain in the contralateral knee increased, there was a steady increase in the proportion with poor post-arthroplasty function (p &lt; 0.0001 for PASS and p = 0.04 for slow walking speed). Compared with patients who had no pre-arthroplasty pain in the contralateral knee, those in the highest category of contralateral pain severity had 4.1 times the risk (95% confidence interval, 1.5 to 11.5) of having poor self-reported post-arthroplasty function. Patients in whom both knees had been replaced at the time of outcome collection were less likely to have poor self-reported function than those in whom only one knee had been replaced. Preoperative pain in the contralateral knee is strongly associated with self-reported post-arthroplasty functional outcome and may therefore be a useful indicator of prognosis or a potential target of perioperative intervention. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.