Preoperative patient-reported outcome measure thresholds create access-to-care barriers
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GRAPEVINE, Texas — Results showed most patients undergoing total knee arthroplasty achieved the minimum clinically important difference at all theoretical patient-reported outcome measure thresholds with low complications and readmissions.
CMS and commercial insurers should consider other outcome measures when it comes to determining eligibility for TKA, rather than using an arbitrary preoperative patient-reported outcome measure (PROM) threshold, P. Maxwell Courtney, MD, said in his presentation at the American Association of Hip and Knee Surgeons Annual Meeting.
“If you're seeing a 52-year-old female who might have a bad varus knee, but she's able to run a 5K on the weekends and is super active, as opposed to the patient who is 85 [years old] who may be in a wheelchair, there's less room for that 52-year-old to improve on her PROM scores,” Courtney said.
“What defines a good outcome following a TKA? Is it a patient achieving some set minimum clinically important difference (MCID) or PROM score, or is it that they did well? They didn't have complications. They weren’t readmitted, and they were still able to go home,” he added.
Courtney and colleagues set theoretical preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) cutoffs at 40 points, 50 points, 60 points and 70 points and retrospectively analyzed data on 25,246 primary TKAs from 2016 to 2019. Patients with preoperative KOOS JR scores below the thresholds were theoretically approved for surgery, while patients with scores above the threshold were theoretically denied for surgery. Researchers used previous literature to settle on an MCID of 14.
MCID achievement across all thresholds
At a threshold of 40 points, 88.3% of patients achieved the MCID at 1 year; at a threshold of 50 points, 85.9% of patients achieved the MCID; at a threshold of 60 points, 79.6% of patients achieved the MCID; and at a threshold of 70 points, 77% of patients achieved the MCID. Courtney noted two-thirds of patients (n = 14,000) would have been denied surgery at a “very low” threshold of 40 points, and almost 5% of patients (n = 1,000) would have been denied surgery even at a “relatively high” threshold of 70 points.
Other outcomes
At thresholds of 40 points, 50 points, 60 points and 70 points, complication rates for approved patients were 2.16%, 2.25%, 2.14% and 2.13%, respectively, while 90-day readmission rates for approved patients were 4.61%, 4.51%, 4.32% and 4.28%, respectively. Courtney noted that compared with denied patients, approved patients had higher rates of achieving the MCID, but they also had higher rates of nonhome discharge at thresholds of 40 points, 50 points and 60 points. He also noted approved patients and denied patients had similar in-hospital complications and 90-day readmission rates.
“There are other outcome measures that our payers need to be considering for surgery other than using an arbitrary preoperative PROM threshold,” Courtney said. “Setting a preoperative PROM threshold could lead to access-to-care barriers for patients who are high functioning, preoperatively, but would otherwise benefit from TKA,” he concluded.
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Sutton RM, et al. Paper 6. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 3-6, 2022; Grapevine, Texas.
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