Clinical and Outcomes Research: Optimizing Patients’ Physical Function after Total Joint Replacement after Total Joint Replacement Patricia D. Franklin MD MBA MPH June 2010 1
Osteoarthritis: public health priority • OA affects half of all adults over 65 years of age 21 million US adults 21 million US adults Women > men • OA is #1 cause of disability in the US OA is #1 cause of disability in the US • OA increases with age and obesity (Knee) • No known cure No known cure • Early symptoms are treated with medication, physical activity, and exercise 2
OA i OA is costly to adults <65 years tl t d lt <65 • Employees with OA have limitations in their Employees with OA have limitations in their physical work activities 23% of the time • Employees lose 8 more annual workdays • Employees lose 8 more annual workdays • Annual costs of OA- $9000/year (benefits plus lost productivity) plus lost productivity) • Limited physical activity- detrimental to Li it d h i l ti it d t i t l t general health 40% of TKR patients are working adults 40% of TKR patients are working adults. 3
OA OA self-care improves function lf i f ti A th iti Arthritis self-care programs (Lorig, 1993, 1999, 2001, 2003) lf – Target self-efficacy; belief in accomplishing a task g y; p g – 20% reduction in joint pain, improved function – Sustained benefits between 1-2 year follow-up – Multiple-component support programs reduce pain and M lti l t t d i d disability in rheumatoid and OA. (Keefe, 2002) – Exercise and Diet programs reduce pain, improve function (Messier Ettinger 2004) (Messier, Ettinger, 2004) Fewer than 5% of OA patients participate p p p in self-care programs.
TJR f TJR for knee and hip OA k d hi OA • For advanced OA, Total Joint Replacement eliminates pain and improves function (NIH Consensus Panel; 2003) • #1 volume surgery in Medicare budget • #1 volume surgery in Medicare budget 725,000 TJR/year; $25.5 billion F Fastest growing users are < 65 years t t i < 65 • Projected utilization growth 670% by 2030 5
1. Patient pain and function informs shared treatment decisions h d t t t d i i 6
I Institute of Medicine: tit t f M di i Vision for 21st Century s o o st Ce tu y Use information technology to support patient -centered, evidence- t t d id ti t based, shared decisions. 7
Goal: Implement patient-reported, computer assessment of pain and function in the UMMHC Arthritis and Total Joint Center 1. Trend patient symptoms in the medical record to guide patient-surgeon shared decisions, 2. Allow UMMHC to assess program outcomes: pain relief and functional gain. 3. Create database of patient outcomes for future research to optimize function. 8
Physical Mental Mental Function Health SF36 SF36 Role Role Physical Physical Emotional Emotional Physical Mental Component Component Component Component (PCS) (MCS) Social Social Bodily Pain Function General Vitality y Health
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Audience assessment of symptoms SF12 brief assessment Physical function Emotional well-being Emotional well being http://www qualitymetric com/demos/TP http://www.qualitymetric.com/demos/TP _Launch.aspx?SID=52304
P ti Patients Successfully Complete Surveys t S f ll C l t S • 73% of patients “totally comfortable” • 19% “not comfortable” and assisted by staff 19% not comfortable and assisted by staff • 5-7 minutes • Scored immediately Scored immediately • Trends over time 12
SF-36 MCS SF 36 MCS Emotional well-being SF-36 PCS trend for physician and patient to Nurse discuss entered data prior to physician visit
UMMS Total Joint Registry UMMS Total Joint Registry February 2010 • More than 14,000 symptom surveys • 8000 repeat assessments for TJR patients • Research priority for NIH and AHRQ-- assure R h i it f NIH d AHRQ optimal TJR outcomes • Surveys also standard in Spine Center; planning for other Orthopedic Centers
2. Decision for TJR is shared 2. Decision for TJR is shared between patient-surgeon. Robert Wood Johnson Foundation Quality-equality Initiative Quality equality Initiative
Wide variation in functional gain after Wide variation in functional gain after successful TKR Distribution of Functional Improvement (12 Month Post Total Knee Replacement Surgery) 15 15 nt Percen 10 10 QuickTime™ and a decompressor are needed to see this picture. 5 5 0 0 -20 0 20 40 SF36 PCS Change Source: Zimmer TKR Registry
Predictors of sub-optimal Predictors of sub optimal post-TKR function Lower pre-TKR PCS (physical function) Lower pre-TKR MCS (emotional well-being) L TKR MCS ( ti l ll b i ) Fair/poor quadriceps (muscle) strength Older age (5 year increase) Extreme obesity (BMI>40) Extreme obesity (BMI 40) 2008 Knee Society Ranawat Award Franklin, Li, Ayers
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3 Patient self-care and physical 3. Patient self-care and physical activity are important for knee OA and TJR patients. NIH 4 year award NIH 4 year award
Joint Action: telephone support for TKR • 180 UMMHC patients To date: 78 intervention; 79 usual care To date: 78 intervention; 79 usual care • 12 week telephone program to support exercise/activity to achieve optimal exercise/activity to achieve optimal function • Structured calls; written information • Structured calls; written information • 100% retention in intervention • Data analyses later this year D t l l t thi
Reminders Logs Goals Information Reminders, Logs, Goals, Information, Accelerometers Figure 10 Context: Post Exercise Context: Bedtime Limits to Activity Today Sets of Left Leg Raises Pain limited my ability to do the following (Check as many as apply): following (Check as many as apply): Type in the number of sets of left Type in the number of sets of left leg raises that you completed. Climb stairs Get dressed 7 8 9 + Cook for self Get to bathroom 4 4 5 5 6 6 - - Bathe 1 2 3 Go to work Exercise 0 . Do chores Sit in chair
UMMS Orthopedic clinical and outcomes research to achieve optimal functional p outcomes for our patients, and nationally. • Conduct comparative effectiveness research of alternative procedures and devices to support alternative procedures and devices to support shared treatment decisions, inform surgical practice and patient self- care for optimal practice and patient self- care for optimal functional outcomes.
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