Clinical and Outcomes Research: Optimizing Patients Physical - - PowerPoint PPT Presentation

Clinical and Outcomes Research: Optimizing Patients’ Physical Function after Total Joint Replacement after Total Joint Replacement

Patricia D. Franklin MD MBA MPH June 2010

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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

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OA i tl t d lt <65 OA is costly to adults <65 years

• 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) Li it d h i l ti it d t i t l t

• Limited physical activity- detrimental to

general health 40% of TKR patients are working adults 40% of TKR patients are working adults.

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OA lf i f ti OA self-care improves function

A th iti lf Arthritis self-care programs (Lorig, 1993, 1999, 2001, 2003)

– 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 M lti l t t d i d – Multiple-component support programs reduce pain and 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 k d hi OA TJR for knee and hip 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 t t i < 65 Fastest growing users are < 65 years

• Projected utilization growth 670% by 2030

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• 1. Patient pain and function informs

h d t t t d i i shared treatment decisions

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I tit t f M di i Institute of Medicine: Vision for 21st Century s o

• st Ce tu y

Use information technology to t ti t t d id support patient-centered, evidence- based, shared decisions.

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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.

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Physical Mental Function Mental Health

SF36 SF36

Role Physical Role Emotional

Mental Component

Physical Emotional

Physical Component Component (MCS)

Social

Component (PCS)

Bodily Pain Social Function General Vitality Health y

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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 t S f ll C l t S Patients Successfully Complete Surveys

• 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

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SF-36 MCS SF-36 PCS SF 36 MCS Emotional well-being 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

R h i it f NIH d AHRQ

• Research priority for NIH and AHRQ-- assure
• ptimal 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

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(12 Month Post Total Knee Replacement Surgery)

Distribution of Functional Improvement

10 15 nt

QuickTime™ and a decompressor are needed to see this picture.

5 10 Percen 5 0 -20 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) L TKR MCS ( ti l ll b i ) Lower pre-TKR MCS (emotional well-being) 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

D t l l t thi

• Data analyses later this year

Reminders Logs Goals Information Reminders, Logs, Goals, Information, Accelerometers

Context: Post Exercise Type in the number of sets of left Sets of Left Leg Raises Context: Bedtime Limits to Activity Today Pain limited my ability to do the following (Check as many as apply):

Figure 10 7 8 9 + 4 5 6

• Type in the number of sets of left

leg raises that you completed.

   

Climb stairs Get dressed Cook for self Get to bathroom following (Check as many as apply):

4 5 6

• 1

2 3 .

   

Bathe Go to work Exercise Do chores



Sit in chair

UMMS Orthopedic clinical and outcomes research to achieve optimal functional p

• utcomes 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.