Arthroplasty Patients Usually Have Other Problems That Affect Post-Op Satisfaction

NEW ORLEANS — Most patients undergoing knee replacement procedures also have joint pain elsewhere, diminishing their overall self-reported health status after surgery, according to a large study presented here — and this could soon pose serious problems for surgeons’ pay.

Just 14% of knee arthroplasty patients treated at the Cleveland Clinic during 2016-2023 came to the operating room without contralateral knee pain or back pain, reported Khaled Elmenawi, MD, a surgeon there. Those with either or both were significantly less likely to report “substantial clinical benefit (SCB)” as defined by Knee Osteoarthritis Outcome Score for joint replacement (KOOS-JR) a year after surgery, he told attendees at the American Academy of Orthopaedic Surgeons’ annual meeting.

Compared with patients reporting pain only in the operative knee, odds of failing to achieve SCB were 30% times higher for those with back pain (P=0.02), 60% higher for those with pain in the opposite knee (P<0.001), and 140% higher for those with both (P<0.001). Contralateral hip pain was also associated with reduced SCB likelihood, he reported.

And this is a concern because CMS will begin publicly reporting this and other patient-reported outcome measures (PROMs) for Medicare beneficiaries at the physician and hospital levels in 2027, and these will be tied to Medicare reimbursements the following year.

In so doing, surgeons worry that CMS is putting the burden on them to fix their other problems. And not only joint pain, necessarily: mental health status is a component of global outcome measures that may be collected and sent to CMS.

“We can be held responsible for patients’ [knee outcomes],” said Anay Patel, MD, of Texas Orthopedic Hospital in Houston, who also presented a paper at the same session. “We should not be held responsible for their mental health.”

He added that he hoped hospital administrators would “put their foot down” and refuse to include PROMs unrelated to the sorts of issues that surgeons can reasonably address.

Patel’s presentation examined this issue from another angle: the differing PROMs that may be used to assess surgical outcomes. His study compared KOOS-JR with PROMIS-10. The former is more focused on joint pain (though not restricted to the operative knee) whereas PROMIS-10 is an overall health-status measure that includes both mental and physical health components. Outcomes according to these measures were included for nearly 1,000 patients treated at his institution.

Correlations between these measures were well short of perfect, Patel said. Mean KOOS-JR scores improved by about 50% from baseline, whereas PROMIS-10 scores rose only about 15%. The latter’s physical component correlated reasonably well with KOOS-JR (r=0.60-0.63 across time points), but mental health scores hardly budged.

His conclusion was that KOOS-JR was the more appropriate measure to be used in judging outcomes, whereas the results showed “the potential reimbursement liability of PROMIS-10 in a pay-for-performance model.”

Elmenawi, reflecting on his study’s findings, said they could help inform preoperative risk stratification, which affects how subsequent outcomes are interpreted. As well, he added, surgeons probably should be more proactive in addressing patients’ joint pain complaints that don’t necessarily involve the one they are proposing to replace. “Preoperative screening and multidisciplinary management of pain in contralateral knee [joints] or back may be helpful,” he said.

Both studies were limited by their retrospective nature, their single-center designs, and the potential for unmeasured confounders to influence the results.

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