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  • Measure Summary
  • NQMC:009371
  • Jan 2015

Total knee replacement: percentage of patients undergoing a total knee replacement who had a history completed within one year prior to the procedure that included all of the following: onset and duration of symptoms, location and severity of pain, activity limitations.

American Association of Hip and Knee Surgeons. Total knee replacement performance measurement set. Rosemont (IL): American Association of Hip and Knee Surgeons; 2015. 29 p. [25 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in October 2015.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients undergoing a total knee replacement who had a history completed within one year prior to the procedure that included all of the following: onset and duration of symptoms, location and severity of pain, activity limitations (e.g., walking distance, use of assistive devices, and difficulty with stairs).

The American Association of Hip and Knee Surgeons (AAHKS) measures Assessment of Patient History, Physical Examination, and Radiographic Evidence of Arthritis are a composite measure and must be used together. See the following related National Quality Measures Clearinghouse (NQMC) summaries:

Rationale

A complete history of the patient will identify any medical problems that will need to be corrected prior to the procedure. In addition, the patient's preoperative activity level and symptoms are important to determine the severity of the patient's knee arthritis and baseline functionality.

In a study conducted by SooHoo and colleagues at 3 hospitals, 54 percent of the patients had documentation of the history of the present illness with variation between the 3 hospitals. Pain evaluation was documented 60 percent of the time and the documentation ranged from 99 percent of the time at the best performing hospital down to 25 percent at the least performing hospital (SooHoo et al., 2011).

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

The initial contact (for patients presenting with acute knee pain) may not require obtaining radiographs but should rely on a comprehensive history and physical exam (American Academy of Orthopaedic Surgeons [AAOS], 2003).

Evidence for Rationale

American Academy of Orthopaedic Surgeons. AAOS clinical practice guideline on osteoarthritis of the knee. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2003. 17 p. [114 references]

American Association of Hip and Knee Surgeons. Total knee replacement performance measurement set. Rosemont (IL): American Association of Hip and Knee Surgeons; 2013 Jan. 29 p. [25 references]

SooHoo NF, Tang EY, Krenek L, Eagan M, McGlynn E. Variations in the quality of care delivered to patients undergoing total knee replacement at 3 affiliated hospitals. Orthopedics. 2011 May;34(5):e43-9.

Primary Health Components

Total knee replacement; complete history

Denominator Description

All patients undergoing a total knee replacement (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who had a history completed within one year prior to the procedure that included all of the following: onset and duration of symptoms, location and severity of pain, activity limitations (e.g., walking distance, use of assistive devices, and difficulty with stairs)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

High Impact Topic Area
During 1991 to 2010, the rate of primary total knee replacement procedures among the Medicare population increased over 161 percent from 93,230 procedures in 1991 to 243,802 procedures in 2010. The rate of revision procedures increased over 105 percent from 9,650 to 19,871 procedures. The majority of the primary total knee replacements were performed on women (approximately 65 percent) (Cram et al., 2012).

The Centers for Disease Control and Prevention (CDC) found that the overall total knee replacement rate increased 58% (from 5.5 to 8.7 per 1,000 population) between 2000 and 2006. Similar increases were observed by sex, age group, and black or white race. Total knee replacement rates were 37 percent lower among blacks than whites (3.6 versus 5.7 per 1,000 population) in 2000, and 39% lower in 2006 (5.6 versus 9.2). In both years, the black/white disparity was lower among women (23% and 28%) than among men (63% and 60%). In 2006, blacks had a lower total knee replacement rate than whites in all 50 states and the District of Columbia (CDC, 2009).

In 2004, there were over 450,000 total knee replacements performed in the United States (American Academy of Orthopedic Surgeons [AAOS], 2008).

Between 2007 and 2009, over 22 percent of adults reported they had been diagnosed with arthritis (CDC, 2010). As the population ages, there will be an increased growth in the number of procedures. It is estimated that the number of total knee replacements performed per year could be over 3 million by the year 2030 (Kurtz et al., 2007).

Costs
Medicare paid approximately $3.2 billion in 2000 for hip and knee joint replacements (Agency for Healthcare Research and Quality, 2003).

The overall inpatient costs for replacement of the knee during 2007 was over $9.2 billion with hospital stays of more than 605,000 (Stranges, Russo, & Friedman, 2009).

Evidence for Additional Information Supporting Need for the Measure

Agency for Healthcare Research and Quality. Total knee replacement: summary. Rockville (MD): Agency for Healthcare Research and Quality; 2003 Dec. 8 p. (Evidence report/technology assessment; no. 86).  [100 references]

American Academy of Orthopaedic Surgeons (AAOS). The burden of musculoskeletal diseases in the United States. 2nd ed. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2008.

American Association of Hip and Knee Surgeons. Total knee replacement performance measurement set. Rosemont (IL): American Association of Hip and Knee Surgeons; 2013 Jan. 29 p. [25 references]

Centers for Disease Control and Prevention (CDC). Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation --- United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2010 Oct 8;59(39):1261-5. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). Racial disparities in total knee replacement among Medicare enrollees--United States, 2000-2006. MMWR Morb Mortal Wkly Rep. 2009 Feb 20;58(6):133-8. PubMed External Web Site Policy

Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA. 2012 Sep 26;308(12):1227-36. PubMed External Web Site Policy

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. PubMed External Web Site Policy

Stranges E, Russo A, Friedman B. Procedures with the most rapidly increasing hospital costs, 2004-2007. Rockville (MD): Agency for Healthcare Research and Quality; 2009 Dec. 9 p. (H-CUP Statistical Brief; no. 82). 

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Unspecified

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Making Quality Care More Affordable
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Efficiency

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients undergoing a total knee replacement

Note: Refer to the original measure documentation for Current Procedural Terminology (CPT) codes.

Exclusions
None

Exclusions/Exceptions

None

Numerator Inclusions/Exclusions

Inclusions
Patients who had a history completed within one year prior to the procedure that included all of the following: onset and duration of symptoms, location and severity of pain, activity limitations (e.g., walking distance, use of assistive devices, and difficulty with stairs)

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Registry data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Measure #1a: assessment of patient history.

Measure Collection Name

Total Knee Replacement Performance Measurement Set

Submitter

American Association of Hip and Knee Surgeons - Medical Specialty Society

Developer

American Association of Hip and Knee Surgeons - Medical Specialty Society

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Total Knee Replacement Work Group Members: David Mauerhan, MD (Co-chair); Jay Lieberman, MD (Co-chair)

American Association of Hip and Knee Surgeons: Nelson SooHoo, MD

American Academy of Orthopaedic Surgeons: James Keeney, MD; Michael Parks, MD

The Knee Society: Jess Lonner, MD; Michael Mont, MD

American Physical Therapy Association: Sara Piva, PT, PhD

Pacific Business Group on Health: Kate Chenok, MBA

American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® (PCPI™): Scott Endsley, MD; Samantha Tierney; Elvia Chavarria

American Association of Hip and Knee Surgeons Staff: Robert Hall; Krista Stewart

Project Consultant: Rebecca Kresowik

Financial Disclosures/Other Potential Conflicts of Interest

None of the members of the Total Knee Replacement Work Group had any disqualifying material interests under the Physician Consortium for Performance Improvement (PCPI) Conflict of Interest Policy. The following is a summary of non-disqualifying interests disclosed on Work Group members' Material Interest Disclosure Statements. Completed Material Interest Disclosure Statements are available upon request.

Work Group Members Disclosures

David Mauerhan, MD (Co-chair)

  • Payment for Consulting Services – Biomet, Inc.

Jay Lieberman, MD (Co-chair)

  • Payment for Consulting Services – De Puy, Inc.

Nelson SooHoo, MD

  • None

James Keeney, MD

  • Officer - Society of Military Orthopedic Surgeons and Mid-America Orthopaedic Association

Michael Parks, MD

  • Stock Ownership – Zimmer, Johnson and Johnson, Merck, Pfizer, P&G, United Health
  • Payment for Consulting Services – Zimmer Holdings, Inc.
  • Research Support – Zimmer Holdings, Inc.
  • Director – American Academy of Orthopaedic Surgery, American Association of Hip and Knee Surgeons and New York State Society of Orthopaedic Surgeons

Jess Lonner, MD

  • Stock Ownership – Mako Surgical
  • Research Support – Zimmer, Mako Surgical
  • Speaking Honoraria – Zimmer, Mako Surgical
  • Royalties – Zimmer
  • Service on Speaker's Bureau – Zimmer, Mako Surgical
  • Payment for Consulting Services – Zimmer
  • Scientific Advisory Board – Healthpoint Capital, C D Diagnostics
  • Service on Editorial Board for Several Peer Reviewed Journals

Michael Mont, MD

  • Research – NIH, Stryker, Tissue Gene, Wright Medical
  • Royalties – Stryker
  • Payment for Consulting Services – Stryker, Tissue Gene, Joint Active Systems, Johnson and Johnson, Salient Surgical

Scott Endsley, MD

  • None

Sara Piva, PT, PhD

  • None

Kate Chenok, MBA

  • None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Jan

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in October 2015.

Source(s)

American Association of Hip and Knee Surgeons. Total knee replacement performance measurement set. Rosemont (IL): American Association of Hip and Knee Surgeons; 2015. 29 p. [25 references]

Measure Availability

Source available from the American Association of Hip and Knee Surgeons (AAHKS) Web site External Web Site Policy.

For more information, contact AAHKS at 6300 N. River Road, Suite 615, Rosemont, IL 60018; Phone: 847-698-1200; Fax: 847-698-0704; Web site: www.aahks.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 29, 2014. The information was verified by the measure developer on July 21, 2014.

The information was reaffirmed by the measure developer on October 20, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

© 2012 American Association of Hip and Knee Surgeons. All rights reserved.

These performance measures are not clinical guidelines. They do not establish a standard of medical care and have not been tested for all potential applications. These Measures and specifications are provided "as is" without warranty of any kind. AAHKS shall not be responsible for any use of these performance measures.

Limited propriety coding is contained in the Measure specifications for convenience. Users of the propriety code sets should obtain all necessary licenses from the owners of these code sets. AAHKS disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

The Measures are subject to review and may be revised at any time by AAHKS. The Measures may not be altered without the prior written approval of AAHKS. Users of the Measures shall not have the right to alter, enhance, or otherwise modify the Measures.

CPT® contained in the Measure specifications is copyright 2004-2011 American Medical Association.

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