Slow but Steady Progress on the AJRR

The dream plays out quite effectively in Lewallen’s head: All joint replacement patients—regardless of body part—would receive a wallet-sized card upon discharge from a hospital or outpatient clinic. The card would contain a numerical code that links the patient to the password-protected American Joint Replacement Registry (AJRR), where their dossier would be stored with millions of other digital files.

“I would love to see us develop this sometime before I retire,” said Lewallen, AJRR medical director and former board chairman. “The card would have a code that brings a patient to a [Web] page where they could sign on using a unique password and look up all the data about their total hip or total knee replacement. Right now, it can be hard to find information on a particular patient’s arthroplasty because maybe the doctor has retired or the hospital changed owners. With the current state of data management, that is not acceptable. But with the registry, when a patient walks into a doctor’s office, say five years after the procedure, and he can’t remember who did the surgery, there would be a way to get that information.”

As simple as it sounds, Lewallen’s vision is pure fantasy at this point. Though the AJRR has been operational for about 14 months now and is stocked with information on more than 36,000 primary and
revision total joint arthroplasty (TJA) procedures, the massive cybervault is still far from completion, much less ready for consumer use. When it debuted in February 2012, organizers confidently set a six-year deadline to collect information from 90 percent of the 4,000 U.S. hospitals where hip and knee TJA procedures routinely are performed. But as of late March, only 140 hospitals, or 3.5 percent of the total, have shared data with the registry.

At this rate, Lewallen may be forced to live out his dream as an AJRR card-carrier rather than a distributor.

Some industry experts are not surprised by the AJRR’s slow shuffle to the finish line. The registry, experts claim, is a noble idea, a proficient way to protect patients against defective replacement parts as well as painful revision surgeries, and save the bloated U.S. healthcare system significant money. In fact, a mere 2 percent dip in TJA revision rates would generate more than $65 million in annual savings; that total, however, could surge to $1.62 billion if the AJRR can cut revision rates in half, as some foreign repositories have done (Sweden’s 34-year-old joint registry, for example, has kept that country’s revision rate at 4 percent, according to the American Medical Association Journal of Ethics).

Such savings potential cannot be overlooked, particularly in an age of perpetually rising healthcare expenses. Yet the lure of cost savings cannot always overcome other hurdles to the registry’s full potential, such as liability, funding, patient confidentiality and device- or company-specific
reporting bias.

Organizers claim the registry meets all privacy, security and compliance requirements under both the Health Insurance Portability and Affordability Act and the Health Information Technology for Economic and Clinical Health Act for administrative, technical, and physical safeguards. In addition, the AJRR has secured funding through the end of the year.

Despite its many obstacles, Lewallen and other AJRR staff members are confident the registry ultimately will meet its goals. At an informational session held during the American Academy of Orthopaedic Surgeons Annual Meeting in March, registry officials discussed the AJRR’s past progress and its future plans.

Besides expanding its staff (Jeffrey P. Knezovich, CAE, as executive director; and Pamella Leiter, MSA, OTR/L, as director, policy and strategic alliances), the AJRR is working to collaborate efforts with the California Joint Replacement Registry and the Michigan Arthroplasty Registry Collaborative Quality Initiative, said Lewallen, a professor of orthopedic surgery at the Mayo Clinic Medical School in Rochester, Minn.

The AJRR also is widening its scope of collectible data. Currently, the AJRR gathers basic information (deemed “Level I” data) to monitor artificial joints throughout recipients’ lifetimes. The Level I data include patient, surgeon and hospital identification as well as procedural facts and implant details.
This year, the registry will begin collecting Level II, III and IV data to risk-adjust hospital and revision results. Level II data will include patient risk factors and comorbidities (as identified through ICD-9 codes); Physician Quality Reporting System measures; surgical approaches; prophylaxis; and American Society of Anesthesiologists scores.

Level III data will encompass 36-Item Short Form Health Survey; hip disability and osteoarthritis outcome score; knee injury and osteoarthritis outcome score; Modified Western Ontario and McMaster Universities Arthritis Index; Oxford Hip and Knee scores; Knee Society Knee Scoring System; and Harris Hip Score. Level IV data will include radiographic images.

“AJRR is also developing reports, including graphical dashboards, to provide to hospitals, physicians, manufacturers and payers,” the AJRR’s preliminary 2012 annual report states. “AJRR will conduct a pilot program in 2013 to identify automated methods to acquire Level II data and to test the features implemented to manage the Patient Reported Outcome Measures process.”