A Surgeon Scorecard Is Associated with Improved Value in Elective Primary Hip and Knee Arthroplasty

Abstract

Background: Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. Methods: We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. Results: After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). Conclusions: The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. Clinical Relevance: Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

The Effect of Feedback on Surgeon Performance: A Narrative Review

“…Winegar et al examined the effects of using a monthly, unblinded surgeon scorecard on economic effects and patient outcomes for patients undergoing total joint arthroplasty (TJA) at a tertiary hospital [ 45 ]. Metrics from the first scorecard issued were compared with those on the tenth scorecard given to surgeons.…”

“…There was also an improvement in home-discharge rate as well as a decrease in 30- and 90-day readmission rates, though these variables did not reach statistical significance. Nonetheless, these findings suggest that surgeons are able to decrease the economic burden of TJAs without detrimental effects on the quality of patients care [ 45 ]. These findings are consistent with previous literature that demonstrates that scorecards can improve operative cost efficiency with equivalent or improved patient outcomes [ 46 ].…”

Preparing for an Era of Episode-Based Care in Total Joint Arthroplasty

“…Scorecards have been suggested for surgical care as they provide surgeons with direct quantitative feedback on their clinical, financial, and operational performance and can inform higher value clinical decision making[ 32 ]. There is some data to suggest scorecard use in TJA is associated with moderate improvement in clinical outcomes such as length of stay and a reduction in direct costs of care, such as implant costs[ 4 ]. However, additional data on whether scorecards more broadly impact clinical outcomes or patient reported outcomes remains to be seen as institutions gain experience with standardized surgical scorecards.…”

“…This realization prompted institution-level quality improvement efforts to make costs associated with clinical decisions more transparent to surgeons, leading to value improvement interventions to increase price transparency. Early evidence suggests that scorecards are associated with reductions in cost variation and median cost in TJA [4], suggesting that direct provider feedback on costs can lead to higher value clinical decision making.…”

Editorial Commentary: Delivering the PROMIS for Patients With Shoulder Disorders—Fool’s Gold, a Mirage, or an Oasis

“…Depending on the stakeholder type, PROMs could be used for clinical research, reimbursement, point-of-care, or benchmarking for patient comparison with a matched population cohort 2,3 or comparative surgeon scorecard. 4 In 2017, orthopaedic practice administrators reported collecting quality measures, patient satisfaction surveys, or PROs for their practices at a rate of 71%, 61%, or 35%, respectively. In such a situation, the practice administrators are concerned about meeting the CMS requirements for Merit-based Incentive Payment…”