QOLIX joint replacement registry field test shows practical advantages of integrating disease-specific and generic PROs

WORCESTER, MA, February 10, 2015 – A national registry recently conducted a field test to collect patient-reported outcomes (PRO) data using a new method.  Patients logged on from home or the clinic to complete the survey, as is typical for web-based assessments, before and after total joint replacement (TJR).  The difference was in what happened next.  The survey used the Quality of Life (QOL) Information System (QOLIX^®) which uses a powerful new adaptive survey logic (ASLX^®) to automatically adapt to the presence of multiple comorbid conditions while also estimating outcomes with metrics equivalent to those underlying widely-used legacy PROs.  Although each of the major elements of QOLIX, including standardized disease-specific (QDIS^®) and generic (QGEN^®) modules, and the power of ASLX had been evaluated successfully in real data simulations, this was the first real-world test of the entire system in an ongoing PRO registry.  Despite collecting more comprehensive and more individualized information, QOLIX surveys were faster in the TJR field test for most patients in comparison with state-of-the-art PRO surveys that were administered in parallel.

The Function and Outcomes Research for Comparative Effectiveness in TJR (FORCE-TJR) registry is sponsored by AHRQ and led by a team of researchers at UMass Medical School in cooperation with a national network of surgeons.  FORCE-TJR goes beyond traditional approaches to comparative effectiveness research (CER) that are based on retrospective analyses of rates of implant failure or revision.  The FORCE-TJR model is patient-centered, more comprehensive, and integrates population-based sampling and prospective monitoring of functional health and other PROs.  The state-of-the art PRO surveys in FORCE-TJR include joint-specific (HOOS or KOOS) and generic (SF-36^® Health Survey) PROs as well as a condition checklist and other survey modules.  In keeping with a secondary objective of FORCE-TJR, we evaluated the potential for improvements in the efficiency and usefulness of PRO surveys that might better satisfy the growing need and likely impending requirements for more systematic evaluations of TJR and for CER in general.

The QOLIX field test showed that more practical PRO surveys are possible and suggested that individualized QDIS-based comorbidity estimates may be useful in explaining variations in generic PRO outcomes.  In terms of practicality, the reduction in survey length using QOLIX was substantial (up to 75%, on average) but varied according to the severity of QOL impact and number of comorbid conditions. In previous QOLIX tests among adults with non-severe joint problems, such as patients after TJR, combined generic and joint-specific QOLIX surveys were shorter – a median of 22 items (3-4 minutes) or less for patients in contrast to the 78 items (about 13 minutes) in the FORCE-TJR survey, a 75% reduction in respondent burden.  For adults with severe joint problems, such as patients before TJR and with severe comorbid conditions, QOLIX reduced respondent burden by about 30% - a median of 55 versus 78 items. 

These gains are not simply the result of using computerized adaptive testing (CAT) in QOLIX. In research to date, in comparison with standard CAT, ASLX reduced respondent burden by another 50% for most respondents.  In terms of providing more useful information, despite being shorter, QOLIX added a more comprehensive joint-specific QOL disease impact scale (QDIS) score that is standardized and normed to the US general population, thereby facilitating interpretation.  QDIS also enabled estimation of an individualized total comorbid impact score that is useful in understanding variations in generic PRO outcomes.

Methods and results from the FORCE-TJR outcomes registry field test of QOLIX will be one of the case-study presentations during a workshop in the Measurement, Design, and Analysis Methods for Health Outcomes Research course at the Harvard School of Public Health. More information on QOLIX is available here.

The FORCE-TJR registry provides enrolling surgeons and hospitals comprehensive, comparative arthroplasty practice feedback and data on total joint replacement (TJR) to improve patient care, meet reporting requirements, compare performance to peer surgeons/institutions, and secure quality incentive payments.  FORCE (Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement) is the nation's first comprehensive TJR registry to include risk adjusted, national norms that document patient reported outcome (PROs) measures, readmissions rates, adverse events, and implant survival.  FORCE data and methods, as well as national comparative benchmarks, were established under a $12 million grant from the Agency for Healthcare Research & Quality that involved more than 150 surgeons representing all practice settings (e.g., urban and rural, high and low volume), and regions of the U.S. For more information or to enroll, find us at http://www.force-tjr.org/.