Authors: Thomas M. Hanson, MD; Paul M. Werth, MS; David S. Jevsevar, MD, MBA
Abstract
Background
Value-based care is predicated on patient involvement in the co-management of chronic conditions. Those who exhibit more responsibility and participation in care are said to have higher “Patient Activation,” a modifiable trait which has been shown to correlate with improved outcomes in lower extremity total joint arthroplasty. Value may be derived by considering patient health outcomes per dollar spent on services, and should therefore be reliant on independent modifiers of patient outcomes. The purpose of this study was to examine if value in total joint arthroplasty is affected by changes in patient activation.
Methods
The patient activation scores of 454 patients undergoing total joint arthroplasty (209 TKA, 245 THA) at a rural tertiary care center between March 2019 and March 2020 were prospectively measured using the Patient Activation Measurement 13-item questionnaire (PAM-13) (T-score; 0-100). PROMIS-10 Global Function, HOOS Jr, KOOS Jr, and M-SANE outcome scores were gauged preoperatively and at 28 days, 6 weeks, 12 weeks, 6 months, and 1 year. Value was assessed as quality over direct costs. Quality was assessed using weighted clinical and patient reported outcomes (measured by mean change) combined with complication rate, periprosthetic joint infection rate, and 30-day readmission rate. A multivariate regression model was used to control for gender, age, BMI, Charlson comorbidity index, income, and employment status.
Results
In total hip arthroplasty, every point increase in patient activation was associated with a 0.20 point rise in quality (y-intercept=109.85, 95% CI: 0.02-0.38, p=0.03) and a 0.19 point rise in value (y-intercept=112.65, 95% CI: 0.01-0.37, p=0.04). Patient activation was not an independent predictor of costs in total hip arthroplasty (y-intercept=97.66, 95% CI: -0.03 – 0.06, p=0.46). In total knee arthroplasty, patient activation was not an independent predictor of quality (y-intercept=100.19, 95% CI: -0.23 – 0.29, p=0.82), cost (y-intercept=89.19, 95% CI: - 0.11 – 0.19, p=0.61), or quality (y-intercept=113.69, 95% CI: -0.31 – 0.28, p=0.93).
Conclusions
Using a standardized equation for quantifying value in total joint arthroplasty, we find that higher patient activation scores lead to improved quality and value in total hip arthroplasty. In stark contrast, we do not see a relationship between patient activation levels and quality or value in total knee arthroplasty. Patient activation was not associated with episode of care costs for either procedure. As such, patient activation may be regarded as a modifiable predictor of value in total hip arthroplasty.