This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
Practice makes perfect. This is the conclusion of an estimated two dozen
studies published in peer-reviewed literature over the past decade documenting
an association between hospital and surgeon procedure volume, and complication
rates in total joint replacement. The bottom line: Patients treated at hospitals
and by surgeons with greater volumes of total joint replacements have lower
rates of mortality and complications than patients treated at lower-volume
Further, when it comes to total knee replacement, a 2003 National Institutes
of Health Consensus Development Conference statement affirms these findings,
saying, "One of the clearest associations with better outcomes appears to be the
procedure volume of the individual surgeon and the procedure volume of the
The UMass Memorial Arthritis and Joint Replacement Center performs more than
1,100 total joint replacements annually, putting it in the top tenth percentile
of joint replacement centers in the United States in terms of procedure volume.
And, like other high-volume centers, UMass Memorial can point to an extremely
low rate of complications among its total joint replacement patients.
"But there is a difference between complication rates and functional
outcomes," pointed out David Ayers, MD, chair of orthopedics and rehabilitation
at UMass Memorial. Dr. Ayers knows whereof he speaks: he and colleague Patricia
Franklin, MD, MPH, MBA, director of clinical research for orthopedics, are
leading experts on outcomes in joint replacement, in demand as speakers at
national and regional conferences, and widely published on the topic.
"A complication is an untoward event or bad occurrence," he added. "We're
looking to measure how patients function after surgery, and how much their pain
level has improved."
"After all, improved function and pain relief are the reasons patients choose
joint replacement," continued Dr. Franklin. "Surgeons have always asked their
patients how they're doing after surgery, but we've never had an objective way
to trend this data and use it to more fully inform clinical decision-making.
Earlier this year, UMass Memorial launched a Patient Decision Center which
gathers and tracks data on patients pain levels and functional status prior to
and for three years after joint replacement surgery. What distinguishes this
initiative is that patients themselves provide the data using a standardized,
"We use the patient's time in the waiting room to do the assessment," said
Dr. Franklin, who explained that the user-friendly, computer-based questionnaire
takes only five to seven minutes to complete, and has already been integrated
into the workflow in the Arthritis and Joint Replacement Center. The assessment
is scored immediately, printed out and given to the patient to review along with
his or her surgeon during the scheduled office visit.
"It's similar to a blood glucose test given to patients with diabetes before
their doctor appointment," she continued. "But with these scores, patients can
see if their pain level and physical functioning are trending up or down, and it
can provide objective information with which to frame discussions about
self-care, activity levels and other treatment options.
"The ultimate goal is to deliver more evidence-based care recommendations for
patients as well as referring physicians," Dr. Franklin added. "For example,
when is the right time to refer a patient for joint replacement surgery? Our
vision is to have patients do a pre-assessment with their referring physician.
This would enable doctors to say to their patients, ‘Patients with your pain
level and functional scores have seen these outcomes from surgery.' And with
ongoing measurement, patients themselves can see how they're doing over time."
"This initiative also tracks a patient's mental and physical well-being," Dr.
Ayers noted. "We know from previous research that patients with heightened
anxiety levels before joint replacement surgery have more difficulty recovering
from the procedure. Their anxiety contributes to fear of stepping on their leg
or fully participating in physical therapy and, as a result, this patient group
is at risk for lower functional outcomes.
"We've learned - and have helped surgeons understand - that these patients
need more comprehensive pre-op education, and postsurgical physical therapy and
support," he added. "This is an example of how our research can change the way
patients are treated to improve outcomes."
It is also an integral component of the comprehensive resources offered at
the UMass Memorial Arthritis and Joint Replacement Center.
"Regardless of how simple or how serious a patient's condition, we offer the
full spectrum of care," Dr. Ayers pointed out. "Here we have all types of
specialists under one roof - orthopedic surgeons, rheumatologists, physiatrists,
nutritionists, physical therapists - so the referring physician doesn't have to
make an ‘orthopedist or rheumatologist' decision.
"At the same time, the care is focused on the patient," he continued. "This
is evidenced by our investment in state-of-the-art technology and its
application to outcomes research. The access to this technology is an undeniable
advantage of being an academic institution," he added.
Another key advantage is the access it affords patients to cutting-edge
clinical protocols, such as a prospective randomized study now underway at UMass
Medical School that compares hip replacements made of tantalum - a newer,
FDA-approved metal - to titanium, the current gold standard. Early access to
technologic advances in orthopedics, such as gender-specific knee replacement
joints (see sidebar) and radiostereometric analysis (RSA), an x-ray modality
that gives patients individualized feedback on how their joint replacement is
functioning in vivo, are other examples of the depth and breadth of resources
available at UMass Memorial.
"Four years ago, UMass Memorial was performing fewer than 400 total joint
replacements a year," Dr. Ayer noted. "But since then (which, coincidentally,
was when Dr. Ayers came on board and spearheaded the opening of the Arthritis
and Joint Replacement Center), the program has experienced enormous success,
bringing a resource to the Central New England community that didn't exist
"Our typical patient is performing on par with the best outcomes at the best
joint replacement centers in the United States," he continued. "Going forward,
patients will be defining their own outcomes." And he is confident that they
will continue to be at the upper end of the national spectrum.