Agreement of the American Academy of Orthopaedic Surgeons Appropriate Use Criteria With Treatment Recommendations From Arthroplasty Surgeons

Abstract

Background: The American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) for Surgical Management of Osteoarthritis of the Knee (2016) and Management of Osteoarthritis of the Hip (2017) are intended to provide treatment recommendations for osteoarthritis (OA). This study examined the agreement of AUC appropriateness classifications with arthroplasty surgeon recommendations for total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods: The cohort included 558 OA patients (397 knee, 161 hip) referred to a specialty arthroplasty clinic. Surgeons completed the online AAOS AUC patient profiles to generate appropriateness ratings. Surgeons' recommendations for treatment were recorded. We performed univariate and bivariate analyses to evaluate relationships between AUC appropriateness and surgeon recommendations.

Results: The knee OA AUC classified TKA as "appropriate" for 309 (77.8%) of the 397 knee OA patients. Surgeons recommended TKA for 123 (31.0%), resulting in 46.8% (n = 186) higher rate of "appropriate" classification by AUC than TKA recommendation by surgeons. Weighted Cohen's κ demonstrated slight agreement (κ = 0.06, 95% confidence interval: 0.04, 0.09) between AUC appropriateness and surgeon TKA recommendation. The hip OA AUC classified THA as "appropriate" for 98 (60.9%) of the 161 hip OA patients. Surgeons recommended THA for 76 (47.2%), resulting in 13.7% (n = 22) higher rate of "appropriate" classification by AUC than THA recommendation by surgeons. Weighted Cohen's κ demonstrated moderate agreement (κ = 0.47, 95% confidence interval: 0.37, 0.57) between the AUC appropriateness classification and the surgeon's THA recommendation.

Conclusions: AAOS AUC guidelines indicated surgical appropriateness significantly more than arthroplasty surgeons. AUC agreed slightly with surgeons for TKA and moderately for THA.

Keywords: Appropriate use criteria; Osteoarthritis; Total hip arthroplasty; Total knee arthroplasty.

Figure 1

American Academy of Orthopaedic Surgeons appropriate use criteria indication profile input screens for (a) surgical management of knee osteoarthritis and (b) management of hip osteoarthritis.

Figure 2

Sankey diagram demonstrating relationships between appropriate use criteria classification and surgeon total knee arthroplasty recommendations. Percentages listed in flow represent the probability of each surgeon’s recommendation for the respective appropriate use criteria classification group. %∗ represents the percentage of patients relative to the total knee osteoarthritis cohort.

Figure 3

Sankey diagram demonstrating relationships between appropriate use criteria classification and surgeon total hip arthroplasty recommendations. Percentages listed in each flow represent the probability of each surgeon’s recommendation for the respective appropriate use criteria classification group. %∗ represents the percentage of patients relative to the total hip osteoarthritis cohort.