Expanding the Scope of Centers for Medicare & Medicaid Services Patient-Reported Outcome Measures Mandatory Reporting: Evaluating Total Hip Arthroplasty Outcomes Beyond Substantial Clinical Benefit for Hip Disability and Osteoarthritis Outcome Score-Joint Replacement

Abstract

Background: The Centers for Medicare & Medicaid Services (CMS) has established the reporting of Patient-Reported Outcome Measures (PROMs) after inpatient total knee and total hip arthroplasty (TKA/THA) as a performance measure. However, its focus on substantial clinical benefit (SCB) for Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) may not capture the full dimensions of PROMs. This study aimed to examine the proportions of the inpatient and outpatient THA patients, covered by Medicare or commercial insurance, who achieved different clinically meaningful improvements [SCB; Minimal Clinically Important Difference (MCID); and Patient Acceptable Symptom State (PASS)] across HOOS-JR, HOOS-Pain, and HOOS-Physical Function Shortform (PS) scores.

Methods: A retrospective study of 18,855 primary THA cases between 2016 and 2023 was analyzed. Demographics and HOOS-JR, HOOS-Pain, and HOOS-PS scores were recorded. The SCB for HOOS-JR was set at 22 points per CMS threshold. Achievement of the thresholds for MCID (7.76, 8.35, 9.47) and PASS (76.8, 80.6, 83.6) for HOOS-JR, HOOS Pain, and HOOS-PS, respectively, was analyzed.

Results: The proportions of Medicare inpatients who achieved HOOS-JR clinically meaningful thresholds were 80% for SCB, 94% for MCID, and 59% for PASS. For HOOS-Pain, MCID and PASS were achieved by 96 and 69%, respectively, and for HOOS-PS, by 88 and 67%. Medicare outpatients demonstrated higher rates of SCB (85%), MCID (96%), and PASS (71%) for HOOS-JR, with similar patterns for HOOS-Pain and PS. In the commercial cohort, inpatients achieved SCB, MCID, and PASS rates of 82, 95, and 61% for HOOS-JR, respectively, while outpatients reached 86, 97, and 73%.

Conclusions: The proportions of patients who achieved clinically meaningful thresholds varied depending on the measurement used, with the greatest variation seen between SCB-JR and PASS-JR. This raises concerns about the sole reliance on SCB-JR under the new CMS policy, as it may not fully reflect the patient's perspective of improvement.