PROMoting Quality - Improving pathways in elective orthopaedic surgery

For some time now, the Federal Joint Committee (G-BA) has been calling for cost-efficient patient focus in the quality management guidelines. However, there is no standardized quality control of the treatment success from the patient’s point of view. ¹ 

Whilst countries such as Sweden or Great Britain have already established mechanisms for the nationwide collection of PROMs for specific clinical areas, many decentralized projects have been developed in Germany. ^2,3 With an increasing understanding of the potential of PROs across multiple players involved in healthcare, a movement towards standardization and comparability is now evident. One of these endeavors is the standardized survey of PROs via the Quality Medicine Initiative with almost 500 members. ⁴

Despite the successful use of PROs in everyday treatment and in research, there is currently limited proof of benefit in terms of cost efficiency in relation to the quality of treatment. The PROMoting Quality study began in 2019 in order to improve the data on the cost-effectiveness of PRO recording in routine care. ⁵

The PROMoting Quality is funded by the Innovation Fund and aims to monitor Patient-Reported Outcome Measures (PROMs) across hip and knee replacement care pathways in order to improve care quality and patient satisfaction whilst keeping costs under control. The ultimate goal is to anchor PRO recordings in routine care as a suitable clinical decision-making tool.

With an aging population, hip and knee replacements are two of the most common inpatient surgeries in Germany. Between 2006 and 2016, the number of surgeries increased by 17% and 38% respectively, and these numbers are expected to increase with life expectancy in conjunction with implantations at an earlier age. ⁶

Nine leading endoprosthetic centers are involved in PROMoting Quality under the consortium of the Technical University of Berlin :

• Charité – University Medicine Berlin

• Orthopedic clinic of the Hannover Medical School in the Diakovere Annastift

• Helios ENDO Clinic Hamburg

• VAMED Ostseeklinik Damp

• RoMed Clinic Prien am Chiemsee

• Sana Kliniken Sommerfeld

• Schön Klinik Hamburg Eilbek

• Schoen Clinic Neustadt

• Waldkliniken Eisenberg

PROMoting is a multi-centre, prospective and randomized-controlled intervention study to investigate the influence of PROs on cost-effectiveness and postoperative complications. The hypothesis is that through the digital collection of PROs following knee and hip joint replacement surgeries, early postoperative complications can be identified. Timely initiation of follow-up treatment should increase patient success and cost-effectiveness of treatments for insurers. The project aspires to close the care gap between the acute inpatient and outpatient through heartbeat’s accredited PROMs sets to track patients’ health progress post-operatively. Without timely and standardized information about symptoms, e.g. the impairment of the patient’s quality of life, doctors can not take steps to address the problems underlying the symptoms before they advance further.

By 2021, more than 8,000 adult patients undergoing elective hip or knee replacements were digitally monitored from hospital admission up to 12 months after discharge using regular PROMs questionnaires (ICHOM standard sets , EQ-5D-5L , HOOS-PS and KOOS-PS) .

In the control group, the PROMs are recorded on admission and one year after the operation. In the intervention group, PROMs are recorded on admission, after discharge and at regular intervals (1, 3, 6, 12 months).

Algorithm-based thresholds alert study assistants when patients deviate from the expected recovery trajectory. In such case, the study assistant will contact the patient and their doctor to examine the follow-up treatment protocol and adjust it if necessary.

After completing the recruitment phase, initial preliminary findings could already be obtained. Validated results and evaluations under the leadership of the TU Berlin are expected in 2022.

To date, patients have submitted 9,000 replies to follow-up questionnaires, resulting in a response rate of 85%. 7 Depending on the following month, 15-30% of the patients in the intervention group triggered algorithm-based alarms.

Concurrently 30% of patients have engaged in conversations regarding their PROMs with their post-treatment physicians. Additionally, surveys among study assistants report time-saving and robust digital workflows with high acceptance rates of the PROM-based interventions.

Innovation cycles in the German healthcare system are traditionally long. These can be interpreted as a lack of willingness to adapt on the part of the physicians involved or of the administrative staff or skepticism towards digital “quick fixes”. Contrary to what is often assumed, this is not an obstacle to innovation per se, but rather an effective filter with regard to practical benefits, patient well-being, quality and evidence. Through PROMoting Quality, PROMs can be collected intuitively via the Heartbeat ONE platform, contribute to patient well-being and provide high-quality research data.

This is why voices are growing louder calling for health policy support towards a patient and quality-centred care system. ⁸ Because digital PROMs can already be used on both a technical and organizational level and should be included in standard care if the benefit is proven in favor of the patient.