Force TJR Annual Report 2014

TJR
FORCE-TJR
ANNUAL REPORT 2014
University
of
Massachusetts
Medical
School
Department
of
Orthopedics
and
Physical
Rehabilitation
T:
!""
$$%
&'(%
(!
$$FORCE)
E:
force-‐tjr@umassmed.edu
W:
www.force-‐tjr.or

FORCE-TJR
ANNUAL REPORT 2014 | 2
TJR
Executive Summary
In
October
2010,
the
Agency
for
Healthcare
Research
and
Quality
awarded
a
program
project
grant
to
the
University
of
Massachusetts
Medical
School
following
a
competitive
application
process.
Since
that
time,
the
Function
and
Outcomes
Research
for
Comparative
Effectiveness
in
Total
Joint
Replacement
(FORCE-‐TJR)
program
has
established
a
novel
TJR
registry
with
a
national
sample
of
US
patients
and
surgeons
to
conduct
comparative
effectiveness
research.
As
of
June
2014,
over
20,000
patients
were
enrolled
from
136
surgeons
in
22
states,
with
hundreds
more
patients
enrolled
weekly.
FORCE-‐TJR
is
the
first
US
national
cohort
of
TJR
patients
representing
all
regions
of
the
US,
with
varied
practice
settings
(e.g.,
urban
and
rural,
high
and
low
volume)
to
collect
comprehensive
TJR
outcome
data.
FORCE-‐TJR
data
are
collected
directly
from
patients,
including
patient-‐reported
outcomes
of
pain
and
function,
early
post-‐operative
adverse
events,
and
implant
failures,
assuring
more
than
85%
response
for
valid,
longitudinal
analyses.
Patient-‐reported
data
are
augmented
with
clinical
data
from
surgeons
and
hospitals.
FORCE-‐TJR
research
is
underway
and
will
continue
indefinitely
as
patients
signed
a
consent
allowing
annual
follow-‐up
for
years
into
the
future.
During
the
past
year
alone,
FORCE-‐TJR
delivered
over
50
presentations
at
eight
national
and
international
meetings
to
broadly
disseminate
the
research
power
of
the
database,
10
manuscripts
are
under
review
or
were
published,
and
seven
ancillary
grants
are
under
review.
The
rapidly
expanding
FORCE-‐TJR
Bibliography
is
attached
to
this
report.
Beyond
research,
the
FORCE-‐TJR
registry
provides
comprehensive,
comparative
arthroplasty
practice
feedback
to
TJR
surgeons
to
support
quality
improvement
efforts.
In
addition,
these
data
can
be
used
to
meet
regulatory
requirements
such
as
the
CMS
Patient
Quality
Reporting
System,
and
value-‐based
proposals
for
accountable
care.
Site-‐specific
comparisons
of
patient
risk
factors
and
outcomes
allow
surgeons
to
understand
the
similarities
and
differences
among
their
patients
and
practices.
In
less
than
four
years,
the
FORCE-‐TJR
infrastructure
and
expertise
has
emerged
as
a
leader
in
the
orthopedic
community
in
patient-‐reported
outcome
collection
and
interpretation,
clinical
care
and
implant
surveillance,
and
best
practice
models
to
assure
consistent
TJR
patient
outcomes.
In
brief,
FORCE-‐TJR
impacts
a
wide
array
of
stakeholders.
o For
Patients:
While
electronic
medical
records
systems
struggle
to
collect,
score
and
integrate
patient-‐reported
outcomes
(PROs),
FORCE-‐TJR
deployed
a
web-‐based
system
that
collects,
scores,
and
trends
over
time
PROs
to
guide
As a former educator, I
think that research is so
important. I was amazed at
how much my joint problem
affected my quality of life
before my first hip was
replaced. I’m looking
forward to having my other
hip replaced by the same
surgeon, and am happy to
participate in the FORCE-TJR
Registry if it will help
anybody.
Patient participant,
Diane D., age 66
(hip replacement)
Lake Havasu, AZ
“
”

FORCE-TJR
TJR
care
for
tens
of
thousands
of
TJR
patients
served
by
member
surgeons.
New
real-‐time
patient-‐reported
outcome
scoring
allows
the
patient
and
surgeon
to
view
trended
pain
and
function
(both
decline
and
improvement)
before
and
after
TJR.
Before
surgery,
patient
pain
and
disability
scores
can
be
compared
to
national
TJR
norms
when
determining
the
timing
for
surgery.
After
TJR,
improvement
can
be
quantified
and
care
tailored
to
support
recovery
o For
Surgeons
and
Hospitals:
Our
unique
national
database
and
risk
adjustment
models
allow
FORCE-‐TJR
to
provide
comparative
valuable
feedback
to
member
surgeons
to
guide
practice.
Quarterly
reports
address
three
critical
questions
that
previously
surgeons
could
not
answer:
1.
How
do
my
patient
risk
factors
such
as
BMI
and
comorbidities
compare
to
other
surgeons?
2.
How
does
the
timing
of
patient
surgery
as
described
by
pain
and
functional
limitations
compare
to
national
practice?
and
3.
Is
the
degree
of
pain
relief
and
improved
function
in
my
patients
comparable
to
the
national
norm?
o For
CMS
and
Private
Insurers:
CMS
initiated
public
reporting
of
post-‐TJR
readmissions
and
complications
in
2014.
To
anticipate
and
monitor
quality,
arthroplasty
surgeons
need
timely
and
risk-‐adjusted
data
to
monitor
outcomes
to
meet
or
exceed
national
goals.
FORCE-‐TJR
comparative
reports
support
quality
monitoring
efforts.
Second,
CMS
issued
a
draft
report
proposing
PRO
collection
and
analysis
following
TJR.
Two
FORCE
surgeons
contributed
to
this
planning
effort,
and
participants
in
the
FORCE
network
already
meet
the
future
expectations.
Finally,
FORCE-‐TJR
proposed
collaborations
with
both
CMS
and
private
insurers
to
clarify
the
role
of
PROs
in
defining
TJR
need
and
outcomes.
These
future
studies
will
guide
efficient
and
effective
patient
selection
and
TJR
care.
o For
FDA
and
implant
manufacturers:
The
FORCE-‐TJR
data
provide
early
post-‐marketing
surveillance
data.
In
contrast
to
registries
that
define
implant
failure
as
revision
surgery,
FORCE-‐TJR
surveillance
includes
post-‐TJR
implant
complications
and
patient-‐reported
pain,
both
events
that
precede
revision
surgery.
FORCE
is
testing
novel
methods
for
monitoring
implant
performance
using
direct
to
patient
strategies,
including
a
pilot
of
an
FDA
developed
APP
for
patient
event
reporting.
o Translational
research:
Ongoing
ancillary
research
includes
collection
of
serum
and
discarded
cartilage
to
evaluate
potential
biomarkers
for
arthritis
and
software
to
aid
x-‐ray
interpretation.
Again, thank you for
allowing us to participate
in what I feel will be of
significant value to the
quality of care that joint
replacement surgery can
offer to the public. Also,
all three of us, and our
nurse manager, do thank
you for managing this
effort so effectively.
Surgeon participant, OK
“
”

FORCE-TJR
TJR
v FORCE-‐TJR
quality
improvement
value
o FORCE-‐TJR
QITM
is
expanding
beyond
the
initial
AHRQ-‐funded
cohort
to
provide
real-‐time
PROs
and
post-‐TJR
adverse
event
surveillance
to
a
growing
number
of
orthopedists.
The
membership
model
allows
us
to
increase
the
number
of
surgeons
and
patients
benefiting
from
the
FORCE-‐TJR
infrastructure
through
quality
monitoring.
In
addition,
orthopedic
surgeons
can
use
the
FORCE-‐TJR
data
to
meet
the
CMS
Patient
Quality
Reporting
System
incentives,
as
well
as
state
and
regional
reporting
requirements.
o In
parallel
with
CMS’
public
reporting
of
30
day
readmission
and
90
day
complications
following
TJR,
the
American
Association
of
Hip
and
Knee
Surgeons
(AAHKS)
and
FORCE-‐TJR
collaborated
to
enhance
the
precision
of
the
CMS
risk-‐adjustment
models
to
assure
more
fair
and
accurate
comparisons.
Ongoing
discussions
will
determine
how
to
implement
this
enhanced
model.
o Implant
evaluation.
Uniquely,
the
rich
FORCE-‐TJR
clinical
and
patient
data
was
merged
with
the
international
library
of
implant
design
and
materials
to
evaluate
outcomes
associated
with
varied
implant
characteristics.
Look
for
future
information
in
the
upcoming
year.
While
we
report
on
the
early
lessons
learned
and
activities
in
this
report,
registry
data
become
even
more
valuable
over
time
as
the
natural
history
of
the
patient
and
implant
outcomes
emerge.
Thus,
FORCE-‐TJR’s
foundation
will
serve
TJR
practice
and
policy
for
years
to
come.
v Highlights
from
current
analyses
o FORCE-‐TJR
disseminated
the
early
comparative
effectiveness
lessons
learned
through
more
than
50
presentations
at
8
national
and
international
meetings
and
the
research
is
accelerating
as
longitudinal
data
are
collected.
o Some
believe
the
shift
to
a
younger
TJR
population
may
suggest
a
less
complex
patient
pool-‐
not
so!
Younger
patients
report
the
same
or
greater
joint-‐specific
and
global
pain
and
decreased
function
pre-‐operatively
compared
to
older
adults.
In
addition,
patients
under
65
years
of
age
are
more
obese
and
more
likely
to
smoke
as
compared
to
older
patients.
I want to get back to where
I was before it all went in
the bucket. I want normal
mobility again. If it (the
study) paves the way for
something even better in
the future, then it’s a
worthwhile use of my time.
Nick L., age 79
(knee replacement)
Oklahoma
“
”

FORCE-TJR
TJR
o Patient
self-‐reported
Pre-‐operative
25th,
50th,
and
75th
percentile
pain
and
function
scores
are
remarkably
consistent
across
surgeons
in
FORCE
suggesting
comparable
indications
for
surgery.
o While
greater
BMI
is
a
risk
factor
for
peri-‐operative
complications,
FORCE-‐
TJR
found
that
at
6
months
after
total
hip
or
knee
replacement,
patients
with
a
BMI
higher
than
35,
also,
reported
significant
gains
in
pain
relief
and
physical
function.
o The
burden
of
musculoskeletal
comorbidities-‐
specifically
moderate
or
severe
pain
in
the
lumbar
spine
and
non-‐operative
hips
and
knees-‐
negatively
affects
self-‐reported
function
at
6
months
after
surgery.
Future
public
comparisons
of
PROs
after
TJR
must
be
cautious
to
adjust
for
co-‐existing
musculoskeletal
conditions.
Patricia
D.
Franklin,
MD
MBA
MPH
David
C.
Ayers,
MD
PI
FORCE-‐TJR
Chair,
National
Stakeholder
Committee
Map of Participating Core Centers and Community Sites
WY
CO
WA
OR
Core Clinical Centers
UMass Medical School, Worcester, MA
Connecticut Joint Replacement Institute, Hartford, CT
The University of Rochester Medical Center, Rochester, NY
Medical University of South Carolina, Charleston SC
Baylor College of Medicine, Houston, TX
PA
VA
VT NH ME
Community Sites currently enrolled
ID
MT ND
MN MI
MI
SD
NE
KS
TX LA
AL GA
SC
NC
NY
MA
CT RI
NJ
DE
MD
DC
WV
FL
MS
OK
IA
MO
IL
IN
OH
KY
TN
WI
AR
NV UT
AZ NM
CA
Community Sites
It’s important to
participate [in FORCE-TJR]
so that people who
have knee replacements in
the future can benefit from
my experience.
Michael L., age 53
(knee replacement) MA
“
”

FORCE-TJR
TJR
CONTENTS
Executive Summary 2
The FORCE-TJR Team 7
Highlights from previously presented research 8
Today’s
TJR
patients
are
younger,
heavier,
and
just
as
disabled
8
Patients
with
high
BMI
report
significant
improvement
9
Pre-‐op
pain
and
function
are
consistent
across
surgeons
10
Pre-‐operative
musculoskeletal
comorbidities
limit
post-‐op
gain
in
function
11
FORCE-‐TJR
Implant
Research
12
MD
website:
comparative
quality
data
13
Why is FORCE-TJR important to US patients, surgeons and policy makers? 15
Arthritis
is
a
significant
public
health
issue
15
Total
joint
replacement
is
common,
costly,
growing
15
Patients’
goals
after
TJR
are
pain
relief
and
functional
gain
15
International
registries
monitor
revisions,
while
FORCE-‐TJR
measures
comprehensive
quality
and
patient-‐reported
outcomes.
15
Goals and benefits 16
Function
varies
widely
after
Total
Knee
Replacement
(TKR)
16
What
are
FORCE-‐TJR
research
goals?
16
How
will
FORCE-‐TJR
design
and
methods
assure
succcess
and
benefit
our
patients?
17
Sample
Data
Collected
20
Patients’ Characteristics 22
Appendix 1: FORCE-TJR Bibliography (through June 2014) 23
Appendix 2: FORCE-TJR Ancillary Research Funding (all funded grants and contracts) 28

FORCE-TJR
TJR
The FORCE-TJR Team
PI:
Patricia
D.
Franklin,
MD
MBA
MPH
Operations
Team
Christine
P.
Bond,
MS
Christine
Goddard
Celeste
Lemay,
MPH
RN
Pamela
Wiley,
MPH
Clinical
Team
David
Ayers,
MD
Courtland
Lewis,
MD
Regis
O’Keefe,
MD
Philip
Noble,
PhD
Vincent
Pellegrini,
MD
Scientific
Team
Patricia
Franklin,
MD
MBA
MPH
Leslie
Harrold,
MD
MPH
Wenjun
Li,
PhD
Hua
Zheng,
PhD
Jeroan
Allison,
MD
MS
Bruce
Barton,
PhD
John
Ware,
PhD
Norman
Weissman,
Ph.D.
National
Stakeholder
Committee
Graphic
Design
and
Report:
Sylvie
Puig,
PhD
David
C.
Ayers,
MD
Chair
University
of
Massachusetts
Medical
School/UMASS
Memorial
Medical
Center
Jeroan
Allison,
MD
MS
University
of
Massachusetts
Medical
School
Elise
Berliner,
PhD
Agency
for
Healthcare
Research
and
Quality
(AHRQ)
Patricia
Franklin,
MD
MPH
MBA
University
of
Massachusetts
Medical
School
Deborah
Freund,
MPH
MA
PhD
Claremont
Graduate
University
(PORT-‐TKR)
Terence
Goie,
MD
University
of
Minneapolis,VA
(AAOS/AJRR)
Gillian
Hawker,
MD
MSc
FRCPC
University
of
Toronto
William
A
Jiranek,
MD
VCU
Health
System
(Knee
Society)
Norman
Johanson,
MD
Drexel
University
College
of
Medicine
(Hip
Society)
Catarina
Kiefe,
PhD
MD
University
of
Massachusetts
Medical
School
Courtland
Lewis,
MD
Hartford
Hospital
(AAHKS)
Danica
Marinac-‐Dabic,
MD
PhD
Food
and
Drug
Administration
(FDA)
Joan
McGowan,
PhD
National
Institutes
of
Arthritis
and
Musculoskeletal
and
Skin
Diseases
(NIAMS)
Mark
Melkerson,
MS
Food
and
Drug
Administration
(FDA)
Carol
Oatis,
PT,
PhD
Arcadia
University
Jyme
H.
Schafer,
MD
MPH
Center
for
Medicare
and
Medicare
Services
(CMS)
Patricia
Skolnik,
MSW
Citizens
for
Patient
Safety
Paul
Voorhorst, MS
MBA
DePuy
Orthopaedics,
A
JJ
company
Jing
Xie,
PhD
Biomet,
Inc.

FORCE-TJR
TJR
Highlights from previously presented research
Today’s TJR patients are younger, heavier, and just as disabled
At
the
time
of
TKR
and
THR,
younger
(65)
patients
have
fewer
medical
illnesses,
but
higher
rates
of
obesity
and
smoking
as
well
as
lower
mental
health
scores
compared
to
older
(65)
patients.
Younger
patients
have
the
same
or
greater
joint
specific
and
global
functional
impairment
compared
to
older
patients,
which
suggest
that
surgeons
use
comparable
standards
for
selecting
TKR
and
THR
candidates
in
younger
and
older
adults.
THR PATIENTS TKR PATIENTS
Characteristics
Age
65
(n=2035)
Age
≥65
(n=3084)
p
value
Age
65
(n=1780)
Age
≥65
(n=1831)
p
value
Gender
(%
female)
47.5
52.5
0.012
61.7
63.1
0.307
BMI
(mean
±
SD)
29.9±6.1
28.5±5.3
0.000
33.1±6.7
30.5±5.6
0.000
Race:
nonwhite
(%)
9.7
5.3
0.000
13.1
6.6
0.000
Smoking
status
(%)
10.2
2.8
13.2
3.4
current
33.7
45.3
33.7
48.9
0.000
0.000
past
56.1
51.9
53.0
47.7
never
Estimated
WOMAC*
(operative
joint)
pain
(mean
±
SD
)
stiffness
(mean
±
SD
)
function
(mean
±
SD)
44.9±20.1
34.6±21.5
43.2
±
19.3
50.6±19.2
40.6±21.4
45.6±19.2
0.000
0.000
0.000
47.3±18.3
38.1±21.4
50.0
±
18.2
53.9±18.7
46.3±21.7
52.8±18.2
0.000
0.000
0.000
Baseline
sf-‐36
PCS
(mean
±
SD
)
31.2±8.5
31.5±8.6
0.300
32.0±8.1
33.0±8.4
0.000
Baseline
sf-‐36
MCS
(mean
±
SD
)
48.4±12.9
51.5±12.1
0.000
49.1±13.0
52.6±11.7
0.000
Charlson
comorbidities
index
(%)
0
1
2-‐5
=6
66.0
17.8
7.8
8.4
49.1
21.1
12.0
17.9
0.000
57.9
21.7
11.9
8.5
45.8
23.1
13.5
17.7
0.000
Pain
in
non-‐operative
hip/knee
joints
(%)
37.6
35.7
0.237
38.2
31.1
0.000
*Based
on
the
HOOS/KOOS

FORCE-TJR
TJR
Patients with high BMI report significant improvement
At
6
months
after
THR,
all
patients
reported
significant
functional
gains
although
patients
with
BMI35
had
lower
mean
functional
gain
than
those
with
BMI35.
All
patients
reported
excellent
pain
relief.
At
6
months
after
TKR,
severely
obese
patients
(BMI35)
reported
improvements
in
both
pain
and
function
equal
to
or
greater
than
patients
with
BMI35.
Obesity
status
Baseline
6
month
Delta
Baseline
6
month
Delta
N
%
Physical
function
(Mean
(SE))
N
%
Physical
function
(Mean
(SE))
Under/normal
weight
530
26%
32.4
(0.4)
46.5
(0.4)
14.1
(0.5)
396
13%
35.2
(0.4)
44.7
(0.5)
9.5
(0.4)
Overweight
763
37%
32.7
(0.3)
45.7
(0.4)
13.1
(0.4)
978
33%
34.3
(0.3)
44.2
(0.3)
9.9
(0.3)
Obese
453
22%
30.2
(0.4)
44.8
(0.5)
14.6
(0.5)
861
29%
33.0
(0.3)
42.3
(0.3)
9.3
(0.3)
Severely
obese
204
10%
28.3
(0.6)
41.2
(0.7)
12.9
(0.8)
457
15%
31.3
(0.4)
41.1
(0.5)
9.8
(0.4)
Morbidly
obese
90
4%
26.6
(0.8)
39.6
(1.0)
13.0
(1.1)
272
9%
29.9
(0.5)
40.4
(0.6)
11.0
(0.6)
N
%
WOMAC
Pain
(Mean
(SE))
N
%
WOMAC
Pain
(Mean
(SE))
Under/normal
weight
515
26%
51.0
(0.9)
91.8
(0.6)
40.9
(0.9)
371
13%
56.4
(0.9)
85.5
(0.7)
29.0
(1.1)
Overweight
745
38%
51.1
(0.7)
90.6
(0.5)
39.5
(0.8)
927
33%
55.4
(0.6)
85.8
(0.5)
30.4
(0.7)
Obese
442
22%
47.3
(0.9)
89.7
(0.6)
42.5
(1.0)
817
29%
53.0
(0.6)
83.6
(0.6)
30.5
(0.7)
Severely
obese
194
10%
45.5
(1.5)
88.4
(1.1)
43.0
(1.8)
426
15%
50.6
(0.9)
84.0
(0.8)
33.3
(1.0)
Morbidly
obese
86
4%
38.2
(2.1)
88.4
(1.4)
50.2
(2.2)
252
9%
47.1
(1.2)
82.6
(1.1)
35.4
(1.3)

FORCE-TJR
TJR
Pre-op pain and function are consistent across surgeons
Consistent
25th
to
75th
%ile
scores
are
reported
across
sites
with
HOOS/KOOS
pain
scores
from
30
to
55,
and
PCS
from
25
to
37,
representing
significant
impairment.
Despite
the
large
numbers
of
patients
electing
THR
and
TKR,
pre-‐operative
pain
and
function
scores
suggest
consistent
patient
selection
across
surgeons
of
significantly
impaired
adults.
These
data
suggest
the
growing
TKA
and
THR
utilization
is
reaching
appropriate
patients.
Figure
1.
Baseline
HOOS/KOOS
Pain
Score
by
Site.
The
red
line
represents
median
across
sites.
Pain
free
is
a
score
of
90-‐100.
Figure
2.
Baseline
SF36
PCS
Score
by
Site.
The
red
line
represents
median
across
sites.
National
norm
is
PCS
of
50.
Figure
3.
Baseline
HOOS/KOOS
ADL
Score
by
Site.
The
red
line
represents
median
across
sites.
Ideal
function
is
a
score
of
90-‐100.

FORCE-TJR
TJR
Pre-operative musculoskeletal comorbidities limit post-op
gain in function
Predictors
of
change
in
pre-‐to-‐6
month
post-‐THR
and
post-‐TKR
pain
and
function
were
examined
using
linear
mixed
models
adjusting
for
clustering
within
site
in
the
first
5300
patients
(3084
TKR;
2233
THR).
After
adjusting
for
sociodemographic
factors,
significant
predictors
of
poorer
6
month
post-‐
THR
pain
included
poorer
pre-‐operative
emotional
health,
poorer
physical
function,
and
any
lumbar
pain
at
time
of
surgery.
These
factors,
as
well
as
greater
BMI
and
moderate/severe
pain
in
the
non-‐operative
knees
and
hips,
predicted
poorer
6
month
function.
Significant
predictors
of
poorer
6
month
post-‐TKR
pain
included
poorer
emotional
health,
higher
Charlson
comorbidity
scores
and
any
lumbar
pain
at
time
of
surgery.
These
factors
also
predicted
poorer
6
month
function.
Variable
Function
PCS
Pain
Function
PCS
Pain
Coef.
P
value
Coef.
P
value
Coef.
P
value
Coef.
P
value
Administrative
data
Race,
non
White
-‐0.088
0.938
-‐4.164
0.008
-‐2.005
0.013
-‐7.336
0.001
Age
group,

65
years
of
age
2.042
0.002
-‐0.388
0.675
1.513
0.001
-‐2.085
0.019
SES,

25,000/year
-‐1.662
0.024
-‐2.763
0.007
-‐1.706
0.002
-‐1.629
0.115
BMI
-‐0.187
0.001
-‐0.039
0.448
-‐0.082
0.003
-‐0.021
0.676
Non
administrative
PROs
SF
36,
MCS
0.146
0.001
0.151
0.001
0.111
0.001
0.166
0.001
SF
36,
PCS
-‐0626
0.001
-‐
-‐
-‐0.551
0.001
-‐
-‐
WOMAC
pain
score
-‐
-‐
-‐0.971
0.001
-‐
-‐
-‐0.874
0.001
Charlson
Comorbidity
Index
1
-‐2.094
0.001
-‐1.470
0.062
-‐1.206
0.005
-‐1.544
0.054
Charlson
Comorbidity
Index
2
to
5
-‐1.528
0.061
-‐1.183
0.297
-‐2.245
0.001
-‐1.66
0.122
Charlson
Comorbidity
Index
≥
6
-‐1.141
0.049
-‐0.914
0.258
-‐1.478
0.001
-‐2.057
0.015
Lower
back
pain,
Mild
-‐1.114
0.024
-‐1.682
0.015
-‐1.266
0.001
-‐2.515
0.001
Lower
back
pain,
Moderate
-‐1.974
0.001
-‐2.269
0.002
-‐2.598
0.001
-‐2.673
0.001
Lower
back
pain,
Severe
-‐2.052
0.005
-‐3.866
0.001
-‐4.434
0.001
-‐4.088
0.002
One
non-‐surgical
joint
with
mod/sev
pain
-‐0.780
0.106
-‐2.207
0.001
-‐1.401
0.001
-‐2.866
0.001
Two
non-‐surgical
joints
mod/sev
pain
-‐3.166
0.001
-‐3.916
0.001
-‐1.630
0.037
-‐4.414
0.003
Three
non-‐surgical
joints
with
mod/sev
pain
-‐5.556
0.001
-‐3.170
0.080
-‐2.262
0.059
-‐7.848
0.001

FORCE-TJR
TJR
FORCE-TJR Implant Research
Understanding
implant
performance
in
patients
with
specific
clinical
profiles
The
FORCE-‐TJR
implant
library
includes
over
54,000
components
of
TKR
and
THR
implants
from
all
US
manufacturers.
To
assure
uniform
component
definitions,
the
FORCE-‐TJR
implant
library
was
merged
with
the
International
Consortium
of
Orthopedic
Registries
(ICOR)
component
library
housed
by
the
Australian
Registry.
The
comprehensive
FORCE-‐TJR
database,
together
with
the
implant
components,
allows
implant
outcome
analyses
for
sub-‐
groups
of
patients
with
specific
clinical
profiles—something
that
has
not
been
possible
in
other
registries.
Tracking
patient-‐reported
symptoms
allows
early
identification
of
differences
in
implant
performance.
For
example,
FORCE-‐TJR
asked:
do
TKR
patients
under
65
years
of
age
achieve
comparable
pain
relief
with
Implant
X
as
compared
to
all
other
implants?
Figure
1
shows
that
a
sub-‐group
of
patients
with
implant
X
(blue)
report
persistent
moderate
pain
at
12
months
post-‐TKR.
The
implant
X
pain
distribution
appears
bimodal
(blue)
as
compared
to
patients
with
all
other
implants
(black).
Next,
at
2
and
5
years,
we
will
determine
if
the
sub-‐group
of
patients
reporting
greater
pain
at
12
months
after
TKR
have
a
higher
revision
rate.
We
will
also
evaluate
differing
implants
categories
to
identify
outcome
variation
by
design
(rotating
platform),
material
(ceramic),
fixation
(cementless),
and
other
attributes.
Figure
1.
Distribution
of
pain
at
12
months
post-‐TKR
with
Implant
X
(blue),
as
compared
to
all
other
implants
(black)
Implant(X(Pa+ents(by((6(month(Pain(
TJR
Implant
X
patients
by
6-‐month
pain
KOOS$
Pain75$
KOOS$
Pain=75$
POST(KOOS(Pain((mean)( 58( 89( P0.0000(
PRE1TKR$PROFILE$
Pre(KOOS(Pain((mean)( 37( 50( p0.0002(
Pre(SF36/PCS((mean)( 30( 33( P0.04(
Pre(KOOS(ADL((mean)( 43( 56( p0.0001(
ModMSevere(Low(Back(Pain( 52%( 24%( P0.027(
Charlson(Index(((((((((((((((((((((0M1( 89%( 75%(
(((((((((((((((((((((((((((((((((((((((((((((((2M5( 10.5%( 3%( p0.288(
POST1TKR$FUNCTION$
Post(SF36/PCS((mean)( 37( 45( p0.0000(
Post(KOOS(ADL( 65( 88( p0.0000(

FORCE-TJR
TJR
MD website: comparative quality data
As
of
April
2014,
over
19,000
patients
were
enrolled
from
more
than
130
surgeons
in
22
states.
The
reporting
website
was
launched
in
September
2012.
It
has
been
updated
quarterly
for
all
surgeons
to
review
their
site-‐
and
individual-‐specific
data.
A
random
sample
of
the
130
surgeons
found
an
average
of
6.2
logins
per
user.
Returning
registry
data
to
surgeons
encourages
active
participation
while
supporting
practice-‐
level
quality
monitoring
and
improvement
efforts
in
patient
care.
We
anticipate
that
returning
data
to
surgeons
will
facilitate
complete
data
capture
and
enhance
future
secondary
uses
of
the
data
to
drive
quality
enhancement,
in
addition
to
patient-‐centered
outcomes
research.
Figure
1.
This
screen
shot
of
the
MD
website
home
page
shows
what
a
surgeon
can
access
after
entering
his/her
secure
login
information.
Graphs
depicting
enrollment
data
as
well
as
tables
of
PROs
are
available
at
the
site
level,
practice
level
and
individual
surgeon
patients
level
as
well
as
comparison
with
all
sites
enrolled
in
FORCE-‐TJR.
Figure
2.
Example
of
knee
surgery
PRO
available
to
surgeon.

FORCE-TJR
TJR
Quarterly
MD
Report
This
executive
summary
of
the
quarterly
surgeon
report
addresses
3
questions:
1. How
do
my
patients
compare
to
patients
at
other
sites
on
key
risk-‐adjustment
factors?
[Patient
Mix]
2. How
do
my
patients
compare
to
other
sites
on
pre-‐TJR
pain
and
function?
[Patient
Selection
and
Timing
of
Surgery]
3. How
do
my
risk-‐adjusted
6
and
12
month
pain
and
function
compare
to
other
sites?
[TJR
patient-‐reported
outcomes]

FORCE-TJR
TJR
Why is FORCE-TJR important to US patients,
surgeons and policy makers?
Arthritis is a significant public health issue
n 50
million
U.S.
adults
diagnosed
with
osteoarthritis
(OA)
n OA
is
leading
cause
of
disability
in
U.S.
adults
n OA
is
#1
chronic
condition
among
women
and
#2
most
costly
chronic
condition
in
U.S.
n Employer
costs
are
$9000
per
OA
employee
Total joint replacement is common, costly, growing
n More
than
1,000,000
Total
Hip
and
Knee
Replacement
surgeries
each
year
n Between
1997
and
2004,
aggregate
charges
(the
‘national
bill’)
for
primary
TJR
surgeries
increased
dramatically:
from
$8.9
billion
to
$50.5
billion
(knees

hips).
n By
2030
the
demand
for
THR
and
TKR
is
projected
to
grow
by
174%
and
673%,
respectively
n Fastest
growth
among
patients

65
years
of
age
Patients’ goals after TJR are pain relief and functional gain
n TJR
is
a
technically
successful
procedure
n Functional
outcomes
vary
with
both
patient
factors
(e.g.,
gender,
age,
comorbidities)
and
health
system
delivery
factors
(e.g.,
hospital
volume)
International registries monitor revisions, while FORCE-TJR
measures comprehensive quality and patient-reported outcomes.
n Scandinavian
TJR
registries
have
existed
for
decades;
UK,
Australia
and
others
have
parallel
registries
n US
efforts
emerging:
American
Joint
Replacement
Registry
and
state-‐based
registries
(California,
Michigan,
Virginia)
n Primary
outcome
=
Implant
failure
and
REVISION
n FORCE-‐TJR
begins
with
patient
goals:
pain
relief
and
functional
gain
(PROs)
and
adds
quality
and
implant
outcomes.

FORCE-TJR
TJR
Goals and benefits
Function varies widely after Total Knee Replacement (TKR)
Distribution of SF36 PCS Score
0 20 40 60 80
What are FORCE-TJR research goals?
SF36 PCS
Franklin, Li and Ayers, 2008
n Establish
a
comprehensive
data
collection
of
over
30,000
diverse
patients
from
130
orthopedic
surgeons
representing
all
regions
of
the
US
and
varied
hospital/surgeon
practice
settings
(e.g.,
urban/rural,
low
and
high
volume).
n Data
collection
platform
will
minimize
patient
and
surgeon
data
entry
burden,
emphasize
patient-‐reported
data,
collect
most
information
at
the
time
of
surgery,
and
use
Internet
technology
to
minimize
data
entry.
n Conduct
research
to
guide
surgical
practice
to
optimize
function
and
patient
outcomes.
Construct,
validate,
and
refine
prediction
algorithms
for
patients
at
risk
for
lack
of
post-‐TJR
functional
gain,
and
for
optimal
TJR
outcomes.
Develop
a
survey
platform
to
answer
questions
related
to
TJR
benefits
among
working-‐age
adults
and
issues
of
disparities.

FORCE-TJR
TJR
How will FORCE-TJR design and methods assure succcess and
benefit our patients?
Design
optimizes
retention
n Minimize
patient
and
surgeon
burden.
o User-‐friendly
web-‐based
and
paper
surveys
to
allow
quick
and
complete
data
capture
o Primary
outcomes
from
patients;
validated
clinically.
o Follow-‐up
data
collection
performed
by
FORCE-‐TJR
staff
n Maximize
participant
retention.
o FORCE-‐TJR
has
developed
new
methods
to
collect
pre-‐TJR
PROs
on
96%
of
patients
and
post-‐TJR
PROs
on
approximately
85%
of
patients.
o FORCE-‐TJR
is
returning
registry
data
to
surgeons
(surgeon-‐specific
comparative
outcome
reports),
thus
encouraging
active
participation
and
supporting
practice-‐
level
quality
monitoring
and
improvement
efforts
in
patient
care
n Optimize
data
collection
flexibility.
o Survey
options
meet
patient
and
office
needs
o Web-‐based
from
home
or
office,
computer
in
office,
paper
Comprehensive
Data
on
a
National
Sample
of
Patients
n Patient
Characteristics
o Gender,
Age,
Race/ethnicity
o BMI
and
Physical
Health
o Co-‐existing
Medical
and
Musculoskeletal
Conditions
(
o Emotional
Health
o Pre-‐operative
level
of
Disability
n Surgical
Factors
o Surgical
Approach
o Implant
Design
and
Material
n System
Factors
o TJR
Hospital
Volume

FORCE-TJR
TJR
Data
primarily
from
patients;
supplemented
by
OR
and
clinical
measures.
MD and Hospital OPTIONAL Medical Record Data
Enroll
over
10,000
patients
annually

FORCE-TJR
TJR
Patient
enrollment
process
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/+)*0*$
1+23$
456($%'()*$
178/9:;8$
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1=$/+)*0*$
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178/9:;8$
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*+$178/9:;8$*?$

FORCE-TJR
TJR
Sample Data Collected
Below
is
a
sample
of
the
data
collected:
PQRS and FORCE-TJR Data Elements, Sample Questions
Patient Pain and Function Survey
Survey Schedule: Pre-Surgery, 6 months Post-Surgery, Annually
Self-Report--Takes 15-20 min to complete
PQRS Measure(s)
Personal
(22 items)
Contact Information/ Demographic data
Needed for all Risk-adjustment
measures,
including:
# 217 Functional Status Knee
impairments ,
#218 Functional Status Hip
impairments, and #220
Functional Status Lumbar Spine
impairments
#358 Patient-centered Surgical
Risk adjustment
Name, address, phone number, email address, date of birth, marital status, education level, race,
gender, etc.
Body Mass Index, Smoking status
PQRS Measure(s)
SF36
(36 items)
General health status
Needed for all Functional
Status measures including:
#109 OA function pain
#131 Pain assessment and
follow-up
#178 RA function and pain
#182 Functional outcome
assessment
#217 Functional Status Knee
impairments ,
Functional Status Lumbar
Spine impairments
Risk adjustment
TKR Group Measure item –
Shared decision making (1 of 4)
During the past 4 weeks, how much of the time have you had any of the following problems with
your work or other regular daily activities as a result of your physical health:
1. Accomplished less than you would
like
2. Had difficulty performing work
All of
the time
ർ
ർ
Most of
the time
ർ
ർ
Some of
the time
ർ
ർ
A little of
the time
ർ
ർ
None of
the time
ർ
ർ
Activity limitations due to current health
Does your health now limit you in activities you might do during a typical day? If so, how much?
1. Bathing or dressing yourself
2. Lifting or carrying groceries
Limited a lot
ർ
ർ
Limited a little
ർ
ർ
Not limited at all
ർ
ർ
PQRS Measure(s)
Comorbidity
Index
(14 items)
Co-Occurring Medical Conditions
Needed for all Risk-adjustment
measures,
including:
# 217 Functional Status Knee
impairments ,
Functional Status Lumbar Spine
impairments
Risk adjustment
Indicate if you have been diagnosed with any of the following conditions:
COPD, Connective Tissue Disease, Diabetes, Cancer, etc.

FORCE-TJR
TJR
OR Data
PQRS Measure(s)
Implant
Data
(14Items)
Data
(14 Items)
14 AJRR elements
TKR Group Measure -
Identification of implanted
prosthesis in operative note (1 of
4)
Institution, Patient First Name, Patient Last Name, Date of Birth, Date of Procedure, Type of
Procedure, Implant Manufacturer, Component Catalogue #, Component Lot #, (Repeat catalogue and
lot # for each component) Cement Type, Cement Antibiotics, Bone Graft Type and Bone Graft Volume
Chart Data
PQRS Measure(s) Treatment
Surgery/Post-Surgery treatment
#131 Pain assessment follow-up
assessment
Venous thromboembolic
cardiovascular risk evaluation
(1 of 4)
preoperative antibiotic infusion
with proximal tourniquet (1 of 4)
Adverse events reporting
Documentation of follow-up plan after pain assessment
Documentation of care plan based on identified functional outcome deficiencies on date of identified
deficiencies
Documentation of shared decision-making discussion of conservative (non-surgical) therapy prior to
procedure
Pre-operative note with evaluation of venous thromboembolic cardiovascular risk evaluation 30 day
prior to surgery
Operative note with preoperative antibiotic infusion with proximal tourniquet
Discharge Summary
ICD9 procedure code
ICD9 primary diagnosis code
Hip/Knee surgical approach data
Post-surgery events/complications
PQRS Measure(s)
Back Pain
(1 item)
Severity of Back Pain
status Risk adjustment
measures including:
#131 Pain assessment follow-up
assessment
impairments
impairments
#220 Functional Status
Lumbar Spine impairments
Risk adjustment
My back pain at the moment is:
No back pain--Very mild--Moderate--Fairly severe--Very severe--Worst imaginable
PQRS Measure(s)
HOOS/
KOOS
(68 items/
71 items)
Symptoms, stiffness, and pain associated with the surgical joint
status and Risk adjustment
measures including:
#131 Pain assessment and
follow-up
assessment
impairments
impairments
#220 Functional Status
Lumbar Spine impairments
Risk adjustment
What amount of pain have you experienced in the last week in your surgical (hip/knee) during
the following activity?
None
Mild
Moderate
Severe
Extreme
1. Sitting or lying down
ർ
ർ
ർ
ർ
ർ
2. Going up or down stairs
ർ
ർ
ർ
ർ
ർ
Physical function (Surgical Joint)
For each of the following activities, please indicate the degree of difficulty you have experienced
in the last week due to your surgical (hip/ knee):
None
Mild
Moderate
Severe
Extreme
1.Getting in/out of car
ർ
ർ
ർ
ർ
ർ
2. Rising from sitting
ർ
ർ
ർ
ർ
ർ
Physical function (Non-Surgical Joint)
For each of the following activities, please indicate the degree of difficulty you have experienced
in the last week due to your non-surgical (hip/ knee):
1.Getting in/out of car
2. Rising from sitting
None
ർ
ർ
Mild
ർ
ർ
Moderate
ർ
ർ
Severe
ർ
ർ
Extreme
ർ
ർ
Surgical joint specific
Please rate your symptoms and difficulties in your surgical (hip/ knee) during the last week
when doing these activities:
Never
Rarely
Sometimes
Often
1.Do you have swelling in your surgical knee
ർ
ർ
ർ
ർ
2.Difficulties to stride out when walking
ർ
ർ
ർ
ർ
Always
ർ
ർ

FORCE-TJR
TJR
Patients’ Characteristics
Patients’
pre-‐op
characteristics
and
6
month
outcomes
Characteristic
Primary
TKR
Primary
THR
Age
(mean
years)
66.6
64.4
Female
(%)
61.7
57.0
BMI
(mean)
31.5
29.1
HOOS/KOOS
(operative
joint)
Pain
(mean)
Function
(mean)
46.0
52.1
42.0
44.4
Baseline
SF-‐36
MCS
(mean)
PCS
(mean)
51.4
32.7
50.1
31.3
6
mo.
HOOS/KOOS
(operative
joint)
Pain
(mean)
Function
(mean)
84.5
82.6
90.5
85.8
6
mo.
SF-‐36
MCS
(mean)
PCS
(mean)
54.3
42.9
54.2
45.1

FORCE-TJR
TJR
Appendix 1: FORCE-TJR Bibliography (through
June 2014)
PUBLICATIONS
1. Franklin
PD,
Lewallen
D,
Bozic
K,
Hallstrom
B,
Jiranek
W,
Ayers
D.
Implementation
of
patient-‐reported
outcomes
in
US
total
joint
replacement
registries:
rationale,
status,
and
plans.
The
Journal
of
Bone

Joint
Surgery.
ICOR
suppl
(in
press)
2. Gandek
B.
Measurement
properties
of
the
Western
Ontario
and
McMaster
Universities
Osteoarthritis
Index:
A
systematic
review”.
Arthritis
Care

Research.
(Hoboken).
2014
Jul
21.
doi:
10.1002/acr.22415.
[Epub
ahead
of
print]
3. Ayers
DC,
Li
W,
Harrold
LR,
Allison
JA,
Franklin
PD.
Pre-‐operative
pain
and
function
profiles
reflect
consistent
TKR
patient
selection
among
US
surgeons.
Clinical
Orthopaedics
and
Related
Research.
Clinical
Orthopaedics
and
Related
Research.
2014;
Jun
2014
Epub
ahead
of
print
DOI
10.1007/s11999-‐014-‐3716-‐5
4. Ayers
DC
and
Franklin
PD.
Hip
Outcome
Assessment.
In
Callaghan
JJ,
Rosenberg
AG,
Rubash
HE,
editors.
The
Adult
Hip
(Callaghan,
Aaron,
Rubash)
Lippincott
Williams

Wilkins;
2014.
5. Devers
K,
Gray
B,
Ramos
C,
Shah
A,
Blavin
F,
Waidmann
T.
Key
Informant
Interview:
Patricia
Franklin,
MD,
University
of
Massachusetts
Medical
School
(FORCE-‐TJR).
In
ASPE
Report:
The
Feasibility
of
Using
Electronic
Health
Data
for
Research
on
Small
Populations;
2013.
6. FORCE-‐TJR
In:
An
Introduction
to
AHRQ's
Third
Edition
of
Registries
for
Evaluating
Patient
Outcomes.
AHRQ
2013.
7. Franklin
PD,
Harrold
LR,
Ayers
DC.
Incorporating
patient
reported
outcomes
in
total
joint
arthroplasty
registries:
challenges
and
opportunities.
Clinical
Orthopaedics
and
Related
Research.
2013;
471(11):3482-‐
3488.
PMCID:
PMC3792256
8. Ayers
DC.
Zheng
H,
Franklin
PD.
Integrating
Patient-‐Reported
Outcomes
(PROs)
into
orthopedic
clinical
practice:
proof
of
concept
from
FORCE-‐TJR.
Clinical
Orthopaedics
and
Related
Research.
2013;
471(11):3419-‐
3425.
PMCID:
PMC3792269
9. Franklin
PD,
Rosal
MC.
Can
knee
arthroplasty
play
a
role
in
weight
management
in
knee
osteoarthritis?
Arthritis
Care

Research
2013
May;
65
(5):
667–668.
10. Franklin
PD,
Allison
JJ,
Ayers
DC.
Beyond
implant
registries:
a
patient-‐centered
research
consortium
for
comparative
effectiveness
in
total
joint
replacement.
JAMA.
2012
Sep;
308(12):
1217-‐8.
PRESENTATIONS
AT
INTERNATIONAL
AND
NATIONAL
MEETINGS
1. Franklin
PD,
Harrold
L,
Li
W,
Ash
A,
Ayers
DC.
Improving
risk
prediction
models
for
readmission:
adding
clinical
variables
to
administrative
data.
International
Congress
of
Arthroplasty
Registries,
Boston,
MA.
(June
2014)
2. Ayers
DC,
Harrold
L,
Li
W,
Noble
P,
Allison
JJ,
Franklin
PD.
Pre-‐op
THR
and
TKR
pain
and
functional
limitation
profiles
are
consistent
across
U.S.
surgeons.
International
Congress
of
Arthroplasty
Registries,
Boston,
MA.
(June
2014)
(Podium)
3. Franklin
PD,
Harrold
L,
Li
W,
Allison
JJ,
Lewis
C,
Ayers
DC.
Are
all
important
predictors
of
pain
and
function
after
TKR
and
THR
included
in
registry
data?
International
Congress
of
Arthroplasty
Registries,
Boston,
MA.
(June
2014)

FORCE-TJR
TJR
4. Noble
P,
Harrold
L,
Li
W,
Allison
JJ,
Ayers
DC,
Franklin
PD.
Disability
at
time
of
surgery
in
younger
vs.
Older
THR
and
TKR
patients:
lessons
from
force-‐TJR.
International
Congress
of
Arthroplasty
Registries,
Boston,
MA.
(June
2014)
(Poster)
5. Zheng
H,
Li
W,
Harrold
L,
Allison
JJ,
Ayers
DC,
Franklin
PD.
Surgeon-‐Specific
Web
Reports
to
Support
Quality
Improvement
in
National
Patient-‐Centered
Outcomes
Research
for
Comparative
Effectiveness
in
Total
Joint
Replacement.
Electronic
Data
Methods
Forum,
San
Diego,
CA.
(June
2014)
(Poster)
6. Franklin
PD,
Harrold
L,
Li
W,
Lewis
C,
Allison
JJ,
Ayers
DC.
Important
predictors
of
patient-‐reported
outcomes
after
THR
and
TKR
not
included
in
risk
models
based
on
administrative
data.
UMCCTS
May
2014
and
AcademyHealth
Annual
Research
Meeting
(ARM),
San
Diego,
CA.
(June
2014)
(Poster)
7. Franklin
PD,
Harrold
L,
Li
W,
OKeefe
R,
Allison
JJ,
Ayers
DC.
Providing
comprehensive,
comparative
post-‐
TJR
outcome
feedback
to
surgeons
for
quality
monitoring
and
value
decisions.
AcademyHealth
Annual
Research
Meeting
(ARM),
San
Diego,
CA.
(June
2014)
(Poster)
8. Franklin
PD.
Activity
measurement
in
TJR
comparative
effectiveness/outcomes
research.
UMCCTS
(May
2014)
(podium)
9. Lemay
CA,
Harrold
L,
Li
W,
Ayers
DC,
Franklin
PD.
Social
support
and
total
joint
replacement:
Differences
preoperatively
between
patients
living
alone
and
those
living
with
others.
UMCCTS
(May
2014)
(poster)
10. Franklin
PD.
Patient
Outcomes
Research
Registry:
Function
and
Outcomes
Research
for
Comparative
Effectiveness
in
Total
Joint
Replacement
(FORCE-‐TJR).
Worldwide
Orthopedic
Arthroplasty
Registries.
March
12,
2014
New
Orleans,
LA.
(Podium)
11. Franklin
PD,
Ayers
DC.
Patient-‐reported
outcomes
in
research.
Orthopaedic
Research
Society,
New
Orleans,
LA.
(March
2014)
(Panel)
12. Harrold
L,
Snyder
B,
Li
W,
Ayers
DC,
Franklin
PD.
Poor
pre-‐operative
emotional
health
limits
gain
in
function
after
total
hip
replacement.
Orthopaedic
Research
Society,
New
Orleans,
LA.
(March
2014)
(Presentation)
13. Ayers
DC,
Harrold
L,
Li
W,
Allison
JJ,
Noble
P,
Franklin
PD.
Do
younger
TKR
and
THR
patients
have
similar
disability
at
time
of
surgery
as
older
adults?
Lessons
From
FORCE-‐TJR.
Orthopaedic
Research
Society,
New
Orleans,
LA.
(March
2014)
(Poster)
14. Franklin
PD,
Harrold
L,
Li
W,
Lewis
C,
Allison
JJ.
Important
musculoskeletal
predictors
of
patient-‐reported
outcomes
after
TKR
and
THR
are
not
included
in
risk
models
based
on
administrative
data.
Orthopaedic
Research
Society,
New
Orleans,
LA.
(March
2014)
(Poster)
15. Franklin
PD.
Harrold
L,
Miozzari
M,
Hoffmeyer
P,
Ayers
DC,
Lubbeke
A.
Differences
In
patient
characteristics
prior
to
TKA
and
THA
between
Switzerland
and
the
US.
UMCCTS
May
2014
and
Orthopaedic
Research
Society,
New
Orleans,
LA.
(March
2014)
(Panel)
)
16. Li
W.,
Ayers
DC,
Harrold
L,
Allison
J,
Lewis
CG,
R.
Bowen
TR,
Franklin
PD.
Do
functional
gain
and
pain
relief
after
THR
differ
by
patient
obese
status?
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Paper)
17. Lubbeke
A,
Miozzari
H,
Harrold
L,
Ayers
DC,
Franklin
PD.
Differences
in
patient
characteristics
prior
to
total
hip
arthroplasty
between
Switzerland
and
the
US
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Paper)
18. Franklin
PD,
Barton
B,
Harrold
L,Li
W,
O'Keefe
R,
Allison
J,
Ayers
DC.
Comprehensive,
comparative
post-‐TJR
outcome
feedback
to
surgeons
for
quality
monitoring
and
value
decisions.
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Scientific
Exhibit)

FORCE-TJR
TJR
19. Harrold
L,
Ayers
DC,
O'Keefe
R,
Lewis
CG,
Pellegrini
V,
Franklin
PD.
The
validity
of
patient-‐reported
short-‐
term
complications
following
total
hip
and
knee
arthroplasty.
UMCCTS
May
2014
and
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Paper)
20. Ayers
DC,
Harrold
L,
Li
W,
Franklin
PD.
Pre-‐op
THR
pain
and
functional
limitation
profiles
are
consistent
across
U.S.
surgeons.
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Poster)
21. Franklin
PD,
Harrold
L,
Li
W,
Lewis
CG,
Allison
J,
Ayers
DC.
Predictors
of
patient-‐reported
outcomes
after
TKR
not
included
in
risk
models
based
on
administrative
data.
American
Academy
of
Orthopaedic
Surgeons,
New
Orleans,
LA.
(March
2014)
(Poster)
22. Johnson
JK,
Donahue
KL,
DeWan
TE,
Li
W,
Franklin
PD,
Oatis
CA.
Identifying
the
effect
of
physical
therapy
interventions
on
functional
outcomes
following
unilateral
total
knee
arthroplasty:
A
retrospective
study.
Combined
Sections
Meeting
of
the
APTA,
Las
Vegas,
NV.
(Feb
2014)
(Poster)
23. Ayers
DC,
Franklin
PD.
Risk-‐adjustment
using
clinical
data
when
comparing
clinical
outcomes
following
TJR.
American
Association
of
Hip
and
Knee
Surgeons,
Dallas,
TX.
(November
2013)
(Panel)
24. Ayers
DC,
Harrold
L,
Li
W,
Franklin
PD.
Pre-‐Op
THR
Patient
pain
and
functional
limitation
profiles
are
consistent
across
US
surgeons.
American
Association
of
Hip
and
Knee
Surgeons,
Dallas,
TX.
(November
2013)
(Poster)
25. Porter
A,
Li
W,
Harrold
L,
Rosal
M,
Noble
P,
Ayers
D,
Franklin
P,
Allison
J.
Musculoskeletal
pain
explains
differences
in
function
at
time
of
surgery
in
Black
TKR
and
THR
patients.
ACR/ARHP
Annual
Scientific
Meeting,
San
Diego,
CA.
(October
2013)
and
UMCCTS
(May2014)
(Poster)
26. Johnson
JK,
Donahue
KL,
DeWan
TE,
Li
W,
Franklin
PD,
Oatis
CA.
What
elements
of
physical
therapy
interventions
contribute
to
improved
outcomes
following
total
knee
arthroplasty?
ACR/ARHP
Annual
Scientific
Meeting,
San
Diego,
CA.
(October
2013)
(Poster)
27. Franklin
PD,
Harrold
L,
Li
W,
Allison
JJ,
Ayers
DC,
Lewis
C.
Important
predictors
of
patient-‐reported
outcomes
after
TKR
and
THR
are
not
included
in
risk
models
based
on
administrative
data.
ACR/ARHP
American
College
of
Rheumatology,
San
Diego,
CA.
(October
2013)
(Poster)
28. Li
W,
Harrold
L,
Allison
J,
Bowen
T,
Franklin
P,
Ayers
D.
Does
functional
gain
and
pain
relief
after
TKR
and
THR
differ
by
patient
obese
status?
ACR/ARHP
American
College
of
Rheumatology,
San
Diego,
CA.
(October
2013)
and
UMCCTS
(May
2014)
(Poster)
29. Franklin
PD,
Barton
BA,
Harrold
L,
Li
W,
OKeefe
R,
Allison
JJ,
Ayers
DC.
Providing
comprehensive,
comparative
post-‐tjr
outcome
feedback
to
surgeons
for
quality
monitoring
and
value
decisions.
ACR/ARHP
American
College
of
Rheumatology,
San
Diego,
CA.
(October
2013)
(Podium)
30. Harrold
L,
Ayers
DC,
OKeefe
R,
Lewis
C,
Pellegrini
V,
Franklin
PD.
The
validity
of
patient-‐reported
short-‐
term
complications
following
total
hip
and
knee
arthroplasty.
ACR/ARHP
American
College
of
Rheumatology,
San
Diego,
CA.
(October
2013)
(Podium)
31. Franklin
PD,
Allison
JJ,
Li
W,
Harrold
L,
Barton
B,
Snyder
B,
Rosal
M,
Weismann
N,
Ayers
DC.
FORCE-‐TJR:
TJR
function
and
outcomes
research
for
comparative
effectiveness
in
US
national
cohort.
Combined
Meeting
of
Orthopaedics
Societies,
Venice,
Italy.
(October
2013)
(Poster)
32. Harrold
L,
Ayers
DC,
Reed
G,
Franklin
PD.
Differences
in
functional
gain
between
rheumatoid
arthritis
and
osteoarthritis
patients
undergoing
arthroplasty:
Results
from
the
FORCE-‐TJR
national
research
consortium.
Combined
Meeting
of
Orthopaedics
Societies,
Venice,
Italy.
(October
2013)
(Podium)

FORCE-TJR
TJR
33. Harrold
L,
Li
W,
Allison
JJ,
Noble
P,
Ayers
DC,
Franklin
PD.
Do
younger
TKR
patients
have
similar
disability
at
time
of
surgery
as
older
adults?
Lessons
from
FORCE-‐TJR.
Combined
Meeting
of
Orthopaedics
Societies,
Venice,
Italy.
(October
2013)
and
UMCCTS
(May
2014)
(Poster)
34. Ayers
DC,
Harrold
L,
Li
W,
Allison
JJ,
Noble
P,
Franklin
PD.
Differences
in
pre-‐op
characteristics
between
TKR
and
THR
patients:
results
from
FORCE-‐TJR
a
national
us
cohort.
Combined
Meeting
of
Orthopaedics
Societies,
Venice,
Italy.
(October
2013)
(Podium)
35. Franklin
PD,
Allison
JJ,
Harrold
L,
Li
W,
Ayers
DC.
FORCE-‐TJR:
a
new
us
paradigm
for
a
national
TJR
registry
collecting
level
1,
2,
and
3
outcomes.
International
Congress
of
Arthroplasty
Registries,
Stratford-‐Upon-‐
Avon,
UK.
(June
2013)
(Podium)
36. Franklin
PD,
Harrold
L,
Miozzari
H,
Ayers
DC,
Lubbeke
A.
Differences
in
patient
characteristics
prior
to
TKA
between
Switzerland
and
the
US.
Annual
meeting
of
the
Swiss
Society
of
Orthopaedic
Surgeons
and
Traumatologists.
Lausanne,
Switzerland.
(June
2013)
(podium)
37. Franklin
PD,
Harrold
L,
Li
W,
Ayers
DC.
Has
the
level
of
disability
at
time
of
TKR
changed
over
the
past
10
years?
Results
from
two
us
cohorts.
International
Congress
of
Arthroplasty
Registries,
Stratford-‐Upon-‐Avon,
UK.
(June
2013)
(Podium)
38. Harrold
L,
Li
W,
Allison
JJ,
Franklin
PD.
for
the
FORCE-‐TJR
Investigators.
Do
younger
TKR
patients
have
similar
disability
at
time
of
surgery
as
older
adults?
Lessons
from
force-‐TJR.
International
Congress
of
Arthroplasty
Registries,
UK.
(June
2013)
(Poster)
39. Ayers
DC,
Harrold
L,
Li
W,
Allison
JJ,
Franklin
PD.
for
the
FORCE-‐TJR
Investigators.
Differences
in
pre-‐op
characteristics
between
TKR
and
THR
patients:
results
from
force-‐TJR
a
national
US
cohort.
International
Congress
of
Arthroplasty
Registries,
UK.
(June
2013)
(Poster
40. Franklin
PD,
Harrold
L,
Ayers
DC,
Hoffmeyer
P,
Lubbeke
A.
Differences
in
patient
characteristics
prior
to
TKA
between
Switzerland
and
the
US.
International
Congress
of
Arthroplasty
Registries,
Stratford-‐Upon-‐
Avon,
UK
and
European
Federation
of
National
Associations
of
Orthopaedics
and
Traumatology,
Istanbul,
Turkey.
(June
2013)
(Poster)
41. Lubbeke
A,
Miozzari
H,
Harrold
L,
Ayers
DC,
Franklin
PD.
Differences
in
patient
characteristics
prior
to
THA
between
Switzerland
and
the
US.
International
Congress
of
Arthroplasty
Registries,
UK
and
European
Federation
of
National
Associations
of
Orthopaedics
and
Traumatology,
Istanbul,
Turkey
(June
2013)
(Poster)
)
42. Franklin
PD,
Allison
JJ,
Li
W,
Harrold
L,
Rosal
M,
Ayers
DC.
FORCE-‐TJR:
Novel
Design
for
National
TJR
Comparative
Effectiveness
Research
Based
on
Patient-‐Centered
Outcomes.
Academy
Health
Annual
Research
Meeting.
Baltimore,
MD.
(June
2013)
(poster)
43. Zheng
H,
Barton
BA,
Li
W,
Allison
JJ,
Ayers
DC,
Franklin
PD.
Comprehensive
data
management
system
for
national
patient-‐centered
outcomes
research
for
comparative
effectiveness
in
total
joint
replacement.
Electronic
Data
Methods
Forum,
Baltimore,
MD.
(June
2013)
(Poster)
44. Franklin
PD,
Li
W,
Harrold
L,
Snyder
B,
Lewis
C,
Noble
P.
Level
of
pain
and
disability
at
time
of
TKR
across
the
past
10
years:
results
from
two
national
cohorts.
Orthopaedic
Research
Society,
San
Antonio,
TX.
(January
2013)
(Podium)
45. Ayers
DC,
Franklin
PD,
Harrold
L,
Lewis
C,
Snyder
B,
Rosal
M.
Differences
between
women
and
men
undergoing
TKR
and
THR
in
a
national
research
consortium.
Orthopaedic
Research
Society,
San
Antonio,
TX.
(January
2013)
(Poster)

FORCE-TJR
TJR
46. Ayers
DC,
Harrold
L,
Snyder
B,
Person
S,
Franklin
PD.
Clinical
profile
and
disability
levels
of
younger
vs.
older
TKR
and
THR
patients:
results
from
a
national
research
consortium.
Orthopaedic
Research
Society,
San
Antonio,
TX.
(January
2013)
(Poster)
47. Ayers
DC,
Harrold
L,
Li
W,
Snyder
B,
Allison
JJ,
Lewis
C.
Greater
musculoskeletal
pain
in
TKR
and
THR
patients
correlates
with
poorer
function
in
a
national
consortium.
Orthopaedic
Research
Society,
San
Antonio,
TX.
(January
2013)
(Poster)
48. Snyder
B,
Yang
W,
Franklin
PD,
Ayers
DC.
Pre-‐operative
emotional
health
affects
post-‐operative
patient
function
but
not
patient
satisfaction
following
primary
total
hip
arthroplasty.
Orthopaedic
Research
Society,
San
Antonio,
TX.
(January
2013)
and
UMCCTS
(May
2014)
(Poster)
49. Franklin
PD,
Ayers
DC,
Allison
JJ,
Harrold
L,
Noble
P.
Building
a
national
consortium
of
orthopedic
practices
for
function
and
outcomes
research
in
total
joint
replacement.
European
Federation
of
National
Associations
or
Orthopaedics
and
Traumatology,
Berlin,
Germany.
(May
2012)
(Poster)
50. Franklin
PD,
Ayers
DC,
Allison
JJ,
Li
W,
Harrold
L,
Snyder
B.
FORCE-‐TJR:
TJR
Function
and
Outcomes
Research
for
Comparative
Effectiveness
in
US
national
cohort.
International
Congress
of
Arthroplasty
Registries,
Bergen,
Norway.
(May
2012)
(Poster)
51. Franklin
PD,
Li
W,
Oatis
CA,
Snyder
B,
Rosal
M,
Ayers
DC.
Importance
of
musculoskeletal
co-‐morbidities
in
the
TJR
registries
that
evaluate
patient-‐reported
outcomes.
International
Congress
of
Arthroplasty
Registries,
Bergen,
Norway.
(May
2012)
(Poster)
52. Franklin
PD,
Snyder
B,
Allison
JJ,
Li
W,
Rosal
M,
Harrold
L.
Differences
in
baseline
characteristics
between
TKR
and
THR
patients:
results
from
a
national
research
consortium.
ACR/ARHP
American
College
of
Rheumatology,
Washington,
DC.
(November
2012)
(Poster)
)
53. Franklin
PD,
Li
W,
Snyder
B,
Lewis
C,
Noble
P,
Ayers
DC.
Has
the
level
of
disability
at
time
of
TKR
changed
over
the
past
10
years?
Results
from
two
national
cohorts.
ACR/ARHP
American
College
of
Rheumatology,
Washington,
DC.
(November
2012)
(Poster)
54. Franklin
PD,
Li
W,
Harrold
L,
Snyder
B,
Lewis
C,
Noble
P.
Do
younger
TKR
patients
have
similar
disability
at
time
of
surgery
as
older
adults?
ACR/ARHP
American
College
of
Rheumatology,
Washington,
DC.
(November
2012)
(Poster)
55. Franklin
PD.
Role
of
risk
adjustment
in
TJR
surgery-‐
lessons
learned
from
NYS
cardiac
surgery
process.
American
Association
of
Hip
and
Knee
Surgeons,
Dallas,
TX.
(November
2012)
(Presentation)

FORCE-TJR
TJR
Appendix 2: FORCE-TJR Ancillary Research
Funding (all funded grants and contracts)
FUNDED
GRANTS
1. Patricia
Franklin,
PI;
David
Ayers,
CO-‐I
;
Jeroan
Allison,
CO-‐I
;
Leslie
Harrold,
CO-‐I
;
Wenjun
Li,
CO-‐I
;
Paul
Fanning,
CO-‐I;
Norm
Weissman,
CO-‐I
Title:
Improving
Orthopedic
Outcomes
Through
a
National
TJR
Registry
Sponsor:
NIH-‐Agency
for
Healthcare
Research
and
Quality
Funding
Period:
9/30/2010
-‐
9/29/2014
(No
cost
extension;
9/30/2014-‐9/28/2015)
2. David
Ayers,
PI;
Patricia
Franklin,
CO-‐PI;
Arlene
Ash,
CO-‐I
Title:
Enhancing
30-‐Day
Post-‐Operative
Prediction
Models
with
the
Addition
of
Pre-‐Operative
Patient
and
Surgeon
-‐
Reported
Variables
Sponsor:
AAHKS
Funding
Period:
2/1/2013
-‐
12/31/2013
3. Patricia
Franklin,
PI;
Jeroan
Allison,
CO-‐I
Title:
UAB
Deep
South
Arthritis
and
Musculoskeletal
CERTs
Sponsor:
AHRQ
P60;
sub-‐award
UAB
Funding
Period:
3/1/2012
-‐
2/28/2015
4. Patricia
Franklin,
PI;
David
Ayers,
CO-‐I
;
Paul
Fanning,
CO-‐I
;
Wenjun
Li,
CO-‐I
Title:
Peripheral
blood
microRNAs
as
Biomarkers
for
disease
stage
in
RA
and
OA
Sponsor:
UMass
Memorial
Funding
Period:
3/1/2012
-‐
2/28/2014
TRAINEE
AWARDS
1. Anthony
Porter,
PI;
David
Ayers,
CO-‐I;
Patricia
Franklin,
CO-‐I
Title:
Disparities
in
Total
Joint
Replacement
Patients
from
the
FORCE
National
Database
Sponsor:
J.
Robert
Gladden
Orthopaedic
Society
Funding
Period:
1/3/2013
-‐
1/2/2014
2. Barbara
Gandek,
PI;
John
Ware,
CO-‐I;
Patricia
Franklin,
CO-‐I
Title:
Psychometric
Evaluation
of
Joint-‐Specific
Patient-‐Reported
Outcome
Measures
Before
and
After
Total
Knee
Replacement
Sponsor:
Alvin
R.
Tarlov

John
E.
Ware
Jr.
Doctoral
Dissertation
and
Post-‐Doctoral
Award
Funding
Period:
1/3/2013
-‐
1/2/201

Force TJR Annual Report 2014

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Force TJR Annual Report 2014