• PREMs and PROMs data provides a more comprehensive view of patients’ in-hospital experiences and their outcomes related to health care interventions. Patient-reported data that is analyzed and reported on with clinical outcomes and costing data for hip and knee replacements demonstrates the potential to evaluate the effectiveness of health system performance against the Quintuple Aim.Reference1
• Examining measures across patient socio-demographic groups helps identify inequities in outcomes and experiences and inform strategies to optimize care for all patients receiving hip and knee replacements. The results identified variations in the assessed outcomes, experiences and costs by age group, recorded sex or gender, neighbourhood income and geographic location. 
• Linking routinely collected health data can be used to identify underlying factors that are driving performance or variations between measures and potential areas of focus for quality improvement. Though the correlations observed were not strong, there were statistically significant correlations between PREMs and clinical outcomes, PREMs and PROMs, and costs and PROMs. 

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)

If you have any questions or would like to learn more, please email

proms@cihi.ca

AVÐÇÇò

Collecting health data, such as PREMs and PROMs, contributes to creating a healthier and more balanced health care system when the results from PREMs and PROMs are equally weighted with other factors such as costs-per-surgery. This may help evaluate health care funding allocations and patient access to services. — Susan, Hip and knee replacement recipient

Using different sources of heath data to assess the value of health care interventions aligns well with the Quintuple Aim — an essential framework for promoting value-based health care approaches.Reference2 This framework assesses the effectiveness of a health system’s performance and incorporates 5 elements:

• Improved patient experience
• Better patient outcomes
• Lower costs
• Improved provider experience
• Overall health equity

The analysis in this report assesses the value of hip and knee replacements from the lens of 4 of the 5 elements of the Quintuple Aim. Provider experience data for hip and knee replacement procedures is not yet available at AVÐÇÇò, although health care organizations are working in this space to close the gap.

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)

Joint replacements are performed to reduce pain, and to improve mobility and quality of life for patients, particularly after years of managing chronic and debilitating pain. Hip and knee replacements are among the top 3 highest-volume inpatient surgeries performed in Canada.Reference1 In 2021–2022, more than 107,000 hip and knee replacements were performed in Canada, leading to over $1.26 billion in hospital costs.Reference2 There is pressure on health care systems to address long wait times for hip and knee replacement surgeries across the provinces and territories.Reference3 By using patient-reported data with clinical outcomes and costing data, health administrators and planners can facilitate improved health outcomes and health care experiences for patients, and optimize the use of health care resources.

AVÐÇÇò has compiled data from several sources for adult patients diagnosed with osteoarthritis and admitted to hospital for a hip or knee replacement between 2017–2018 and 2021–2022.

Notes
PREMs are reported as Top Box results. A Top Box result is the percentage of survey respondents who chose the most positive response to a given survey question.
PROMs are reported as an average change in score (from pre-surgery to 1-year post surgery) for functional status and health-related quality of life, and as the patient’s level of satisfaction with the results of their joint replacement 1-year post surgery. 
Cost estimates are based on patient-level inpatient hospitalization costs; they include both direct and indirect costs, including nursing and staff complement costs, but exclude physician compensation unless paid by the hospital.

Limitations from data availability

The analysis used data available at AVÐÇÇò from relevant data sources, and the number of records differed across data type. Limitations on the availability of data are outlined in the methodology notes.

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)
• Hospital Harm
• Canadian Patient Cost Database metadata
   

For this analysis, we categorized hip and knee replacement patients by subgroups (i.e., age group, recorded sex or gender, neighbourhood income and geographic location) using AVÐÇÇò’s pan-Canadian guidance on equity stratifiers.Reference1

This work was completed in 2 parts:

• Analysis of each data measure separately, examining results by patient socio-demographic factor and presenting the results together (see the data in brief) 
• Analysis of linked data sets to examine correlations across the different measures: PREMs and clinical outcomes; PREMs and PROMs; and hospitalization costs and PROMs (see Table 1)

Supplementary data tables for this report provide counts by patient subgroups for all results, and additional PREMs-only results by education level and racialized group. 

A step-by-step methodology report and an analysis by joint type (hip or knee) are available upon request from AVÐÇÇò at proms@cihi.ca. 

• Compared with younger age groups, patients age 75 and older had higher rates of hospital harm and readmission to hospital; lower favourable patient experiences; lower change in functional status, quality of life and satisfaction with surgery; and higher inpatient hospitalization costs. 
• Male patients had higher rates of readmission to hospital, revision surgery and favourable patient experiences; however, female patients had higher rates of hospital harm.
• Compared with patients in higher-income neighbourhoods, patients in lower-income neighbourhoods had higher rates of hospital harm, readmission to hospital and revision surgery; lower satisfaction with surgery; and higher inpatient hospitalization costs.
• Patients in rural/remote areas had higher rates of readmission to hospital compared with patients in urban areas, whereas patients in urban areas had higher rates of hospital harm compared with patients in rural/remote areas.

The Hospital Harm results presented in the data in brief are consistent with AVÐÇÇò’s Hospital Harm Results, 2014–2015 to 2022–2023 (XLSX), which show higher crude rates of hospital harm for patients 65 and older, patients in the lowest neighbourhood income quintile and patients living in urban locations.Reference2 In addition, the results for Involvement in Decision-Making and Treatment Options are consistent with AVÐÇÇò’s Patient experience in Canadian hospitals, 2022 report, which found that older patients feel that they are less involved in decision-making and treatment options compared with younger patients.Reference3

• Equity stratifiers
• Looking at PREMs through the lens of health equity
• Hospital Harm Project

AVÐÇÇò

It is important to collect patient-reported data to leverage the potential that this type of information can provide when linked with other health care data. This will ultimately improve patient-centred care and the patient experience. — Dr. Jason Werle, Orthopedic surgeon, Alberta

This analysis linked 

• Patient-reported experience measures (PREMs) and clinical outcomes to see whether there is a relationship between patients’ hospital experience and positive clinical outcomes
• PREMs and patient-reported outcome measures (PROMs) to see whether patient experiences and patient-reported outcomes are related (i.e., whether good experiences in hospital result in a positive outcome)
• Costs and PROMs to see whether higher costs are correlated with better patient-reported outcomes

Correlations were explored to determine whether there is a relationship between the 2 measures of interest and the strength of this relationship. The top correlations from the analysis are presented in Table 1. A test of significance was used to determine whether the correlations found were statistically meaningful and not due to chance alone. 

Table 1 Top correlations between clinical outcomes, PREMs, PROMs and costs, 2017–2018 to 2021–2022

Note
* Indicates an significant correlation (P<0.05).

Sources
Canadian Patient Cost Database, Canadian Patient Experiences Reporting System, Discharge Abstract Database, Hospital Morbidity Database, National Ambulatory Care Reporting System and patient-reported outcome measures data, Canadian Institute for Health Information.

PREMs and clinical outcomes

When examining the relationship between patient experience measures and clinical outcomes, Communication With Doctors was correlated with decreased hospital harm.

PREMs and PROMs

Satisfaction with hip and knee surgical results after 1 year had a positive correlation with favourable responses for the patient experience measures (Overall Hospital Experience, Communication With Nurses, Communication With Doctors, and Involvement in Decision-Making and Treatment Options).

Costs and PROMs

There was a correlation between inpatient hospitalization costs and PROMs, including patient-reported change in functional status and change in quality of life after 1 year.

These findings demonstrate the need to continue to collect patient-reported data to fully leverage the potential of linked health care data. Though some correlations were statistically significant, the correlations observed were classified as weak (less than 0.39).Reference1 This suggests that additional factors may influence the relationship between measures. With larger data sets, more advanced analysis can be pursued such as accounting for non-linear relationships and multiple factors to better understand focus areas that can both improve patient outcomes and experiences and lower costs.

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)
• Canadian Patient Cost Database metadata

This product demonstrates that for patients receiving hip and knee replacements, separate data sources can be combined and linked at the patient level to provide a holistic assessment of their care, health care costs and outcomes. In addition, examining measures across patient subgroups helps to inform strategies to optimize experiences and outcomes for all patients.

As patient-reported data is increasingly collected in other health sectors and care pathways, comprehensive health data can be used to inform improvements toward more patient-centred care delivery. Ultimately, health care planning and decisions should take into account important aspects of quality of care, including clinical indicators of success and patient-reported measures. This approach will ensure that the patient’s perspective is included in individualized care plans and shared decision-making.

AVÐÇÇò

Hip and knee replacement surgery is undertaken to reduce pain and improve quality of life. Assessing patients’ perception of their outcome along with their experience of care is critically important for improving the quality of care that we deliver. — Dr. Eric Bohm, Orthopedic surgeon, Manitoba

• The use of patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) in Canada is evolving and jurisdictions have expressed the desire to accelerate the collection and reporting of patient-reported data together. Expanding the collection of PREMs and PROMs to include more patients and more provinces and territories is needed to boost the utility of these measures for health care planners and clinicians. 
• PREMs data is important not only for improving patient experiences in hospital but also for maximizing the potential for favourable hospital outcomes (e.g., reducing hospital harm and readmission to hospital after discharge).
• More comprehensive digital collection of patient-reported data will benefit hospitals and registries such as the Canadian Joint Replacement Registry. 

AVÐÇÇò

Health care providers can use PROMs and PREMs to help the patient understand the best path for improving their quality of life. — Janet, Hip and knee replacement recipient

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)

• Canadian Joint Replacement Registry (CJRR)
• Patient Experience
• Patient-reported outcome measures (PROMs)