MSK5 – Patients Suffering From a Knee Injury who Improve Physical Function

Measure Title: Patients Suffering From a Knee Injury who Improve Physical Function

Measure Description Percentage of patients 18 years or older suffering from a knee injury who achieve the Minimal Clinically Important Difference (MCID) in the KOS or PROMIS Physical Function, or like mapped measure during the performance year.

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.

This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in KOS/PROMIS Physical Function/or like mapped measure.

Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or start of care with a knee injury evaluated and treated by a Physical Therapist (PT), Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.

Numerator: The total number of patients with knee injuries to achieve an MCID in their KOS change score (> or = to 10) or (> or = 2.1) in PROMIS Physical Function change score or like mapped measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the performance year.

Denominator Exclusions: Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15

Denominator Exceptions: Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress or follow a standard care pathway. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions: None

Published Specialty: Physical Therapy/Occupational Therapy

High Priority Measure: Yes

Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)

Include Telehealth: Yes

Inverse Measure: No

Proportional Measure: Yes

Continuous Variable Measure: No

Ratio Measure: No

Score Range: N/A

Number of Performance Rates: 1

Performance Rate Description: This measure will include the combined rate of;
Rate 1) Total number of patients aged 18 years or older with a knee injury who achieve an overall score change of > or = the MCID in the KOS, PROMIS Physical Function or like mapped measure.

Risk Adjusted Status: Yes

MIPS Reporting Options: Traditional MIPS

Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care

Clinical Recommendation Statement: “”Patients regularly enter the clinic with compromised knee function, measurable via the KOS. Through effective rehabilitation there are marked, measurable improvements. This gap for improvement will always exist in these knee patients, as this is a true “”””””””pre- vs. post-“””””””” measurement.

Piva et. al. (2009) demonstrate that the standardized effect size of the Activity of Daily Living Scale was 0.63, Guyatt responsiveness index was 1.4, area under the curve was 0.83 (95% confidence interval: 0.72, 0.94), and the minimum clinically important difference corresponded to an increase of 7.1 percentile points. Standardized effect size of the Numeric Pain Rating Scale was 0.72, Guyatt responsiveness index was 2.2, area under the curve was 0.80 (95% confidence interval: 0.70, 0.92), and the minimum clinically important difference corresponded to a decrease of 1.16 points. Medicare patients (n=255) completed the KOS for various clinical knee conditions. Average age was 73.3 (6.2). Baseline KOS score was 49.4 (17.3). 75.8% patients achieved significant clinical improvement (one MCID). The proportion of patients who failed to progress is 24%. Fritz JM, Hunter SJ, Tracy DM, Brennan GP. Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. PTJ. 2011; 91: 330-345.

The use of PROMIS Physical Function Computer Adaptive Test (CAT) for measuring lower extremity functional improvement in physical therapy patients is strongly recommended. Supported by robust evidence, including studies by [Neville et al., 2023][1] and [Rothrock et al., 2019][2], the PROMIS Physical Function CAT offers an efficient and precise way to assess lower extremity function. Its adaptive testing tailors questions to patient responses, enhancing accuracy while minimizing patient burden. Validity and reliability, with decreased floor and ceiling effects make it an invaluable tool for evaluating lower extremity function. Integrating the PROMIS CAT into clinical practice empowers therapists to make informed decisions and optimize patient care by tracking progress and tailoring interventions effectively.

[1] Christopher Neville, Judith Baumhauer & Jeff Houck (2023) Are Patient Reported Outcome Measurement Information System scales responsive in patients attending physical therapy with foot and ankle diagnoses?, Physiotherapy Theory and Practice, 39:7, 1493-1503, DOI: 10.1080/09593985.2022.2037116
[2] Rothrock NE, Kaat AJ, Vrahas MS, O?Toole RV, Buono SK, Morrison S, Gershon RC. Validation of PROMIS Physical Function Instruments in Patients With an Orthopaedic Trauma to a Lower Extremity. J Orthop Trauma. 2019 Aug;33(8):377-383. doi: 10.1097/BOT.0000000000001493. PMID: 31085947.””

Measure Rationale: “”According to the World Health Organization (2022), MSKD effects 1.71 billion people worldwide, is the leading cause of disability globally, and is the primary reason for rehabilitation treatment. The total economic burden of MSKD is around $980.1B, which represents 5.7% of the gross domestic product and 30% of the national health expenditures (Wright, et al., 2014). Knee pain and dysfunction prompt more visits to outpatient clinics than any other musculoskeletal region except for the lumbar spine (Karrashch, et al, 2014) and is one of the most common reasons older adults seek care (Hochberg & Watkins-Castillo, n.d.). Those experiencing osteoarthritis related knee pain often have concurrent symptoms that include functional mobility limitations, fatigue, and sleep disturbances as well as feeling emotionally and physically drained (Arthritis Foundation, 2017). According to Pain Management Best Practices from Health and Human Services (2019), physical therapists (PTs) and occupational therapists (OTs) play a pivotal role in the multidisciplinary team’s management of both acute and chronic pain by contributing to maintaining function in an effort to reduce opioid prescriptions. PTs and OTs are also positioned to improve long-term outcomes by providing high-quality and timely care while reducing downstream costs. Improving care quality begins with tracking outcomes, and use of the Knee Outcome Survey (KOS – legacy11) patient reported outcome measure (PROM) has proven to be a reliable cost effective measurement tool. Fritz, et al. (2011) performed an original study on the outcomes of physical therapy in Medicare patients utilizing the legacy measures, including the use of the KOS. Results of the 3-year study, including over 14,000 episodes in an outpatient setting, established that use of legacy PROMs facilitated the identification of factors related to improvement and utilization. A further study by Brennan, et al (2017) reviewed over 165,000 Medicare patient PROs and found that the legacy have been validated as a standard approach to identifying accurate functional limitations and detecting improvements while using the KOS as one of the measurement tools. Lynch et al., (2015) identified that the KOS tool was reliable in measuring outcomes following surgery at one and two years; additionally, the tool supports the patient viewpoint in a comprehensive analysis of the patients function. Another study by Adhama, et al (2021) regarding older adults with OA supported that the KOS has high levels of internal consistency, test-retest reliability, and construct validity. Lastly, research done by Collins,. et al. (2011) demonstrated that the KOS can consistently be administered in less than 5 minutes, requires no training or assistance for interpretation, and is self- explanatory (no burden) for the respondent. Given the economic and psycho-social burden of knee pain and disability, use of valid, reliable, and feasible outcome tools are paramount not only for the direct management of individual patient care, but also for the ability to collectively compare health outcomes among providers to determine effective treatment and help drive value.

The use of the PROMIS Physical Function Computer Adaptive Test (CAT) is strongly recommended for physical therapists, orthopedic therapists, and musculoskeletal doctors for assessing back function in clinical practice. Supported by robust psychometric evidence, including studies by Kenney et al. (2019) and Hung et al. (2017), the PROMIS Physical Function CAT demonstrates excellent reliability, validity, and efficiency. Its adaptive testing algorithm tailors questions to individual responses, enhancing measurement precision and minimizing patient burden. This tool’s clinical applicability is underscored by its ability to capture subtle changes, as highlighted by Horn et al. (2020), making it an indispensable resource for tracking progress and facilitating informed treatment decisions, ultimately improving patient outcomes.

Blyth, F. M., Briggs, A. M., Schneider, C. H., Hoy, D. G., & March, L. M. (2019). The Global burden of musculoskeletal pain-where to from here?. American Journal of Public Health, 109(1), 35–40. 10.2105/AJPH.2018.304747
Brennan, G. P., Hunter, S. J., Snow, G., & Minick, K. I. (2017). Responsiveness to change of functional limitation reporting: Cross-sectional study using the intermountain roms scale in outpatient rehabilitation. Physical Therapy, 97(12), 1182–1189. 10.1093/ptj/pzx093
Fritz, J. M., Hunter, S. J., Tracy, D. M., & Brennan, G. P. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91(3), 330–345. 10.2522/ptj.20090290
Health and Human Services (2019). Pain management best practices. https://www.hhs.gov/sites/default/ files/pain-mgmt-best-practices-draft-final-report-05062019.pdf
Hochberg, M., & Watkins-Castillo, S. (n.d.). Joint pain and joint replacement. Bone and Joint Initiative USA. https://www.boneandjointburden.org/fourth-edition/iiib70/joint-pain-and-joint-replacement
Kenney RJ, Houck J, Giordano BD, Baumhauer JF, Herbert M, Maloney MD. Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy? Am J Sports Med. 2019 May;47(6):1396-1403. doi: 10.1177/0363546519832546. Epub 2019 Apr 10. PMID: 30969782.
Hung M, Saltzman CL, Greene T, Voss MW, Bounsanga J, Gu Y, Anderson MB, Peters CL, Gililland J, Pelt CE. Evaluating instrument responsiveness in joint function: The HOOS JR, the KOOS JR, and the PROMIS PF CAT. J Orthop Res. 2018 Apr;36(4):1178-1184. doi: 10.1002/jor.23739. Epub 2017 Oct 9. PMID: 28921658.””