Value-based Healthcare: Improving Outcomes through Patient Activation and Risk Factor Modification.

As orthopaedic surgery shifts toward value-based payment and delivery models [12], clinicians and payers alike are prioritizing efforts to identify patients at risk of poor clinical and patient-reported outcomes following an orthopaedic procedure. What if there was a measurable parameter thatwe could use to help patients improve their ownhealth, inexpensively, and with little risk? Such a parameter exists—although surgeons likely do not know about it. That parameter is called patient activation, which is a patients’ level of engagement in their own health. In our view, the more engaged a patient is, the more “activated” they are in taking interest in and managing their health, as well as interacting with their surrounding health ecosystem. We believe this concept is especially relevant in the context of patient risk factors surrounding orthopaedic surgery. While identifying and ameliorating modifiable risk factors (BMI, high A1C, and smoking cessation) early along the care continuum can predictably improve patient-reported and clinical outcomes following surgery [5], the role of patient activation as a modifiable risk factor has not been definitively proven. Validated patient-reported survey instruments for measuring activation include the Patient Activation Measure (PAM-13/PAM-10) and the Effective Consumer Scale (EC-17) [7, 10]. Survey instruments like PAM specifically assesses activation and the personal and psychological competencies (knowledge, skills, confidence) required to manage one’s health. The EC-17 scale is designed to measure an individual’s skills, behaviors, and effectiveness in dealing with their condition andmaking decisions to effectively manage their health. Intuitively, the propensity to engage in adaptive health behaviors demands a level of self-efficacy, which can be measured using tools such as the validated Pain Self Efficacy Questionnaire [11]. These measures have been developed mostly for chronic conditions involving non-musculoskeletal populations. Not surprisingly, many orthopaedic surgeons are unaware of the concept of patient activation, let alone the existence of these measures. Still, there is a growing body of work in orthopaedics, particularly in upper extremity, spine, and total joint arthroplasty evaluating the impact of patient activation on clinical and patientreported outcomes [5, 13, 14]. These studies found greater decreases in pain and disability, as well as improved adherence with physical therapy in patients who were more activated. A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the latest Value-based Healthcare column (formerly Orthopaedic Healthcare Worldwide). Valuebased Healthcare explores strategies to enhance the value of musculoskeletal care by improving health outcomes and reducing the overall cost of care delivery. We welcome reader feedback on all of our columns and articles; please send your comments to eic@ clinorthop.org. One author (KJB) certifies that he, or a member of his immediate family, has received or may receive payments or benefits as a consultant, during the study period, an amount of USD (USD 10,000 to USD 100,000) from The Centers for Medicare & Medicaid Services (Baltimore, MD, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. K. J. Bozic MD, MBA (✉), Dell Medical School at the University of Texas at Austin, 1701 Trinity Street, Austin, TX 78712 USA , Email: kevin.bozic@austin.utexas.edu A. Alokozai, Medical Student, Tulane University School of Medicine, New Orleans, LA, USA P. Jayakumar, Assistant Professor in Surgery and Perioperative Care, Director of Clinical Research and Outcome Measurement. UK Harkness Fellow in Health Care Policy and Practice Innovation. Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas atAustin, Austin, TX,USA K. J. Bozic, Chair, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas atAustin, Austin, TX,USA