JBJS - 2026-08-05 - Journal Article
CMS-Proposed Substantial Clinical Benefit Thresholds Correlate with Patient-Reported Measures After Primary Total Joint Arthroplasty: Improvement, Satisfaction, and Willingness to Repeat Surgery.
Wang Z, Janney CA, Guo E, Carender CN, Hallstrom BR, Kheir MM
Topics
Key Takeaway
CMS-proposed SCB thresholds of 22 points (HOOS JR) and 20 points (KOOS JR) are externally validated, with ROC-derived optimal thresholds of 24–26 points for THA and 21–24 points for TKA depending on anchor, and 20% of patients failed to meet CMS benchmarks.
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Summary
This study asked whether CMS-proposed SCB thresholds for HOOS JR and KOOS JR are clinically valid predictors of patient satisfaction, improvement, and willingness to repeat TJA. Using logistic regression and anchor-based ROC analysis on 3,465 cases from the MARCQI registry, preoperative scores were poor predictors (AUC <0.6), while postoperative score change was strongly predictive for both THA (AUC 0.77–0.85) and TKA (AUC 0.71–0.79). Youden-index-derived thresholds closely approximated CMS benchmarks, and 20% of patients failed to achieve the proposed SCB cutoffs.
Key Limitation
Single-institution data from a high-volume academic registry (MARCQI) may not reflect the case mix or PROM completion rates of community or low-volume centers where CMS penalties will have the greatest financial impact.
Original Abstract
BACKGROUND
The U.S. Centers for Medicare & Medicaid Services (CMS) requires the collection of patient-reported outcome measures (PROMs) after primary total joint arthroplasty (TJA), with penalties for noncompliance affecting all Medicare reimbursement. The CMS will publish risk-standardized improvement rates based on substantial clinical benefit (SCB) thresholds of 22 points for the HOOS JR (Hip disability and Osteoarthritis Outcome Score for Joint Replacement) and 20 points for the KOOS JR (Knee injury and Osteoarthritis Outcome Score for Joint Replacement). Our aims were to determine if preoperative scores predicted postoperative PROMs, to externally validate the SCB thresholds, and to analyze them with different anchors.
METHODS
We retrospectively identified patients who underwent TJA at our institution between 2015 and 2023. The HOOS JR and KOOS JR were prospectively collected in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI); all other variables were obtained from electronic medical records. Logistic regression analyses and anchor-based receiver operating characteristic curves were generated to determine threshold values and the efficacy of using preoperative and postoperative scores as predictors of patient improvement, satisfaction, and willingness to repeat surgery.
RESULTS
In total, 3,465 cases (1,498 total knee arthroplasties [TKAs] and 1,967 total hip arthroplasties [THAs]) were included. Preoperative scores failed as predictors (area under the curve [AUC], <0.6) of patient improvement, satisfaction, and willingness to repeat surgery. The change in scores for TKA, particularly at 1 year postoperatively, was predictive of improvement (AUC, 0.79), satisfaction (AUC, 0.77), and willingness to repeat surgery (AUC, 0.71); and the change in scores for THAs was predictive of improvement (AUC, 0.85), satisfaction (AUC, 0.82), and willingness to repeat surgery (AUC, 0.77). The Youden index indicated that change thresholds of 24 points for patient improvement, 24 points for satisfaction, and 26 points for willingness to repeat surgery provided the best predictions at 1 year after THA. Similarly, change thresholds of 21 points for patient improvement, 22 points for satisfaction, and 24 points for willingness to repeat surgery provided the best predictions at 1 year after TKA. Twenty percent of patients did not achieve CMS-proposed SCB thresholds.
CONCLUSIONS
Although preoperative scores were not predictive of patient-reported outcomes, the degree of score improvement postoperatively was strongly associated with patient improvement, satisfaction, and willingness to repeat surgery. CMS-proposed SCB thresholds appear to be validated in our population and compare favorably with the thresholds produced in this study.
LEVEL OF EVIDENCE
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.