Growing up outside Cleveland in the 1970s, Randy Voss spent plenty of time playing competitive sports on the football field and basketball court. He endured plenty of nicks and dings as a result, and often hobbled about on crutches, both during and after high school.

His ankles took the most abuse. “I had a lot of sprains,” he said, adding that he simply pushed through them. There wasn’t much in the way of sophisticated medical care, and slow healing wasn’t his goal anyway.

“You just tried to get back on the field as soon as you could,” Voss said.

The result was severe damage to the joint tissue in the right ankle, as well as spurs and bone chips. Voss underwent several ankle procedures over a roughly 30-year period, culminating in a 2006 surgery that removed bone from his heel, placed it underneath the ankle and secured it with pins and screws. That helped to stabilize the joint for a while, he said. Gradually, though, the support deteriorated, and his ankle and foot became severely misaligned. Activities became potential misadventures, “even comic,” as he put it.

“My stability was very poor,” Voss said. “I had to watch what I was doing so I didn’t fall over.”

A new approach to ankle repair

Early in 2020, Voss sought care from Dr. Kenneth Hunt, medical director of the UCHealth Foot and Ankle Center – Central Park. Hunt, who had implanted a 3D-printed talus, the large bone in the ankle, in 2019 – the first such procedure at UCHealth University of Colorado Hospital on the Anschutz Medical Campus – explored with Voss the possibility of a total ankle joint replacement. Hunt would surgically remove the damaged bones and tissue and implant a titanium and polymer device to serve as a new ankle stand-in.

Voss opted for the surgery, which Hunt conducted in late July 2020. It was a success – more on that later – but his procedure was more than a stand-alone case. Rather it is part of a systematic effort to gather data from patients on a variety of orthopedic procedures and measure their outcomes.

The effort, which began in October 2019, is a collaboration between UCHealth and PatientIQ, a Chicago-based company that provides a national platform for automated collection of “patient reported outcomes,” or PROs. The idea is to glean from patients how they perceive the care they receive and use the insights to improve it.

Ask the patients, improve the outcomes

The value of PROs lies in their reflection of people’s everyday experiences with surgeries and other procedures. Has the care diminished pain? Did a procedure achieve the improvements in daily function that patients expected? Do they feel isolated because of their recovery time or have they improved their social interactions?

To assess what patients report, PatientIQ uses a variety of “patient reported outcome measures,” or PROMs, that have been validated for specific areas providers want to assess, including patients’ pain and their general, physical and mental health. Other PROMs include tests for specific diseases and injuries. For example, a foot and ankle specialist like Hunt might use two validated tests, the Foot Function Index and the Foot and Ankle Ability Measure, to objectively assess patients’ injuries before and after a procedure.

As Hunt explained in a 2019 article he co-authored for Foot and Ankle Orthopaedics, PROMs “reflect the patient’s perceptions of their health status and help quantify the impact of conditions and injuries as well as improvement following treatment.”

In addition, by aggregating data – the UCHealth system includes information from some 23,000 patients treated by 40 orthopedic surgeons – providers have a better chance of understanding the successes and failures of procedures and holding themselves accountable for their patients’ outcomes, Hunt said.

“Our goal is to create a system where we can track every patient who comes through the door,” he said. The tracking doesn’t cease when a patient leaves the clinic or hospital, Hunt added.

“A patient might experience persistent or worsening symptoms even if they aren’t rehospitalized,” he said. “We want to know how a patient actually does following treatment, even after they have completed their treatment.”

The patient outcomes survey says…

The system relies on a series of short patient surveys, available from mobile devices or computers, to track their progress, noted Michael Tuffiash, quality data manager for the University of Colorado Department of Orthopedics. (See box for further details.)

“We get both a general and specific picture of where each patient sees their health before, during, and after their course of care,” Tuffiash said. He emphasized that the surveys require a total of only about five minutes of time to complete, an important consideration for patients already dealing with burdensome injuries. Patients who do not complete a survey before a clinic visit for any reason can complete it at the clinic on a secure iPad or a kiosk, much like one passengers use to get an airline boarding pass.

The surveys are not specifically designed to measure patient satisfaction, but Hunt said they are an important tool for engaging patients in “shared decision making” about their own care. Patients get a clear picture of the effect their condition or injury has on their function, the procedure with the best chance of improving their lives, and the methods providers will use to track their recovery.

“Patients are much more empowered than they were before,” he said. “This approach is a key part of the evolution of care delivery in the United States.”

Careful preparation for surgery improves outcomes

The system worked well for Randy Voss, who said he spoke extensively with Hunt and his team about his goals for the ankle replacement surgery. At 61, he wasn’t headed back to the football field, but he wanted to return to biking, golfing, hunting and fishing without pain and worries about his balance.

After several conversations, Voss said he felt the team understood “what I was dealing with and what I was trying to improve upon.” With that, he said was convinced that the surgery would accomplish that and allow him to be comfortably active for the long haul.

Voss first had a standing, weight-bearing CT scan of his ankle that Hunt used to make a custom replacement device. Four weeks after the July surgery at UCHealth Broomfield Hospital, he could bear weight on the joint, and two weeks after that, he shed his walking boot. He continues rigorous physical therapy at UCHealth Steadman Hawkins Clinic – Denver. In late January, six months after the surgery, he said the new ankle is within one centimeter of normal range of motion, and he’s enjoying an active, pain-free life.

Voss said he continues to complete surveys every few months to assess his pain, mobility and activity levels. “It’s very interactive,” he said, and a far cry from his experience with the 2006 surgery.

“That was one day in, one day out, we hope it works out and that was about it,” he said. “This has been more of a life-evolving approach. Dr. Hunt and his team told me, ‘This is why we are doing this, and we want to be engaged with you to make sure you are meeting your objectives.’ I felt I could do what I wanted to do for years to come.”