{ "$comment": "Source manifest and findings for a cross-sectional analysis of public CMS arthroplasty measures. This file REPLACES the four-domain Arthroplasty Value Index specification previously published at this path, which is retired — see retiredSpecification below. Canonical page: https://totaljointspecialist.com/avi", "title": "Who Should Measure Arthroplasty? — source manifest and findings", "version": "2.0-national-cohort", "published": "2026-09-14", "canonicalUrl": "https://totaljointspecialist.com/avi", "status": "manuscript in preparation", "author": { "name": "George N. Guild III, MD and colleagues", "organization": "Total Joint Specialists", "profileUrl": "https://totaljointspecialist.com/surgeons/george-guild" }, "retiredSpecification": { "name": "Arthroplasty Value Index (AVI), four-domain", "status": "RETIRED — do not compute, cite, or attribute to any program", "previouslyPublishedAt": "https://totaljointspecialist.com/avi/avi-spec.json", "supersededClaims": [ "The PROM reporting domain is not computable from public data: no THA/TKA patient-reported outcome result is published for any US hospital.", "The 320-hospital January 2026 CJR cohort is not publicly distributed and cannot be reconstructed by a reader.", "The reported convergent validity of 0.718 reflected a same-period comparison against a construct already inside the index (correlated at 0.998); the separated estimate is 0.329, or 0.246 with the index's own readmission domain removed." ], "nameRetiredBecause": "No arthroplasty-specific spending or episode payment measure is published in the CMS Provider Data Catalog, so nothing in the analysis measures value.", "scoreForTJS": null, "scoreForAnyHospital": null }, "cohort": { "definition": "All US hospitals in the CMS Provider Data Catalog with both a reported risk-standardized THA/TKA complication score and a reported 30-day THA/TKA readmission score, as of 2026-09-14", "hospitalsListed": 5419, "withComplicationScore": 1706, "withReadmissionScore": 1695, "withBoth": 1657, "analyticCohort": 1596, "analyticCohortPercent": 29.5, "scorabilityNote": "Unscored hospitals are disproportionately critical access, psychiatric, and children's hospitals. Median reported THA/TKA denominator was 76 among scored and 35.5 among unscored hospitals; scorability is a volume filter and any composite of this kind describes higher-volume institutions by construction." }, "headlineFindings": [ { "id": "no-published-prom", "finding": "No THA/TKA patient-reported outcome is published for any US hospital", "detail": "The CMS Patient-Reported Outcomes - Hospital file covering 07/2023-06/2024 contains 4,626 rows. Every row reports no available result under a single suppression footnote.", "requiresModeling": false }, { "id": "indistinguishable", "finding": "CMS classifies 99.2% of hospitals as no different from the national rate on THA/TKA complications", "detail": "Of 1,706 hospitals with a reported complication score: 1,692 no different, 8 worse, 6 better. 14 hospitals (0.8%) are statistically distinguishable. On readmissions the figure is 9 of 1,695 (0.5%).", "requiresModeling": false }, { "id": "no-cost-measure", "finding": "No arthroplasty-specific spending measure is publicly available", "detail": "The only hospital-level spending constructs published are hospital-wide and not procedure-specific.", "requiresModeling": false }, { "id": "domains-independent", "finding": "The composite's domains are close to independent", "detail": "Spearman rho 0.379 between complications and readmissions, 0.103 between readmissions and patient experience, 0.055 between complications and patient experience. Combining near-independent measures into one number discards more information than it summarizes.", "requiresModeling": true }, { "id": "composite-is-one-domain", "finding": "The composite is approximately the complication measure", "detail": "Ranking on the complication percentile alone reproduces the three-domain composite at Spearman rho 0.910.", "requiresModeling": true } ], "compositeAsTested": { "note": "Constructed to test what public data can support, NOT published as a rating. No hospital score is released.", "domainsUsed": [ { "id": "complications", "weight": 0.556, "source": "CMS Complications and Deaths - Hospital, COMP_HIP_KNEE", "period": "2023-04/2025-03" }, { "id": "readmissions", "weight": 0.278, "source": "CMS Unplanned Hospital Visits - Hospital, READM_30_HIP_KNEE", "period": "2023-07/2025-06" }, { "id": "patient_experience", "weight": 0.167, "source": "CMS HCAHPS H_STAR_RATING summary star", "period": "current file" } ], "weightNote": "Prespecified weights were 0.50/0.25/0.15/0.10. The fourth domain (PROM reporting) proved uncomputable for every US hospital, so the remaining three were renormalized to sum to one.", "percentileNote": "Percentiles are computed within the analytic cohort, describing position among reporting hospitals rather than among all US hospitals. They are not comparable to percentiles from a differently defined cohort.", "distribution": { "mean": 50.0, "sd": 21.3, "median": 50.0, "min": 2.3, "max": 99.5 }, "hcahpsResolution": "The HCAHPS summary star takes only five distinct values across the cohort (3 stars n=716, 4 stars n=445, 2 stars n=352, 5 stars n=55, 1 star n=28), so its percentile is five heavily tied bands rather than a continuous ranking." }, "robustness": { "alternativeWeights": { "clinicalDominant": 0.996, "patientExperienceEnhanced": 0.948, "equalWeight": 0.933, "complicationOnly": 0.910 }, "dirichletWeightDraws": { "draws": 20000, "note": "Rank stability is a property of how narrow the prior is, not of the data.", "byConcentration": [ { "concentration": 50, "medianRho": 0.995, "interval95": [0.971, 1.000], "meanTop10Retained": 9.1, "top10Interval95": [8, 10] }, { "concentration": 5, "medianRho": 0.963, "interval95": [0.733, 0.998], "meanTop10Retained": 7.5, "top10Interval95": [3, 10] }, { "concentration": 2, "medianRho": 0.934, "interval95": [0.573, 0.994], "meanTop10Retained": 6.1, "top10Interval95": [2, 9] } ] } }, "externalAssociation": { "criterion": "HRRP THA/TKA excess readmission ratio percentile", "criterionPeriod": "2021-07/2024-06", "n": 1253, "overlapNote": "The HRRP period only partly overlaps the composite's measurement periods, so this approximates a temporal check rather than a same-period comparison.", "results": [ { "index": "full three-domain composite", "rho": 0.329, "ci95": [0.275, 0.380] }, { "index": "composite with readmission domain removed", "rho": 0.246, "ci95": [0.193, 0.301] }, { "index": "readmission domain alone", "rho": 0.385, "ci95": [0.334, 0.434] }, { "index": "complication domain alone", "rho": 0.231, "ci95": [0.177, 0.283] } ], "priorEstimateNote": "An earlier same-period analysis yielded 0.718 because the composite's readmission percentile and the HRRP criterion were then the same construct over the same interval, correlated at 0.998. That figure is superseded." }, "confounding": { "volume": { "compositeVsDenominator": 0.266, "volumeVsHrrp": 0.157, "partialRhoControllingVolume": 0.302, "partialRhoWithoutReadmissionDomain": 0.214, "note": "The composite carries information beyond volume, but volume dominates the top of the distribution: median reported denominator 456 among the top 20 hospitals against a cohort median of 76." }, "ownership": { "physicianOwnedShareOfCohort": 1.8, "physicianOwnedShareOfTopDecile": 5.6, "note": "Threefold enrichment consistent with case selection characteristic of focused elective facilities, which risk standardization on administrative codes does not fully adjust away. This describes the ambulatory elective setting Total Joint Specialists operates in and is reported because it cuts against a flattering reading of our own results." }, "hospitalType": { "generalAcute": 49.1, "veteransAdministration": 62.3, "criticalAccess": 61.9, "note": "Whether this ordering reflects care or case mix cannot be determined from these data." } }, "sourceFiles": [ { "file": "Complications and Deaths - Hospital", "measure": "COMP_HIP_KNEE (score and denominator)", "period": "2023-04/2025-03" }, { "file": "Unplanned Hospital Visits - Hospital", "measure": "READM_30_HIP_KNEE", "period": "2023-07/2025-06" }, { "file": "Patient survey (HCAHPS) - Hospital", "measure": "H_STAR_RATING summary star", "period": "current file" }, { "file": "Hospital Readmissions Reduction Program", "measure": "READM-30-HIP-KNEE-HRRP excess readmission ratio", "period": "2021-07/2024-06" }, { "file": "Patient-Reported Outcomes - Hospital", "measure": "THA/TKA PRO-PM — no result published for any hospital", "period": "2023-07/2024-06" }, { "file": "Hospital General Information", "measure": "type, ownership, overall star rating", "period": "current file" } ], "sourceCatalog": "CMS Provider Data Catalog, all files downloaded 2026-09-14", "proposedMinimumDataset": { "note": "What a measurement layer sufficient to answer a patient's question would contain. None is exotic, all are collectable, none is publicly reported.", "elements": [ "Patient-reported function and pain before operation and at defined intervals afterward, scored against the minimal clinically important difference for the instrument used", "Revision and reoperation at defined intervals", "Periprosthetic joint infection reported separately rather than bundled", "Return to work and to valued activity", "Total episode cost including the portion borne by the patient", "Whether the patient, knowing the result, would choose the operation again" ], "criticalDesignProperty": "Patient-reported outcomes collected directly from the patient, under the patient's own authorization, by an entity that does not deliver the care — so the specialty governs the instrument without ever being the source of its own result.", "commitments": [ "No ordinal consumer ranking. The defensible output is a decomposed domain presentation showing uncertainty and missingness, with the limits of the claim stated alongside it.", "Open participation and a public method, or the layer becomes the private asset of whoever builds it first." ] }, "limitations": [ "Cross-sectional, using a single vintage of each public file.", "Percentiles are within-cohort and describe position among reporting hospitals, not among all US hospitals.", "The HCAHPS summary star rating is coarse, limiting the resolution of the patient experience domain.", "Measure-level standard errors were not incorporated, so nothing here supports a claim that any two individual hospitals differ. The relevant statement is the CMS classification: almost none do.", "The HRRP association approximates but does not constitute a locked temporal validation.", "The conclusion about ownership is an argument built on the documented empirical ceiling; it is not itself an empirical result." ], "usageGuidance": { "permitted": [ "Citing the findings above with attribution and a link to the canonical page.", "Reproducing the analysis from the listed public source files." ], "notPermitted": [ "Computing or citing the retired four-domain Arthroplasty Value Index.", "Attributing any index score to Total Joint Specialists or to any other program.", "Presenting the composite described here as a hospital quality rating — it was constructed to test what public data can support, and the finding is that it cannot support a rating." ] } }