Interview with Dr. Brian Hallstrom, MARCQI Program Director and President-Elect of ISAR

Dr. Brian Hallstrom, MD, is the Program Director of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) and a Clinical Professor of Orthopaedic Surgery at Michigan Medicine. He was recently named President-Elect of the International Society of Arthroplasty Registries (ISAR). In this interview, Dr. Hallstrom discusses how MARCQI and ISAR connect, the role quality improvement plays on an international stage and future goals for patient care-focused arthroplasty registries. (Note: Interview lightly edited for length and clarity.) 

Can you share what ISAR is and what it works towards?

Dr. Brian Hallstrom: ISAR is the International Society of Arthroplasty Registries. It is comprised of leaders of arthroplasty registries around the world to enable collaboration and education. It also helps newer registries because we can share knowledge about how we got started and what we've learned.

What is your story with ISAR?

Dr. Brian Hallstrom: I went to ISAR's first meeting held in Norway in 2012 and really tried to learn as much as possible from the existing registries. The first national registry started in Sweden in the 1970’s. We had a lot to learn because we were just getting MARCQI started. Now MARCQI members are presenting at ISAR meetings as we've matured and collected more projects and data.

As a registry, we’ve been actively involved on ISAR committees and developing international relationships with people who run arthroplasty registries all over the world. Due to our involvement with ISAR, we've had representatives from Sweden, Australia and the UK come and present as keynote speakers at our MARCQI meetings.

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How will your work with MARCQI shape your role as President-Elect of ISAR?

Dr. Brian Hallstrom: A lot of the work that MARCQI has done is somewhat unique in the registry community because we're structured as a quality improvement project. Many of the registries are focused on just implants and how they're performing. There are a lot of different implants, and a big focus of registries has been on figuring out which implants are not performing well and calling out outliers. While we do track and report on implant performance, MARCQI is very much focused on collaborative quality improvement in Michigan and reducing complications after surgery. We've been able to contribute a lot of ideas and be active participants in ISAR. MARCQI has gone from being the mentees to providing a lot of good data, information, ideas and projects that other programs have adopted.

What are your responsibilities as President-Elect?

Dr. Brian Hallstrom: I'll be president-elect for two years. My role is to help support the president, Anne Lubbeke from Switzerland. I'll be on committees and working to support her and the work that ISAR's doing and helping to decide on ISAR's direction going forward. In two years, I'll take over as president, and my term will be two years. At that point, I'll be leading the steering committee for ISAR and continue to help registries around the world collaborate to improve the outcomes of implant knee replacement surgeries around the world.

Are there any projects or initiatives within ISAR that could be shaped by MARCQI work and vice versa?

Dr. Brian Hallstrom: I've been the chair of the ISAR Patient-Reported Outcome Measures work group for a couple of years now, and that's something that we've been working on in MARCQI since its inception. We've collected a lot of data and been able to present it back to ISAR. There's continued work with the use of these patient-reported outcome measures called PROMs, to help not only assess the improvement that patients are making after surgeries with different techniques and different implants but also to look at things like the appropriateness of surgery and the optimization of preparing people for surgery.

There's also an effort to have implant registries work together to identify outlier implants that are not performing well across registries. ISAR works closely with the industry to make sure that we're communicating these things and when there are issues that the industry is aware of them. We’ll also be trying to expand ISAR to other procedures like shoulder or ankle joint replacement.

We heard a South African registry adopted one of MARCQI’s pain control measures, and you found out while attending an international meeting in Hamburg. Can you share that story?

Dr. Brian Hallstrom: One of the abstracts being presented at the meeting in Hamburg was on a quality improvement project in South Africa to reduce opioid prescribing. In the method section researchers cited that they used MARCQI opioid prescribing guidelines, which was published on our website a few years ago. They're using our guidelines as their criteria and showed improvement and reduced prescribing without any negative clinical impacts on patients and significant positive outcomes. They had never reached out to us about it, but they found our guidelines and liked them enough to implement them for this project.

This momentum is going to hopefully lead to a future collaboration with them, as they're currently developing a project that is very similar to one that we're in the process of building regarding patient preparation and appropriateness. It's a great example of how ISAR fosters collaboration around the world and allows us to develop these relationships for collaboration.

Where do you see ISAR work heading in the future?

Dr. Brian Hallstrom: There's always technological changes in orthopedics, and especially in arthroplasty. What has been shown by a lot of the registries over the last couple of decades is that not all these changes are advancements. One of the things that's going on has been the rapid adoption of robotic technology. To date, there's been very little evidence that it's actually providing any real clinical benefit. And it’s significantly more expensive! So, one of the things that we're looking at in registries around the world are the outcomes and implications of these technologies and how they are going to help patients. 

Any final thoughts on ISAR, MARCQI or the CQIs?

Dr. Brian Hallstrom: The CQI program is so unique. It enables physicians to build projects and grow something, like MARCQI. There's no way we could have done that without having the backing of the CQI program.

It's always interesting to talk to people around the country and the world about the CQIs. They’re really pretty amazed at what we do in Michigan. I think it has empowered us to do all the work that we've done and develop an international reputation