Executive reports: Introduction & foreword

NJR Editorial Board Chairman's foreword ~ Mr Martyn Porter

The NJR started collecting data in April 2003 and last year we reported up to ten years of clinical activity and outcomes analysis. The NJR now contains more than 1.6 million records and is growing with more than 200,000 cases submitted a year.

The phenomenal success of joint replacement means that outcomes are measured over decades rather than years. As the reporting period of the NJR moves forward we will start to see important determinants that influence the outcome and longevity of the procedure. In the first ten years we unfortunately observed high failure rates of some resurfacings and total hip replacements used with a metal-on-metal articulation.

Although the registry could not predict or indeed prevent these failures it was instrumental in detecting the size of the problem as it unravelled. By working in close partnership with the Medicines and Healthcare Products Regulatory Agency (MHRA) and the profession, the registry clearly influenced the regulatory actions and prevented further harm to patients. Patient safety is of paramount concern and the actions of the NJR influenced global regulatory responses. 

The NJR continues to observe a higher revision rate following partial knee replacement and isolated replacement of the patello-femoral joint. There may be other benefits to patients in carrying out some operations that have a higher re-operation rate. Still, it is essential to understand what these benefits are and to encourage the profession to optimise outcomes and fully engage the patient in the decision-making process.

The data on other joint replacements including shoulder, elbow and ankle continues to evolve. Over the past decade, the NJR has grown into a sizeable organisation that engages with multiple stakeholders including patients, hospitals, surgeons, regulators and industry. The NJR provides comprehensive IT systems to ensure the relevant data is made available to these groups allowing them to make more informed decisions to benefit patient care and enhance patient safety.

NJR data is also being used to facilitate service evaluation including procurement and a national review of orthopaedic services within England*. These initiatives have been sponsored by NHS England and demonstrate the value of high quality data in terms of evaluating and redesigning healthcare provision. 

Following the 2012 change in status of the NJR Steering Committee to an NHS England Committee of Experts, further structure and governance changes have ensued. This includes the establishment of the Medical Advisory Committee which will provide the necessary forum for effective clinical and professional engagement from the key professional groups particularly the British Orthopaedic Association, the British Hip Society, the British Association for Surgery of the Knee, the British Elbow and Shoulder Society and the British Orthopaedic Foot and Ankle Society. 

What are the key messages from this report?

Firstly, that the data is complex and needs careful consideration. Registry data is observational but limited by confounding factors and limitations of follow-up. For example, the classic debate as to whether cemented fixation for hip replacement is better (or not) compared to uncemented fixation is almost redundant in that it depends on other factors such as patient age, gender, bearing surface and period of observation.

For most patients, revision rates of less than 5% at ten years can be achieved. A number of different types of replacement and brand can have a similar performance suggesting that there may not be a ‘best’ device and a number of devices have acceptably low revision rates and are safe for patients. The NJR has also identified patient groups and devices that have a statistically higher revision rate. Still, we are aware that revision is not the final arbiter of success or failure and that other factors including risk of death, function, patient reported outcomes and cost-effectiveness also need to be considered and evaluated.

The main changes in this year’s report relate to the inevitable transition to online reporting which increases functionality and access to data. This year the data previously contained in Part Two (descriptive information on activity and practice) will move to an interactive web-based service that allows more detailed individual enquiry. Expect further developments of this nature in years to come at www.njrreports.org.uk.

Finally, I would like to thank everyone who has helped to make the NJR the success that it has become. Particularly to patients for consenting for their details to be recorded, surgeons for inputting their data and the whole NJR Editorial Board, NJR management team and contractors for their hard work and dedication.

National Joint Registry Steering Committee Chairman's introduction ~ Laurel Powers-Freeling 

Once again it is my pleasure as Chairman of the National Joint Registry Steering Committee (NJRSC), to introduce our 11th Annual Report, which outlines the substantial progress and work of the NJR during the year 2013/14. This is also the first year of the roll-out of new digital annual reporting arrangements and the launch of a new ‘NJR Reports’ website.

This year has been particularly exciting as we have celebrated the 10th anniversary of the NJR, with a number of stakeholder events held throughout the year. These provided an opportunity to showcase the many achievements of the registry, which has grown to be the largest of its kind in the world since its inception more than ten years ago.

NJRSC membership and appointments

There have been a number of changes to the membership of the NJRSC with the expiry of a number of member terms of office. I would therefore, like to take the opportunity to acknowledge the significant contributions made by those outgoing members for their work in having made the NJR the successful and world-leading registry it is today. Professor Alex MacGregor, epidemiology representative (since 2002) and Chairman of the NJR Research Sub-committee, Mick Borroff, industry representative (since 2003), and Andrew Woodhead, NHS management representative (since 2007), have each been highly dedicated to the NJR and provided valuable input to our various all important sub-committees.

Specifically, I would like to record special thanks to Professor Paul Gregg, NJRSC Vice Chairman and surgeon member, who since his appointment in 2002, has been instrumental in the development of the NJR. Notably, this has been through Chairmanship of the Surgeon Outlier and Data Quality Sub-committees as well as his leadership in these important areas.

In turn, a number of new NJRSC appointments have been made and I am delighted to welcome Martyn Porter, previously a surgeon member, to the new post of NJR Medical Director and Vice Chairman; Professor Mark Wilkinson, as epidemiology representative and Research Sub-committee Chairman; Nicholas Wishart and Michael Green as industry representatives; Rob Hurd as NHS management representative; and Professor Andrew Price and Peter Howard (previously Chairman of the RCC Network and co-opted surgeon member), as surgeon representatives. I also welcome the additional co-opted membership of the British Orthopaedic Association (BOA) President, currently  Professor Tim Briggs, to signify greater collaboration between the NJR and the orthopaedic surgical profession. This will be further strengthened in 2014/15, with the establishment of the new Medical Advisory Committee and greater involvement of the specialist orthopaedic societies in the work of the sub-committees.

Key developments and achievements

We are proud to announce some key developments and achievements during the course of the review year. These include giving greater transparency to our work aims through the publication of a number of strategic documents, namely a three-year Strategic Plan 2013 to 2016, a supporting annual work plan and a communications strategy. Work also started on the production of a data quality strategy and a research strategy. These two key documents will be published during the coming year 2014/15 and will set out our proposals for addressing these priority areas of work.

A major change to our operating arrangements involved reviewing the NJR economic model, with the aim of reducing costs to the NHS and independent sector through revising the levy collection and securing a fair and proportionate contribution from orthopaedic device manufacturers as key NJR stakeholders. Work was ongoing throughout the year and from April 2014 new arrangements are to be implemented which will see the cost of the NJR levy reduce from £20 to £15.60 gross per procedure, representing a significant saving to healthcare providers.

Associated with these economic changes, we continued work with the Department of Health (DH) and the QIPP Orthopaedic Procurement Group, to evaluate the results of the price benchmarking pilot study. This has demonstrated the enormous benefit of this initiative and has generated considerable interest with those surgeons and providers involved in the pilot, given the potential to achieve significant savings through analysis of price and usage of orthopaedic implant devices. It is exciting to be able to confirm that from April 2014, price benchmarking will be rolled out nationally as a new NJR service available to all NHS organisations; with online reporting services available to NHS procurement teams. 

Following the first publication of individual consultant outcomes in July 2013, work has continued with the BOA to develop the range of quality indicators available for publication in 2014/15. It has now been agreed that in September 2014 the NJR will extend published information on individual surgeons to include 12-month and 36-month profiles for hip, knee, ankle, elbow and shoulder surgeons as well as the use of ODEP-rated prostheses for hip replacement. An important step forward for 2014 will be a formal data validation period in which surgeons and hospitals will be able to validate the data for publication against these indicators.

This year the NJR has worked closely with the DH to create a new best practice tariff for primary hip and knee replacement. For 2014/15, the tariff will be linked to two NJR indicators – compliance and consent. We welcome this development, which will ensure improved quality of data reporting to the NJR, as well as raising the profile of the registry with healthcare commissioners. NJR PROMs continued with distribution early in the year of the three-year PROMs questionnaires. Analysis of feedback is planned to continue during 2014/15.

As the largest arthroplasty registry in the world, we continue to collaborate internationally, making presentations at both the International Consortium of Orthopaedic Registries and International Society of Arthroplasty Registries (ISAR) conferences and working with colleagues from other national registries. The most significant initiative currently ongoing is probably the introduction of Unique Device Identifiers, which is being pursued within the NJR, together with the complementary opportunities to improve our component database. Also from April 2014, NJR Medical Director, Martyn Porter, will become President of ISAR, which will present an increased opportunity for NJR international involvement. 

Future plans 2014/15

Additional plans for the 2014/15 operating year include development of the NJR Clinician Feedback System to provide an improved reporting format to aid surgeon appraisal, revalidation and validation of data, continued development of the NJR Patient Network and involvement of patients in sub-committee activity as well as evaluation of a patient implant card pilot and evaluation of a two-year shoulder PROMs pilot.

While I gave my thanks to colleagues who had stepped down from the NJRSC at the beginning of this introduction, I would also like to mention all remaining members of the NJRSC and NJR Sub-committees for their valuable contribution. In particular the chairmen of those committees: Paul Gregg again for his leadership of the Outlier and Data Quality Sub-committees; Keith Tucker, who chaired the NJR Implant Performance and Scrutiny Sub-committee; Martyn Porter, who chaired the Editorial Board (and oversaw the preparation of this report); and Professor Alex McGregor, who chaired the NJR Research Sub-committee.

We are also grateful to Peter Howard for chairing the NJR Regional Clinical Coordinators Network and all the surgeons who participate as Regional Clinical Coordinators and underpin the success of the NJR with their support at local level.

Finally, my thanks to the NJR contractors, Northgate Information Solutions (UK) Ltd, the University of Bristol and to all the management and communications team at the Healthcare Quality Improvement Partnership (HQIP), in particular Elaine Young, NJR Director of operations, for providing sound management of the NJR every day.