Annual progress: Work of NJR Committees

2014/15 Regional Clinical Coordinators (RCC) Sub-committee Chairman’s report  ~ Mr Matthew Porteous

The RCC network continues in its role of providing broad based clinical input to the NJR.  Members provide support for Regional Coordinators in their efforts to improve compliance and data quality, act as a sounding board for ideas and provide a route for feedback from their local hospitals and orthopaedic community.

Comprising both a geographically representative group of clinicians as well as representatives from HQIP and Northgate, it also provides a source of interested clinicians to sit on the research, editorial board and data quality sub-committees.  
The last year has seen major improvements in clinician feedback with the ability to download an individual report as a file suitable for consultant appraisal, listing details of volume and outcome of both hip and knee replacements.  Funnel plots available online can also plot trends over time to illustrate to individual surgeons how their outcomes have changed.  
Looking forward, the RCC will have a major role to play in assisting with, and rolling out the data completeness and data quality audit programme over the coming year as well as ongoing implementation of the NJR’s overall supporting data quality strategy.

The opportunity should not be passed to thank Peter Howard the outgoing committee chair, who has steered the RCC group since 2007, for his leadership and dedication to the NJR in general and the RCC Network in particular.

2014/15 Data Quality Sub-committee Chairman’s report ~ Mr Martyn Porter

The group met four times in the year, with the overarching focus being the implementation of the NJR’s Supporting data quality strategy and initiating the projects that will help to assess and improve data quality in the registry. As the internal and stakeholder feedback and consultations captured in 13/14, the requirement for more granular data publication under the transparency agenda is one driving factor behind the need to develop a comprehensive plan to identify areas for improvement and ensure confidence and robustness of the data and its analysis.

Formalisation of the data quality strategy

Particularly pleasing to see was the fruition of the thorough consultation and stakeholder feedback on data quality, coming to conclusion through the formalised and published NJR strategy for supporting data quality 2014/16. 

Read ‘Supporting data quality – NJR strategy 2014/16’ >

This plan sets out the five key work areas for the registry and outlines areas where the registry will be working to grow understanding and best practice to ensure that data is accurate and complete at the point of submission by healthcare providers:

1. Support quality hospital data collection, entry and submission
2. Monitor data accuracy and data completeness
3. Facilitate validation through routine NJR reporting
4. Work collaboratively to promote the benefits of data validation
5. Provide appropriate external review to ensure compliance
6. Pilot data completeness and quality audit project

In February 2015, six hospitals started working with the registry to pilot a data completeness and quality audit toolkit to assess the quality of hip and knee data in the database for the preceding financial year. Both an NJR Data Quality Lead and NJR Clinical Lead were named in the unit to oversee the audit implementation and evaluate the impact of data that was identified as missing from the NJR or missing/incorrectly coded in hospital systems.

The outcomes of the pilot audits helped to shape the development of an audit toolkit, which is designed to relieve the burden on hospitals as the NJR launches its national programme of data completeness and quality audits in the 15/16 year.

Designed to be an annual event, the audit programme will be one way that hospitals can achieve a new Quality Data Provider certification award – designed to recognise best practice in NJR compliance and quality. Linked in to the certification too will be the formalisation of a NJR Data Quality Lead and NJR Clinical Lead in each unit across the country.

We look forward to gauging levels of data quality at a procedure level for the first time through this project as well as furthering other areas of work detailed within the Supporting data quality strategy in the forthcoming 15/16 year. I would encourage everyone involved and interested in this work to keep up to date by signing up to the NJR eBulletin or visiting www.njrcentre.org.uk to review the dedicated data quality area.

2014/15 Research Chairman’s report ~ Professor J Mark Wilkinson

The Research Sub committee (RSC) is responsible for delivering the research agenda of the NJR. The RSC’s aims are to maximise data access for researchers and to promote the profile and branding of NJR outputs, but also to protect the NJR dataset and strengthen its governance through safe, effective, and efficient data management in line with UK legislation.

The committee takes formal responsibility for the release of data for research through an impartial and objective mechanism and has oversight of the use and reporting of NJR data by research groups. We have recently reviewed and revised our research strategy. Developments include a new single entry point for all research applications arising within or external to the NJR, the development of an annually updated build of the research dataset, and plans to develop a bespoke data access portal for researchers.

Use of NJR data this year

During the period 2014/15, the committee sanctioned the release of data to 18 research projects. 

Analyses based on NJR data continue to achieve a high publication profile and include a paper in the Lancet led by the University of Bristol team documenting 45 day mortality after knee replacement for osteoarthritis. The study showed postoperative mortality after knee replacement has fallen substantially between 2003 and 2011. Efforts to further reduce mortality should concentrate more on older patients, those who are male and those with specific comorbidities, such as myocardial infarction, cerebrovascular disease, liver disease, and renal disease.

A full list of publications related to NJR data is included in the online appendices. The NJR Research Portfolio section of our website catalogues all NJR research data releases with their progress reports, together with links to all publications related to NJR data.

Areas of NJR supported research

In 2014 we conducted a mapping exercise to better understand the current research environment and the key stakeholders in musculoskeletal research, to ensure the research questions posed justify access to the data and minimise duplication and redundancy in the supported research. Proposed research must be of potential benefit to patients, feasible, relevant, novel, and ethically sound. Accordingly, we have established a broad set of themed areas within which we will consider applications for data access.

Annual Data Build and Data Access Portal

Work is underway to develop a ‘research-ready’ dataset, enabling researchers to utilise the NJR Annual Report dataset as a research resource.  Concurrently, we are developing a Data Access Portal to maximise safe access to the NJR dataset. Access to the portal for approved projects will be made using an access key unique to each project applicant. Together these resources will facilitate more comfortable engagement with the broader national and international research agenda, reducing the burden on researchers by providing a single, clean source of data that is updated each year with a new cumulative dataset.

Research Fellows

The RSC continues to foster its Research Fellowship scheme in partnership with the Royal College of Surgeons of England, designed to build registry-based research capacity within the clinical orthopaedic community. We are pleased to confirm a new Research Fellow was appointed in February 2015, Tanvir Khan, and a second recruitment round is planned for the autumn of 2015.

Research application pathway

All applications for a research project, external and internal, are now managed by the NJR Research Sub-committee through a single portal of entry and management pathway.

Applications requesting unlinked and fully anonymised NJR data are directed down the ‘external’ route, whilst applications requesting access to linked datasets or patient identifiable data (PID) are directed down the ‘internal’ or ‘collaborative’ project route. Internal projects require participation of an NJR Steering Committee member co-applicant to guarantee UK data governance requirements for traceable PID.

Quarterly submission and review deadlines are set for all research applications and investigators who are considering including NJR data in external funding applications are encouraged to submit an expression of interest to the NJR Research Officer in the first instance.

Where it is envisaged that aspects of proposed work might duplicate or overlap with existing research on the register, before submitting a formal application for the data applicants are encouraged first to check the NJR Research Portfolio and discuss their proposals both with the NJR Research Officer and with other groups carrying out similar projects.

Full details of the NJR’s research application pathway, together with detailed guidance notes for applicants, can be found at www.njrcentre.org.uk.
 

Surgeon Outliers committee Chairman’s report ~ Mr Peter Howard

The analysis of the registry data has continued on a six-monthly basis. The sub-committee meets soon after the production of each report, and then again three months later to monitor responses. Each report has seen the identification of further potential outliers based on the Funnel plot analyses. Over the last year for hip surgery, these have been predominantly surgeons with stemmed metal-on-metal hip replacements as a significant part of their practice.

From March this year an additional analysis has been included, namely that of the last five years of data. This will be included in the Annual Clinical Report to Trusts, and appear on the Clinician Feedback website and the individual surgeon report (for use in appraisals). This allows more contemporary practice to be observed, and is particularly useful where a surgeon/unit has made a significant change in their implant usage.

Annual Clinical Report to Trusts,  Local Health Boards, Independent sector, and surgeons

The Annual Clinical Report will continue to be the mechanism that demonstrates overall performance of the individual organisation compared to the rest of the registry on the same measure used in previous reports, namely data quality, mortality and revision rates of primary procedures. Funnel plots are shown for the different sub-types of hip and knee replacement as outlined in previous annual reports. The volumes of shoulder, elbow and ankle replacements will been included for the first time in the 2015 report.

Revision rates for the unit and its individual surgeons will now also be shown for the last five years of data, and will also separate resurfacing from large head metal-on-metal hip replacement. The sub-types of knee replacement continue to be displayed separately as well as showing the combined rates.

Outlier methodology

The outlier methods are under on-going review by the committee, which includes the NJR statistical analysis team, and ad hoc discussions with other organisations such as the Scottish Arthroplasty Project, with its experience with the CUSUM analysis. It is anticipated that the Funnel plot method used for the last five years will continue, and will be augmented in the future, possibly with CUSUM.

Mortality

Bristol are re-examining the method by which mortality is analysed, giving particular attention to risk adjustment and the calculation of the standardized mortality ratio. The fall in mortality for both knee and hip replacement over the last 12 years may also need to be factored in.

Consultant Level Reports to support revalidation and appraisal

Consultant Level Reports are available through the Clinician Feedback website, containing a complete surgeon report and funnel plots. This will be updated annually. Many units now mandate the usage of these reports in the annual appraisal process, which is supported by the British Orthopaedic Association. 

Thanks are again expressed by the Chairman to the members of the committee for their contributions both in and out of the committee meetings.

2014/15 Implant Performance Chairman’s report ~ Mr Peter Howard

I took over the chair of the implant performance and scrutiny groups in April 2015. I would first like to thank Keith Tucker, the outgoing chair, for all his work since the establishment of these committees and guiding them through their first five years. He will continue to attend meetings in his capacity as ODEP and Beyond Compliance representative – a new position within the Implant Performance Group.

The Implant Performance Committee comprises members of the Scrutiny Group together with representatives from industry. The group held a meeting with a wider invitation to the implant industry, at the 2014 Brighton BOA Congress which was very well received. The Scrutiny Group includes surgeons, representatives from the MHRA, Northgate and the University of Bristol and the NJRSC Chair. Both groups are supported by HQIP.

Examining the data

The NJR data is refreshed and analyzed every six months. The Scrutiny Group assesses potential outlier implant performance and notifies the MHRA when there are concerns. This process is refined constantly and, as a result of recent reviews it is likely that more comprehensive reports will be developed for the future. An implant (and implant combinations in hips) is considered as a potential outlier when there are more than 100 cases and the overall revision rate (based on the PTIR) is more than twice the expected rate, using non-overlapping confidence intervals for statistical significance.

It is planned that future reports will contain details of surgical performance, including case mix.

Notification from surgeons of poor performance

We often receive reports from individual surgeons voicing concerns about specific implants. We know that the NJR database does not always pick up on devices which are ‘variations’ within a brand that has excellent results overall. That is to say, a relatively minor modification or variation within a brand might not be performing as well as would be wished. The NJR describes this anomaly in data analysis as ‘camouflaging’. These reports allow an in-depth analysis to be carried out in a targeted fashion, that the overall data analysis does not routinely do. We continue to encourage surgeons who have concerns about any implant brand or a particular range to contact us directly.

Data from the other major joint replacement registries is always monitored and used to provide areas of focus for our analyses.

Future development

As always, we are looking to improve our skills at identifying poor performance, whilst at the same time identifying excellent performance. We see the introduction of Unique Device Identifiers (UDI) as an opportunity for the NJR’s component database to be improved along with our capability to detect poor performance.

The NJR Implant Performance Committee also works closely with other international registries through the International Society of Arthroplasty Registers (ISAR) and the International Consortium of Arthroplasty Registers (ICOR).  Foremost in this collaboration is the development of an international database of implant attributes, which will facilitate improved implant analysis and international comparisons.

Implants and combinations identified as outliers

Details of implants and combinations identified as outliers are included in Part 4 of this year’s report [include link]. There has been only one new notification in knee replacements in the last five years. Hip replacements have had many more, but almost all have been large head metal on metal devices – all of which have now been discontinued.

2014/15 Editorial Board Chairman’s report ~ Mr Martyn Porter

The Editorial Board’s role continued in 2014/15, meeting to discuss, develop and assure the quality of data and analyses presented through the NJR Annual Report. In particular, work focused on the launch of a dedicated new website for the 11th Annual Report information – found at www.njrreports.org.uk. 

A new digital format 

In the development of the new NJR Reports website, members of the Editorial Board provided invaluable contributions in expanding the appeal of NJR’s annual report data. A key development has been the interactive filter options offered in the presentation of clinical activity data for all joint types. It is hoped that these intuitive, flexible options will help readers to engage with the data presented.

Go to the clinical activity reports >

Promoting the 11th Annual Report findings

Other achievements for the year included the launch of the 11th Annual Report at the BOA Congress in Birmingham, September 2014. The sessions were shaped by two key themes; key messages from the 11th Annual Report including research on mortality and patient risk-factors and the future of evidence-based practice. The latter session invited thoughts on evidence-based practice from each of the specialist orthopaedic societies with discussion focussing on the interpretation of data and how this should be changing clinical practice. 

Public and Patient Guide progress

The Editorial Board has been particularly pleased to see the development of the patient guides this year. The patient-friendly versions are now offered in five editions covering hip, knee, ankle, elbow and shoulder surgery separately. This provides greater potential for their future development as the data and analysis available for each joint varies. The guides will be able to provide a far more tailored view to patients as the detail grows – particularly for the newer joints on the registry (ankle, elbow and shoulder).

Go to the public and patient guides >

Aligning in-depth studies and research interests

The Editorial Board has always supported an in-depth research study programme and is delighted to see the developments in the NJR’s approach to research and the strategic direction being shaped by NJR Research Sub-committee Chairman Professor Mark Wilkinson.

From this point forward, the Editorial Board will be sharing developments in the Annual Report data and outcomes analysis with the research committee in order to ensure that pertinent in-depth studies can be taken through the internal research application pathway.

2014/15 NJR Medical Advisory Committee Chairman’s report ~ Mr Martyn Porter

The NJR is pleased to have established its Medical Advisory Committee, meeting quarterly to provide clinical leadership and oversight to the registry’s work and provide a forum for discussion and engagement with the profession through specialist orthopaedic societies.

In addition to the NJR Steering Committee and NJR Regional Clinical Coordinator Network surgeon members, representatives from the British Hip Society, British Association for Surgery of the Knee, British Foot and Ankle Society and the British Elbow and Shoulder Society also attend.

Key areas of consultation with the Medical Advisory Committee in the 2014/15 period included:

• Publication of individual consultant surgeon outcomes
• Publication of hospital-level outcomes through information ‘dashboards’
• NJR’s approach to supporting unit-level data quality and
• Advice on developing relationships with national bodies such as the Private Healthcare Information Network (PHIN) 

The forum also provided helpful and collaborative discussion on the Getting It Right First Time national review of which NJR data was a significant part. 

2014/15 NJR Executive Committee report

The NJR is pleased to have established its Executive Sub-committee, meeting monthly to provide additional operational decision-making capability to the NJR Steering Committee’s work.

The Executive Committee met twice in 2014/15 and membership alternates on a bi-monthly basis between a core group comprising the NJRSC Chairman, NJR Medical Director and NJR Director of Operations and an extended group with additional representatives comprising Chairman of the Sub-committees and main contractors as required. Please see the online appendices for a record of members and attendance at meetings.

The Executive Committee has delegated authority from the NJRSC on operational decisions under a financial threshold of £50,000 and where projects constitute a change in the strategic direction of individual work streams and projects. 
Given the expansion of the NJR’s work in recent years, as set out in the refreshed NJR Strategic Plan for 2015/18, this committee has already provided invaluable support. It is essential that the registry can remain flexible and responsive as stakeholder requirements and demands change. 
 

2014/15 NJR Steering Committee report

This section provides brief outlines of the work undertaken by the NJR Steering Committee (NJRSC) and its sub-committees during 2014/15. Although brief, these sections intend to demonstrate the ever-increasing scope of the registry’s work and the commitment required by its members to meet the needs of its orthopaedic stakeholders.

Structure, governance and operating model

The NJR Steering Committee has overseen the implementation of enhanced structure, governance and operating arrangements endorsed by members, external stakeholders and NHS England. 

Following extensive consultation on the appropriate format and remit of a new Medical Advisory Committee and Executive Committee, the NJRSC is delighted to report that both new committees have been established. Please see the related ‘tabs’ to read about the inaugural work of these groups. 

These changes have been coupled with ongoing appointments for new NJRSC members, as existing terms of office have come to an end.

New members

For a second year, the work to re-appoint and appoint new members has represented a significant undertaking particularly as a number of long-standing members continue to reach the conclusion of their terms of office.

Working closely with the Department of Health appointments team and NHS England, the NJR management team and the NJRSC Chairman and members have successfully re-appointed and appointed the following members in the reporting period:
 

The co-opted position for the British Orthopaedic Association President was taken up by Professor Colin Howie on his election in September 2014 and Immediate Past President Professor Tim Briggs’s position will continue for the 2015/16 year in his capacity as lead of the national ‘Getting It Right First Time’ project.

At the time of writing, the announcement of an orthopaedic surgeon member and patient representative member was expected. Since that time, and in June 2015, orthopaedic surgeon Professor Amar Rangan was appointed to the NJRSC for a three year term, with orthopaedic surgeon Mr Hussain Khazi appointed as a co-opted member for a two-year term. 

A GP with special interest in orthopaedics is expected to be recruited in the 15/16 period in addition to the recruitment of an independent healthcare sector member following the resignation of member JJ De Gorter. Further information regarding these appointments will be available at www.njrcentre.org.uk.

These positions, being taken up in the 15/16 period, signal the conclusion of terms of office for the first two roles for long-standing members Mr Keith Tucker (orthopaedic surgeon) and Mary Cowern (patient representative). Both had their terms extended in 13/14 until 30/04/2015 and 30/09/2015 respectively. Latterly, the appointment of the independent sector representative will signal the conclusion of JJ De Gorter’s term of office. 

NJR must thank all of its members, past and present, for their considerable contribution to the registry. For Keith Tucker, particular thanks must be expressed for his contribution as Chairman of the NJR Implant Performance Sub-committee and providing key liaison between the registry and ODEP and new initiatives such as Beyond Compliance. Looking forward, for Mary Cowern, the registry must praise her driving force for patient engagement which oversaw the development of a strong patient voice in decision-making, the launch of the Public and patient guides and the establishment of the NJR Patient Network. For JJ De Gorter, particular thanks for his experience and specialist knowledge must also be shared, particularly through the NJR Editorial Board.

The membership of the NJR Steering Committee and membership of all sub-committees for 2013/14 can be found in online appendices. Further information can also be found in the Chairman’s introduction.