Introduction to NJR Reports

NJR Editorial Board Chairman's foreword ~ Mr Martyn Porter

The NJR is now in its 12th year of reporting and has achieved compliance in excess of 90%. It already covers England, Wales and Northern Ireland and has (from 1 July 2015) extended to the Isle of Man and the number of hospitals and surgeons reporting data continues to represent a significant logistical exercise. The high compliance rate has been supported further through the introduction of the Best Practice Tariff for hip replacements which provides incentives for hospitals to report data to the NJR. The number of cases reported to the registry every year is now in excess of 200,000 and I would like to acknowledge the support and expertise of Northgate Public Services in providing the IT support for the programme.

The University of Bristol has once again provided excellent support in terms of analysing the outcomes following primary surgery and many peer review publications have been produced from the registry data.

The NJR continues to work with many stakeholders including patients, regulators, hospitals, industry, individual surgeons and procurement. Over the last year we have continued to develop various public-facing websites including hospital ‘dashboard’ information published in March 2015. We have also developed the level and type of reports available to surgeons. Moreover, the NJR is working increasingly with other agencies to support improvements in joint replacement outcomes notably NHS England, the DH’s QIPP team and the GIRFT initiative.

The format of the Annual Report continues to evolve and we are attempting to produce more information online and I would like to draw your attention to the material previously referred to as Part Two which is the descriptive NJR data. There is now an excellent interactive platform at www.njrreports.org.uk which allows the user to filter data so they can access the information they require.

What are the main headlines for 2014?

The trends reported last year continue. The revision rates following primary total hip replacement remain low (less than 3% in many cases at 11 years). The debate regarding fixation as an isolated observation seems to become less of an issue in that it is the combination of the fixation, articulation and patient characteristics which influence the revision outcome. In particular, the controversy created by the poor results of the metal-on-metal articulation need to be considered and if necessary, filtered from the other aspects of the arthroplasty. This is particularly relevant when looking at the data for uncemented fixation where the metal-on-metal articulation was used more frequently. Once this is removed we are now seeing fairly similar revision estimates at 11 years.

It is interesting again to see the effects of patient factors which influence the outcome. Undoubtedly revision remains a problem in young patients under 55 years and is very low for patients over 75 years.

This year, results of revision hip replacement analyses are presented for the first time and it is sobering to see that re-revision rates are almost the order of magnitude higher than the primary procedure. We know that revision operations are also very expensive compared to primary procedures and it will become imperative to examine the fate and provision of revision surgery over the coming years.

The knee replacement data again continues similar trends with the unicompartmental knee having almost a three-fold revision risk compared to total knee replacement. Though, we do note a lower morbidity and mortality rate and we need to further explore the functional differences before we can come to any dogmatic conclusions regarding partial and total knee replacement. In other words, I would like to re-emphasise that revision is not the only consideration.

There is an excellent section on Patient Reported Outcome Measures (PROMs) in relation to knee replacement in this year’s report. These data must be one of the largest cohorts ever reported and are fascinating in terms of the questions which arise from the preliminary data. We intend to report on PROMs in hip replacement next year.

We also report on ankle, shoulder and elbow replacements. As these are carried out less frequently and we have a shorter follow-up period and data are still at a relatively early stage. I am pleased that the British Elbow and Shoulder Society (BESS) and the British Orthopaedic Foot and Ankle Society (BOFAS) are working very closely with the NJR to take the analysis of the data forward.

Finally, I would like to thank all members of the NJR Steering Committee and Sub-committees and indeed all the orthopaedic surgeons in hospitals that contribute data. We are carrying out a major data quality evaluation exercise in 2015/16 and this will provide valuable insight into the accuracy of our data and should in itself drive up data quality.

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

As Chairman of the National Joint Registry Steering Committee (NJRSC) for the past three years, it is always a pleasure to introduce our Annual Report. This 12th edition, outlining the substantial progress and work of the NJR during the year 2014/15, showcases the registry’s development, which continues apace. None more so than in the continued roll-out of new digital annual reporting arrangements and the launch of new interactive clinical activity reports at the dedicated ‘NJR Reports’ website (www.njrreports.org.uk).

Moving further into our second decade of data collection, we are entering a new chapter of development and work, firstly through the management and analysis of nearly 2 million records and secondly, through the increased utility that our maturing dataset holds. The registry in particular supports transparency by using and sharing relevant hospital, surgeon and implant-pricing data, as well as enabling the linkage of NJR data with other expanding healthcare information, where it is strategic to do so, and it helps tackle issues and problems in joint replacement surgery.

NJRSC memberships

Similarly to the last reporting period, there have been a number of changes to the membership of the NJRSC with the expiry of a number of long-standing members’ 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 a successful and world-leading register.

In particular I would like to thank Keith Tucker, whose term of office recently expired, for his long and dedicated service to the NJR. Keith was a long-standing orthopaedic surgeon member of NJRSC, as well as Chairman of the NJR Implant Performance and Scrutiny Sub-committees. His outstanding commitment and his valuable input to all aspects of our work, has helped to shape the NJR and make it what it is today.

I would also like to record my special thanks to Mary Cowern, patient member representative, whose term of office is due to expire in 2015/16. With the NJR since 2006, Mary has spearheaded the drive for greater patient engagement in the registry and brought the patient voice to the heart of NJRSC decision making. She has shared her experience and expertise across the programme and I would like to acknowledge the valuable and significant contribution she has made.

In turn, a number of new NJRSC appointments have been made and I am delighted to welcome Professor Amar Rangan as a surgeon member and Ms Gillian Coward as a patient member and also the additional co-opted membership of Mr Hussain Kazi, surgeon representative and Mr Matthew Porteous as Chair of the NJR Regional Clinical Coordinators Sub-committee.

We are also delighted to have benefited from closer collaboration between the registry and the profession. This is both through the co-opted role of the British Orthopaedic Association (BOA) President to the NJRSC and the establishment of the Medical Advisory Committee through which specialist orthopaedic societies are formally represented. Current BOA President Professor Colin Howie took on the role from September 2014, with immediate past-President Professor Tim Briggs then taking up a co-opted position as national lead for the Getting It Right First Time (GIRFT) initiative. This year, Colin leaves the NJRSC when his term of office as BOA President expires in September. I would like to thank Colin for his considerable contribution to the NJRSC over the last year, which has been appreciated, and I look forward to welcoming his successor for 2015/16.

Key developments

Following on from the extensive strategic work done over the past couple of years, we are delighted to report the completion and publication of the NJR’s Supporting Data Quality Strategy. This strategy, found at www. njrcentre.org.uk, outlines the registry’s current and future intentions for ensuring data quality. Crucially, this includes a programme of work in partnership with hospitals to encourage greater compliance; while data capture for the NJR is mandatory, many hospitals struggle to achieve it.

One of the ways we will be seeking to support hospitals in 2015/16 is through a national programme of local audits to assess data completeness and quality. In the first instance, we intend to work with organisations to review records from one 12-month period. Following on, we will help them each subsequent year to carry on identifying where data might be missing to improve the general quality of their data in the registry.

Those actively taking part in the audit in the coming year, and already achieving best practice and demonstrating quality in their processes, will now gain the new NJR Quality Data Provider certification. Renewable annually, this award is designed to recognise quality data provision and the commitment to patient safety through compliance. Conversely, the certification will also highlight those hospitals who do not comply with mandatory NJR requirements, communicating this status through the NJR data publication and NHS Choices websites, thus allowing patients to be aware of hospitals that choose not to meet NJR quality standards.

The NJR’s new economic model arrangements – established in 2014 to reduce the cost burden to the NHS and healthcare sector – continued with the full establishment of the complimentary implant price-benchmarking service (INFORM) to all NHS organisations. More than 60 NHS organisations have now provided their data to the NJR reporting system that in return, shares benchmarks against averages and best implant prices as well as wider organisation-level reports.

With Lord Carter’s Efficiency and Procurement Programme developing quickly, we will be pleased to see provider use of this service increase. For those NHS procurement and clinical teams wanting to examine local cost protocols and access reports by procedure type and patient case-mix, we hope to see organisations take the opportunity to register for the enhanced service (EMBED). This service, available for a reasonable, additional subscription charge, has the benefit of extended data reports to inform local dialogue and discussion about the relationship between implant cost and quality in outcome. The need to have such dialogue is supported by the GIRFT review. Moreover, NJR services will also be an important source of evidence for the sustained momentum in the Department of Health’s Quality, Innovation, Productivity and Prevention programme (DH QIPP).

Following the second publication of individual consultant outcomes in November 2014, work has continued with the BOA to develop the range of quality indicators available for publication in 2015. It has now been agreed that later this year the NJR will extend published information on individual surgeons to patient case-mix information and potentially, subject to further development, individual compliance (data submission rates) for primary and revision procedures.

In March 2015 however, the registry led on the development and publication of unit-based measures to complement the information already available for surgeons. Published in the format of ‘dashboards’ at www.njrsurgeonhospitalprofile.org.uk, the hospital indicators extended further to cover revision and mortality, patient reported outcomes and improvements (PROMs) as well as patient case-mix and information relating to the quality of data they submit to the NJR.

These developments were significant, not only in terms of quality in presentation to patients and the public, but in the planning and delivery that was achieved in a period of just six months. The hospital profiles and the associated dashboards will be an important area for refinement, as part of the surgeon data release in November 2015.

As the largest arthroplasty registry in the world, our international collaboration continues with NJR’s Medical Director, Martyn Porter, holding a term of office as President of the International Society of Arthroplasty Registers. This has become increasingly important as the registry readies itself for the introduction of Unique Device Identifiers, and the need to prepare the database to ensure it has the ability to harmonise with global orthopaedic device initiatives. This agenda has led to the start of a whole component database upgrade which is due to complete in December 2015. Representing a significant work programme, these improvements will enable the NJR to report at a granular level and track implant performance in an enhanced and more detailed way.

Additional plans for the 2015/16 operating year include:

• Expansion to the Isle of Man from July 2015
• Continued development of NJR Clinician Feedback, Supplier Feedback and the Annual Clinical Report and Implant price-benchmarking services available through Management Feedback
• Completion of the five-year NJR-funded PROMs programme for hip and knee as well as completion of the three-year follow-up for shoulder replacements. First analysis of knee PROMs is already included in the 12th Annual Report and further work continues as this new area is explored
• Refresh and refinement of NJR Surgeon and Hospital Profile service
• National roll-out and implementation of the NJR’s data quality audit programme

Acknowledgements

While I gave my thanks to colleagues who had stepped down from the NJRSC at the beginning of this introduction, I would like to end by mentioning all remaining members of the NJRSC, and NJR Sub-committees, for their valuable contribution, in particular the chairs of those committees. I would encourage you to read and review the reports from the committee chairmen at www.njrreports.org.uk which provide a strategic view and professional insight into key work areas.

We are also grateful to the orthopaedic surgeons who comprise the NJR Regional Clinical Coordinators Sub-committee and who participate as regional leaders to underpin and champion the work and success of the NJR as well as helping shape service delivery and direction. Finally, my thanks to the NJR contractors, Northgate Public Services (UK) Ltd, and 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 whose tireless efforts support the NJR’s evolution from strength to strength.