Introduction to NJR Reports

The NJR Annual Report comprises four parts 

Parts One (annual progress), Two (clinical activity data) and the enhanced Part Four (Implant and Trust-, Local Health Board- and unit-level outcomes) are published online here at the registry’s dedicated Annual Report website. The NJR’s Annual Report website is part of a long-term strategy to share our annual dataset in a more accessible, responsive and timely manner. Part Three (the analyses of outcomes after surgery) continues to be published as a printed report.

Part One: executive summaries, annual progress and highlights 2015/16

These sections provide a general outline of the work of the NJR undertaken in the financial year from 1 April 2014 to 31 March 2015.  As well as providing summary information about the NJR’s key data quality indicators of compliance, consent, and linkability, this section includes brief summaries of the work undertaken by the NJR throughout the year and the individual NJR sub-committee reports.

Part Two: clinical activity 2015

This section provides reports about clinical activity as reported to the NJR as at 28 February 2016.  All reports are based on the calendar year 1 January to 31 December 2015.  Clinical activity reports under Part Two are interactive, enabling users to view the data in a number of different ways through the use of built-in filters.  The reports and accompanying text can also be downloaded as pdf files.

Part Three: outcomes after joint replacement 2003 to 2015

These sections provide an analysis of survivorship for hip, knee, ankle, and shoulder replacements undertaken between 1 April 2003 and 31 December 2015.  Unfortunately, as was the case last year, the NHS Health and Social Care Information Centre (NHS HSCIC) was unable to provide the NJR with any data from either the Hospital Episodes Statistics (HES) service or the NHS England Patient Reported Outcomes Measures (PROMs) study.  This has, unfortunately, restricted the types of analyses that the NJR would have wished to undertake using NJR data linked to these two datasets.  Part Three is provided both as a printed and an online, electronic PDF document.

Part Four: implant and unit-level activity and outcomes 2015

This section provides a series of indicators about clinical level activity and the outcomes of surgery at both a Trust/Local Health Board and hospital level.  These include indicators of potential outlier performance for both mortality and revision rates in both hip and knee.

This information is also published online as part of the hospital dashboards at www.njrsurgeonhospitalprofile.org.uk.

This year we have also included data on implant performance, contrasting between the better performing implants and those that have higher than expected rates of revision and were reported to the MHRA. 

Chairman’s foreword 

Laurel Powers-Freeling, National Joint Registry Chairman

As Chairman of the National Joint Registry’s Steering Committee [NJRSC] for the past four years, it is always a pleasure to offer a foreword to our Annual Report. This 13th edition, outlining the substantial progress and work of the NJR during the year 2015/16, showcases the Registry’s significant developments, which continue apace in what has been another challenging and exciting year. 

Key Work and Developments

The core purpose of the NJR, to collect, manage and analyse data to provide early warning of issues related to patient safety and improve the quality of outcomes and cost effectiveness of joint replacement surgery, remains as important as ever. This is particularly true as our maturing dataset now reaches 2.1 million records - maintaining our position as the largest arthroplasty register in the world.

The key focus for the NJR this year has been the implementation of an intensive national data quality audit across all NHS units, as part of the NJR’s ‘Supporting Data Quality Strategy.’ The audit, designed to assess variation in local hospital and surgeon level data completeness and quality, has involved significant dedicated NJR resource. The outcome in year one of the audit, while indicating a low overall level of missing records, has highlighted a higher percentage of missing records for revision rather than primary procedures; this is a serious concern and is a matter we will thoroughly investigate and report upon. The audit will be rolled out again in 2016/17, with the inclusion of the independent healthcare sector, in a continued effort to validate NJR data quality and ensure it is robust.

Associated with the audit has also been the successful recruitment of a valuable network of NJR Data Quality and Clinical Leads at all hospitals, to support the NJR with this work, as well as the implementation of the NJR Quality Data Provider certification. Renewable annually, the scheme rewards hospitals for completion of the audit as one of the NJR’s six qualifying criteria designed to recognise quality data provision to the NJR and commitment to patient safety. This is a unique scheme which we have been proud to roll out, with 39 Trusts achieving the award during the year and hopefully many more to join during 2016/17.

Monitoring surgeon and implant performance continues to be a key function of the NJR and this year the surgeon outlier process has been reviewed to ensure it continues to be robust and facilitate our role in supporting surgeons and Trusts to review practice and performance. 

The registry continues to underpin NHS England’s openness and transparency programme through the orthopaedic clinical outcomes publication (COP) programme. Work has continued with the BOA and relevant specialist societies, to ensure the accurate reporting of consultant-level outcomes, which this year included patient case-mix information and surgeon-level NJR compliance rates for primary and revision procedures. Published on the public-facing NHS Choices, MyNHS and NJR’s dedicated Surgeon and Hospital Profile websites, this work links directly to the NJR’s efforts to improve data quality.

An additional area of national policy which the NJR continues to support is the work now gathering momentum surrounding Lord Carter’s Efficiency and Procurement Review. Orthopaedic implants are used in significant volumes on a daily basis throughout the health service, and represent a high spend area with noticeable variation in pricing across organisations. With this in mind, reducing the cost burden to the NHS remains a focus of the NJR.  We have now fully established a complimentary implant price-benchmarking service (INFORM) as part of Trusts’, Local Health Boards’ and providers’ NJR subscription, which gives them the ability to benchmark the price they pay for orthopaedic implants against the ‘best’ national prices achieved.

Furthermore, for those NHS procurement and clinical teams wanting to examine local cost protocols and access reports by procedure type and patient case-mix, organisations can now take up the opportunity to register for the NJR’s 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. (Please see the back of the Annual Report for further details.) The need to have such dialogue underpins the ‘Getting It Right First Time’ initiative. Moreover, these services remain an important source of evidence for the sustained impetus in the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) programme. 

In July 2015, the NJR welcomed the Isle of Man and extended its data collection, reporting and information services to Noble's Hospital, which carries out hip and knee replacements across a population of more than 85,000 and will undoubtedly lead to benefits for patients. 

As the largest arthroplasty registry in the world, our international collaboration continues with NJR’s Medical Director, Martyn Porter, concluding a term of office as President of the International Society of Arthroplasty Registers (ISAR). This has become increasingly important as we continue to develop Unique Device Identifiers and complete a significant enhancement to the underlying component database. On this, working in close collaboration with EPRD, the German orthopaedic registry, the NJR has this year undertaken a project to define and capture increased classification data on each of the implants recorded. This will enable the NJR to better assess the performance of implants that share common characteristics and to also better understand if certain product characteristics demonstrate better or worse outcomes for patients.  A consistent classification across NJR and EPRD and the ongoing work of ISAR supports the increased desire to move to a global standard across all orthopaedic registries.  This is seen as a positive move to enable international registries to work together more closely in sharing intelligence on device surveillance across the globe. Opportunities for continued international collaboration and sharing best practice will continue to be a key strategic element for the NJR in the coming year. 

Future Plans for the coming year 2016/2017

In addition to our core schedule of activities, we will:

• Refresh and update the NJR website (www.njrcentre.org.uk) 
• Continue development of NJR information systems, including enhanced Clinician Feedback to aid surgeon appraisal, Supplier Feedback, Management Feedback and Trust Annual Clinical Reports
• Develop  a dedicated NJR data access and research portal to allow researchers to access the NJR data set via secure access
• Provide further analyses and investigation of NJR PROMs at 3 and 5 years

Acknowledgements

During this reporting period, there have been changes to the membership of the NJRSC. I would wish to covey my sincere thanks to outgoing independent healthcare sector member Dr Jean-Jacques de Gorter, for his valuable contribution to the NJR, which I have much appreciated, and to welcome his successor Mr David MacDonald, and also welcome new patient member Gillian Coward. I very much look forward to working with them. This year I have also appreciated the significant contribution made by Mr Tim Wilton. As BOA President, Tim joined the NJRSC as a co-opted member from September 2015 and leaves the Steering Committee this September when a new president takes up post. I look forward to welcoming his successor.

The NJR Regional Clinical Coordinators Sub-committee has also seen a number of changes to its membership during this period. Regional Clinical Coordinators (RCC) underpin and champion the work and success of the NJR, as well as helping shape service delivery and direction. I offer my thanks to all members – both outgoing and incoming – who have supported this important committee, especially Mr Matthew Porteous for his significant contribution as RCC Sub-committee Chairman.

Finally, I would like to end by again thanking all remaining members of the NJRSC, and NJR sub-committees, for their valuable contribution and enthusiasm. In particular, my thanks to Mr Martyn Porter, NJR Vice Chair and Medical Director, and to the chairs of each of the NJR sub-committees for their valuable contribution, hard work and insight. I would encourage you to read and review the reports from each committee chairman here where they provide strategic oversight and professional awareness into key work areas.
Also my thanks to the NJR management team, in particular our NJR Operations Director, Elaine Young.

Thanks also go to our NJR contractors, the communications team based at the Healthcare Quality Improvement Partnership, Northgate Public Services (UK) Ltd and the University of Bristol, for all their hard work and efforts throughout the year in progressing the NJR work agenda.