Annual progress: Work of NJR Committees

2016/17 Regional Clinical Coordinators (RCC) Sub-committee Chairman’s report - Mr Matthew Porteous

The Regional Clinical Co-ordinator network continues to facilitate two way communications between surgeons contributing to the NJR and the NJR itself.  RCCs are surgeons representing all the regions and countries who enter data into the NJR.  They provide a route for both problems and ideas for improvement to be fed back centrally by contributing organisations and individuals and assistance to the Regional Coordinators in helping hospitals who enter data into the NJR and are experiencing difficulties.  In the last two years they have become more active in communicating with their constituent hospitals and their early intervention has helped resolve a number of issues very rapidly.  They have also proved a useful sounding board for ideas and giving a sense of the way that the wider profession feels about issues related to the NJR which has been invaluable in developing new policies.  RCC members are active for example in assisting in the review of pathways for Surgeon and Unit outliers ensuring their compliance with national guidelines.

The past year has continued the trend of increasing activity for committee members with the need not only to complete the 2014/15 Data Quality Audit programme but initiate the 2015/16 audit. Committee members have played a major role.  It is a tribute to all working in the audit that the huge efforts put in to collecting the data seem to be paying off in terms of bringing about changes in many previously non or reluctantly compliant organisations that have led to a dramatic improvement in data contribution second time around.   RCCs have made a number of suggestions for improving the audit process not least of which has been work to improve regular communications with hospital lead clinicians using the NJR ebulletin.  

At the end of 2016 a number of RCCs retired from the role, some of these had served on the committee for many years.  I would like to take this opportunity to thank them for their contribution in making the NJR, and in particular would like to thank Colin Esler who has ably served as the committee vice chair for a number of years. 

Seven new RCCs started on the committee in 2017 and their appointments have improved the representation of upper limb and foot and ankle surgeons serving on the committee.

2016/17 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 second retrospective data quality audit of arthroplasty procedures recorded by the NJR for financial year 2015/16. This has been the work surrounding the data quality audits rolled-out across all eligible NHS hospitals, and for the first time during 2016/17, independent sector hospitals too.

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

NJR Data Quality Audit

The requirement for more granular data publication under the transparency agenda continues to be the driving factor behind the need to develop a comprehensive programme to identify areas for improvement and ensure confidence and robustness of the data and its analysis.

A full update on the audit's first year and early finsings from the second can be read here.

Engaging more NHS trusts and the independent sector

We have already seen a number of NHS hospitals demonstrate a marked improvement in data quality following the previous year’s audit process.  However, we are conscious that some hospitals continue to struggle with systemic process and resource problems, whilst others have not benefitted from clinical leadership on use of national audit and data quality improvement techniques. 

To help providers overcome these barriers, the NJR’s Data Quality Strategy will be strengthened through the introduction of a dedicated NJR Data Quality Assurance Team.  This team will provide the NJR with additional capacity to work closely with hospitals to identify and resolve data quality issues; review underlying data entry processes; and support process changes through examples of good practice.  Perhaps most importantly though, the team will increase the automation of data quality reporting and feedback, where possible, thus making this area of work more timely and effective to providers.

The Data Quality Audit has lifted the lid on the NJR’s dataset.  The overall scale of missing records in the registry is low, dispelling previous critique about the quality of the data in recent years.  Yet, clearly more work is required to investigate why revision procedures are missing at a higher proportion, and then the registry can proudly declare its position as both the largest and the most robust arthroplasty register in the world.

I will be handing the Data Quality baton over to Mr Matthew Porteous from summer 2017. Matthew will do an excellent job in continuing this important work. 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.

2016/17 Research Chairman’s report - Professor J Mark Wilkinson

The Research Sub-committee (RSC) is responsible for delivering the research agenda of the National Joint Registry. The NJR is a uniquely powerful resource that provides a foundation for definitive research into the full range of clinical, mechanical, economic, social and biological factors influencing the outcome of joint replacement. The data can also help establish the impact of joint replacement surgery on the well-being of patients and the general population. The RSC works to facilitate an effective two-way flow of ideas between the research environment and the wider healthcare economy. The aim is to enhance the understanding of the science of arthroplasty, improve and enhance clinical practice and benefit public health.

Research application submission process

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 a commitment to uphold the standard and consistency of work that is carried out on NJR data in line with UK legislation. Our priority is to ensure that any research question justifies access to the data and offers potential benefit to patients. Research should align to the NJR’s priority framework and be feasible, ethical, relevant and methodologically sound.

If you would like to submit a research application, the first step in this process is to complete an expression of interest. This form and further guidance information can be accessed on the research pages of the NJR website [link].

Research ready dataset and Data Access Portal

Work is progressing well in delivery of our “research-ready” dataset and online Data Portal, with both outputs due to launch in 2017. These resources will enable researchers to utilise the NJR Annual Report dataset more effectively as a research source, reducing the burden on researchers by providing a single, “clean” source of data that is updated each year with a new cumulative dataset. Supporting the goal of reproducible research, data analyses can be published with their data and software code so that others may verify findings and build upon them. We will provide educational resources to aid researchers using NJR data for the first time, including an introductory guide and open-access educational ’test’ dataset. This will be supplemented with a list of suitable reading materials and practical guides for more complex issues.

Research Fellowship Scheme

The RSC continues to foster its Joint Clinical Research Fellowship scheme in partnership with the Royal College of Surgeons of England. We are pleased to confirm the appointment of a seventh Research Fellow, Jonathan T Evans, and look  forward to welcoming new applicants who can help us to maximise the value of NJR data to the community and find new ways to drive improvement and quality in orthopaedics. Prospective future fellows are encouraged to apply to our annual rolling programme.

Use of NJR data this year

The RSC champion external use of the NJR dataset to answer questions of clinical relevance. The NJR dataset has provided opportunities for a number of external researchers this year. During the period 2016/17, the committee sanctioned the release of data to ten research projects, six of which are externally-led projects. The NJR dataset has been used as the key resource in thirteen research papers published during this same time period, of which nine were conducted or led by external, independent researchers. We will be showcasing a number of these research studies at the British Orthopaedic Association Conference 2017.

We are currently addressing in depth several topics that relate to our identified priority areas. Topics of focus have included infection demographics, predictors and outcomes; surgeon education, training and volumes; mixing of components from different manufacturers in total hip arthroplasty, and outcomes of joint replacement in minority patient groups. One study examined provision of arthroplasty according to ethnicity. Over 640,000 patient records were studied in the first large-scale study of ethnicity and joint replacement in the UK. We found that the rates of joint replacement vary substantially with ethnic background. Another study looked at nearly 720,000 joint replacement patients demonstrating that clinicians should be aware of a patient’s potential for post-operative complications relating to the digestive system as well as cardiovascular risks. We have also examined the ‘weekend effect’ for elective joint replacement and find a lower mortality risk in patients undergoing elective surgery at the weekend versus those operated between Monday and Friday. We are also carrying out work addressing data quality and the completeness of the NJR dataset, accuracy, and systematic bias and recommendation on approaches to minimise their impact.

Working with patients 

Keeping patients at the centre of what we do is a guiding principle of all NJR research activity to better inform decision-making at the individual patient and surgeon level. In development is a personalised decision aid for patients considering hip or knee replacement. This simple tool, supported by Arthritis Research UK, will help patients considering joint replacement make evidence-based choices about their treatment and share decision-making with their clinicians when considering the benefits and risks of undergoing joint replacement. We are working in collaboration with the NJR Patient Network to contribute to the development and validation of this decision aid. 

Please see the NJR Research Project Portfolio, which catalogues all sanctioned research projects, progress reports and NJR updates in relation to research using the NJR dataset together with links to all publications related to NJR data. 

A full list of publications related to NJR data is included in Appendix 4.   

Further information

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

2016/17 Surgeon Outliers committee Chairman’s report - Mr Peter Howard

Committee name and work

The committee name has altered (From Surgeon Outlier Committee) to take into account the increasing focus on unit level performance and its reporting. 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 NJR’s funnel plot analyses. From March 2015 the last five years of data was added as an additional analysis. This is examined on a rolling basis, allowing more contemporary practice to be observed, and also offering a reflection of greater data accuracy. It is particularly useful where a surgeon/unit has made a significant change in their implant usage and/or practice.

Annual Clinical Report 

The Annual Clinical Report (ACR) issued to Trusts, Health Boards, independent organisations and units, and to surgeons has been further refined this year. In the future it is planned to show which surgeons in a unit have accessed their own annual report (intended for use in appraisal).

There is increased focus on unit outliers, this last year has seen the involvement of the CQC to whom the committee reports. Persistent outlier units will be expected to provide a response and management plan. In some cases a recommendation will be made to undergo an independent external review.

Clinician Feedback

The NJR’s Clinician Feedback website has several new features of value to surgeons. Details of revisions and their outcomes are now available, for the first time. Refinement of the presentation of the data is under way.

Management process of potential Surgeon Outliers

The process for managing surgeons whose data shows a standardised revision or mortality ratio significantly greater than the expected has evolved over the last six years. It has been formally reviewed and documented this year, and agreed through the Medical Advisory Committee.

The committee now notifies all surgeons whose data lies between the 95 and 99.8% control limits of their status, a formal alert, and going forwards will require a response/acknowledgement of this. This is being done to give advance warning to those surgeons so that they can examine their data and practice and if possible take measures to prevent further deterioration. Surgeons in this category are alerted, but once acknowledged no further action is taken – the CEO is not involved in the process.

2016/17 Implant Performance Chairman’s report - Mr Peter Howard

The Implant Performance Committee comprises members of the Scrutiny Group together with representatives from industry. The Scrutiny Group includes surgeons, representatives from the MHRA, Northgate Public Services, the University of Bristol and the NJRSC Chair. Both groups are supported by the NJR management team based at HQIP.

Examining the data

The NJR data is refreshed and analysed 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 patient-time incidence-rates (PTIR) is more than twice the expected rate, using non-overlapping confidence intervals for statistical significance.

When an implant has been notified to the MHRA because of its poor performance, once a period of three years has elapsed then data for the whole NJR is analysed to give baseline PTIRs with the outlier data excluded. This is similar to the method used in assessing surgeon performance.

Notification from surgeons of poor performance

We continue to encourage surgeons who have concerns about any implant brand or a particular range to contact us directly. This enables us to focus on a specific area that might otherwise be camouflaged by the overall brand if the remainder is performing well.

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. 

Foremost in this collaboration is the development of an international database of implant attributes, which will facilitate improved implant analysis and international comparisons. The database is now established and is being populated with data from the implant companies.

Implants and combinations identified as outliers

Details of implants and combinations identified as outliers are again included in Part 4 of this year’s report. There has been one new notification to the MHRA in knee replacements in the last year, one hip acetabular component, and two hip stem/cup combinations. All of these implants are still in use and none of the hip ones are metal-on-metal.

2016/17 Editorial Board Chairman’s report - Mr Martyn Porter

The role of the Editorial Board is to oversee NJR communications that include:

1. The timely production of the NJR annual report
2. A series of publications aimed at patients: Public and Patient Guides to joint replacement surgery
3. The NJR reports website

Annual Report

The format of the annual report is produced in partnership with Northgate Public Services, the main informatics provider, and the University of Bristol, the main analytic provider for the NJR. The format and contents of the report are continually under review with important contributions are made from the orthopaedic specialist societies, industry and patients. Particular attention is given to the regular or standard reports and the more detailed and research orientated topics that are considered to be of importance to the stakeholder community.

The continual development of the interactive NJR Reports website has allowed users to interrogate the data to produce tailored reports for clinical activity. This reduced demand on the published report and allowed more interaction from the public, as well as offering the potential for more detailed data to be available electronically. 

Enhancing the digital format 

With the continued development of the NJR Reports website, members of the Editorial Board provided invaluable contributions towards the interactive filter options offered in the presentation of clinical activity data for all joint types. The intuitive, flexible options help readers to engage with the data presented and have been well received by users of the NJR Reports website. 2015/16 also saw the inclusion of the interactive NJR’s Public and Patient Guides to joint replacement surgery on the website (see below).

Promoting the 13th Annual Report findings

Other achievements for the year included the launch of the 13th Annual Report at the BOA Congress in Belfast in September 2016 and securing coverage in the relevant key trade magazines/ news outlets about the report's findings. Additionally, the report's findings was outlined as part of an NHS England guest blog.

Public and Patient Guide progress

The Editorial Board has been particularly pleased to see the continued development of the NJR’s Public and Patient Guides to joint replacement surgery (PPGs) in conjunction with the NJR Patient Network. With input from the Patient Network, five editions of the public and patient guide (PPG) were produced in January 2017, which continue to offer the NJR the ability to tailor the information provided to address differences by surgery type.  This remains particularly important as the data grows for ankle, elbow and shoulder replacements by allowing the patient guides to remain manageable in terms of size and format for the years to come. 

The Editorial Board acknowledges that the guides’ readership still only represents a small proportion of pre-operative patients annually. However, anaylsis of the number of downloads and views of the interactive PDFs to the PPGs show that they are a popular resource which we can expect to grow as the demographic requiring joint replacement becomes even more technology literate. Each hospital who report to the NJR is sent one copy of each relevant PPG with an enclosed cover letter encouraging units to contact the NJR Centre for further copies.

There has been maintained engagement with Patient Network members throughout 2016/17, most specifically to ensure that additional NJR patient focused resources are appropriate.  For example, the Patient Network helped to redesign the NJR’s patient information leaflet. 

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. I would particularly encourage you to explore the research published since the last annual report on ethnicity and joint replacement  and the main cause of death following primary total hip and knee replacement for osteoarthritis.

The NJR Reports Website

The website is continually reviewed and updated to reflect the requirements of NJR reporting.

2016/17 NJR Medical Advisory Committee Chairman’s report - Mr Martyn Porter

The NJR’s Medical Advisory Committee meets 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 Sub-committee, surgeon members, representatives from industry, and 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 2016/17 included:

• NJR’s approach to supporting unit-level data quality 
• Discussing broader applications for audit data to improve orthopaedic outcomes
• Supporting patient safety
• Helpful and collaborative discussion on the Getting It Right First Time national review of which NJR data plays a significant part
• Advice on developing relationships with national bodies such as the Private Healthcare Information Network (PHIN) 
• Publication of individual consultant surgeon outcomes
• Publication of hospital-level outcomes through information ‘dashboards’
• Supporting data requirements for specialised commissioning
• Supporting regulation and service review

2016/17 NJR Executive Committee report - Laurel Powers-Freeling 

The NJR Executive committee meets monthly to provide additional operational capability to the NJR Steering Committee’s strategic and governance role. The committee 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.

Importantly, 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.

2016/17 NJR Steering Committee

This section provides brief outlines of the work undertaken by the NJR Steering Committee (NJRSC) and its sub-committees during 2016/17. 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 is a NHS England Committee of Experts and is responsible for the work and progress of the NJR.

Membership 2016/17

During this reporting period, there have been some changes to the membership of the NJRSC. Professor Andrew Price stepped down from his role as a surgeon member of the committee as he formally became part of the NJR’s statistical analysis contractor team. Work was undertaken with the Department of Health’s appointments team to find Andrew’s replacement and also to appoint a senior specialist practitioner with an interest in orthopaedics. Mr Martyn Porter, NJR Vice Chair and Medical Director, and Sue Musson, patient representative member, were both granted extensions to their membership of the NJRSC until March 2018 and October 2017, respectively.

The co-opted position for the British Orthopaedic Association President was taken up by Mr Ian Winson on his election in September 2016. Professor Tim Briggs continued as a co-opted member of the NJRSC for the 2016/17 year in his capacity as National Director for Clinical Quality and Efficiency, NHS Improvement.

NJR must thank all of its members, past and present, for their considerable contribution to the registry. 

The membership of the NJR Steering Committee and membership of all sub-committees for 2016/17 can be found in online appendices. Further information can also be found in the Chairman’s introduction.