Developments

Our in-house communication team has designed and built the architecture and structure for our new website in a completely new content management system, working with a collaborative approach alongside our NJR management team and our valued patient-representatives for input in reviewing and creating new web content.

As our public-facing information portal, the aim of the upgrade has been to develop increased functionality to make the website more engaging and enable us to develop new supplementary visual material so that we can tell you more about the work we do and demonstrate more imaginatively how the NJR benefits all stakeholders across the orthopaedic sector.

In 2019, we commissioned the development of a cloud-ready, platform-based application framework for provision of future NJR services. The rationale for the implementation of the new NJR IT platform includes a focus on the need to develop a modern, unified environment with the ability to move to a cloud-based infrastructure. The platform development will include developing reusable services that will transfer across user groups, so that functionality and developments can be shared across all systems on the portal. Optimisation of modules for access on mobile devices will also be included.

The first phase of development (iteration 1) transferred clinician feedback services into the new environment along with a more interactive reporting service. This was launched in March 2021 and included the following modules:

• Interactive outcomes and clinical practice reports
• Consultant and Surgeon Level Report (CLR & SLR)
• Annual Clinical Report (ACR)
• Clinical Outcomes Publication Preview (COP)
• Clinician Profile Edit
• Contacts Database

Iterations 2 and 3 will take place during 2021/22 and will include development of other NJR services:

• Component Database
• Supplier Feedback, including interactive reporting services (SF)
• Interactive Management Feedback Service (MF)
• New availability of Implant Data Library
• New semantic layer to aid researcher access to NJR data – with enhanced data dictionary
• Data Entry
• Data Quality Tool
• Data Access Portal

In 2019, the NJR launched the NJR Patient Decision Support Tool. This is a web-enabled personalised patient decision-making tool for patients considering hip or knee replacement. This simple tool, whose development was supported by the charity Versus Arthritis, will help patients considering joint replacement to make evidence-based choices about their treatment and in share decision-making with their clinicians when considering the benefits and risks of undergoing joint replacement.

This project represents a substantial initiative on the part of NJR members to meet one of the core objectives: to improve accessibility of the NJR resource to patients and promote shared, informed and value-based decision-making. Decision tools fill the gap between population-level data and its application to the patients’ individual circumstances, to better inform patients making choices about healthcare interventions, enhance patient participation in the process, and benefit healthcare economies through improved clinical outcomes and better resource utilisation.

Having now launched this tool (available at: https://www.njrcentre.org.uk/patients/patient-decision-support-tool/), we are continuing a collaboration with the University of Sheffield to further develop it. This will involve developing algorithms that will allow the most up-to-date NJR data to be used to calculate the projected risks and benefits of joint replacement surgery.

In 2018, the NHS Healthcare Safety Investigation Branch identified a requirement to reduce the number of ‘Never Events’ associated with joint replacement surgery. The NJR was identified as a means by which this could be achieved.

For hip surgery, a Never Event is where there is a mismatch in size between the acetabular cup/liner and the head or where different brands of head and stem are used in modular components. For knees, a Never Event relates to side, e.g. a left-sided component being put into a right knee.

The data entry system was updated to enable it to detect potential Never Events and to warn the data entry user. At the same time as warning the user, the system generates emails to NJR Centre staff so that this can be investigated. If an alert is confirmed as a genuine Never Event, the Consultant in Charge is contacted by a surgeon member of the NJR Steering Committee to confirm what action, if any, will be taken.

A very small number of Never Events are identified in this way each year but the number of ‘false alarms’ is considerably higher. These alarms are most often likely to be due to mistakes in data entry, such as selecting the wrong side for the operation or using the wrong label detail for recording the implants.

As part of this focus on Never Events, we have been working to deliver the validation rules that are applied in data entry to an external environment, so that it can be used in support of intra-operative checks. An Application Programming Interface (API) has been developed so that hospital theatre systems can interface with NJR’s checking rules. A smartphone application is also being developed so that clinical teams can carry out validation checks even if their hospital does not have a compatible front-end system.

For more information about how to access the NJR’s implant validation API, please visit our website: njrcentre.org.uk

The NJR’s research activity has been developed over a number of years and has led to a large number of important and impactful publications – delivering valuable evidence about how joint replacement surgery works with the key aim of being used to improve patient safety and outcomes.

The NJR now commissions an ongoing programme of research with the University of Bristol and this focusses on a rolling programme of four research topics for detailed examination. These projects are jointly led by a clinician from the NJR team and a clinical academic from the University of Bristol, guiding expert statisticians to ensure that the analysis is of the highest possible quality.

The current NJR research programme consists of these topics:

• Inequalities in provision and outcomes of arthroplasty performed in England
• Development of an Orthopaedic Arthroplasty Specific Morbidity Index
• Factors associated with revision and its outcomes
• Examination of data quality in the national PROMs programme

We also support external research groups to access and use NJR data for research under strict data control measures. The NJR research committee reviews submissions from groups across the country, and advises and supports in ensuring that NJR data can be best used to inform and improve practice. A full portfolio of NJR research applications can be found at https://www.njrcentre.org.uk/research/.

The NJR Data Access Portal (DAP) has been developed to streamline research applications by providing a secure working environment, including analysis tools, for researchers and users of NJR data, whilst enabling the NJR to manage and control our data more effectively. By providing access to the data without the need for datasets to be sent to third parties, it is anticipated that the governance burden that research teams face will be significantly reduced.

Following a meeting of the NJR Steering Committee in 2018, it was agreed to establish a PROMs working group, which is led by the Chair of the NJR’s Research Committee, Professor Mark Wilkinson. This group oversees a number of workstreams that involve the collection, analysis and reporting of patient reported metrics.

ePREMs: In April 2020, the NJR started an electronic Patient Reported Experience Measures (ePREMs) pilot, however this exercise was soon paused due to the impact of Covid. This pilot will now take place throughout 2021/22. We would like to communicate with patients who have had a joint replacement, to invite them to participate in completing a questionnaire in relation to their experience of joint surgery. It is hoped that they will share their experiences with us and we intend to use this feedback to improve the healthcare given to all patients. The project and invitation to patients to complete the questionnaire will be run for 12 months as an initial pilot. Thereafter the project will be extended, if deemed successful, and the outcomes will be further communicated.

Assessment of PROMs data quality: As the NJR increasingly uses PROMs metrics from the national PROMs programme (undertaken by NHS Digital) alongside revision and mortality endpoints, an examination of the quality and representativeness of national PROMs for the population of patients in England who have hip and knee replacement surgery is now being undertaken. This important work that is being carried out by the University of Bristol on behalf of the NJR will aim to ensure that clinicians, hospital managers and regulators can have confidence in using patient reported metrics to assure quality.

Use of PROMs in implant reports: The NJR now routinely includes reporting of PROMS metrics in implant reports made available to manufacturers via the NJR Supplier Feedback service. This means that patient reported metrics can be considered alongside revision rates when examining the performance of an implant or construct. Increasingly, regulatory bodies internationally are requiring PROMs to be included as part of submissions to support device assurance. The NJR is currently developing a system that will make a library of these implant reports available to clinical teams – this platform will launch in 2021/22.

Shoulder PROMs: For shoulder replacement joint surgery, we commenced regular six-month follow-up questionnaires in April 2017 for patients who had undergone surgery after 1 October 2016. Three-year follow-up was commenced in October 2019. The disappointingly low rate (<25%) of pre-operative PROMs submissions is being addressed by the British Elbow and Shoulder Society, in conjunction with the NJR and the Getting It Right First Time (GIRFT) programme. Response rates to questionnaires sent directly to patients at their home addresses post-surgery averages at just over 80%.

Our NJR Data Quality Audit programme has been devised to assess the completeness and quality of the data submitted to the registry. This enables us to compare patient records for procedures recorded in local hospitals’ databases (e.g. Patient Administration Systems (PAS)) to that in the registry, with the aim of investigating the accuracy of the number of arthroplasty procedures submitted to the registry, compared to the number carried out.

The importance of the Data Quality Audit is clear when considered in the context of our primary aims. To achieve those aims, there are two principal outcomes of interest to the NJR: revision surgery and mortality volumes.
 
Revision surgery is an indicator of implant failure or surgical performance. This is determined by linking a primary arthroplasty procedure to a subsequent procedure which typically occurs a number of years after the primary procedure. Therefore, compliance with reporting revision surgical procedures is essential to estimate implant failure rates and surgical performance more accurately.

Mortality data is collected from Civil Registration Data which is obtained from NHS Digital and linked to individuals within the registry. However, it is important to remember that joint replacement is a very successful operation with a very low mortality rate and all surgeons and hospitals have outcomes in line with the expected range.

In 2020/21 we began a national roll out of a semi-automated audit process which enables units to check their data quality on a monthly or quarterly basis. This has greatly reduced the number of mismatches that have to be checked each time the audit is run, and the pre-rollout pilot suggested that this rapidly becomes part of the normal workflow. This subsequent roll out is underway for hip, knee, elbow, ankle and shoulder data and 314 hospitals have now completed an audit of their 2018/19 data, with 199 hospitals having completed an audit of 2019/20 data and 46 hospitals having started auditing their 2020/21 data. If you yourself work for a hospital that has not yet signed up for the audit programme, please contact enquiries@njrcentre.org.uk or via the NJR website.

For the previous five years a manual NJR audit had been undertaken each year to achieve exactly the same checking of anomalies and update of missing data by reconciling the PAS and the NJR sources with each other. This semi-automation of the old audit process is therefore a most beneficial development as it has enabled a less cumbersome process for hospitals, thus making the process easier to engage with to continue to ensure the high quality, validity and accuracy of data entered into the registry.

In order to ensure that more historic data anomalies are able to be addressed in elbow surgery, we are working with the British Elbow and Shoulder Society (BESS) to carry out a national manual audit of elbow arthroplasty data. This involves surgical trainees reviewing patient records and identifying missing cases. For more information, please contact BESS on njrelbowaudit@gmail.com.

Similar spotlight data quality exercises involving dual mobility hip replacements, reverse shoulder replacements and multi-compartmental knee replacements are being developed in consultation with the relevant specialist societies.

In 2018, the NJR started working with the German Arthroplasty Registry (EPRD) to develop a common classification system for defining the attributes of hip and knee arthroplasty components. This classification has now been adopted by both registries with each managing their own local databases, which are populated by industry implant suppliers.

Our own component database is now fully implemented across Supplier Feedback services and attributes are being completed by industry. Use of this classification data for NJR reporting will commence in 2021/22.

Both the NJR/EPRD have now agreed to license the component classification system to the International Society of Arthroplasty Registers (ISAR) for their International Prosthesis Library (IPL) platform meaning the hip and knee components can be classified in the same way in registries across much of the world. This work will provide the valuable benefits of improving the comparability of data, increasing the opportunity to pool results for identifying poor outcomes and decreasing the burden on industry colleagues in data upload.

This year, colleagues at the University of Oxford and University of Bristol proposed a new component classification for shoulder arthroplasty devices, which is planned to be published on open access and will be free to license. This classification will form the basis of a new shoulder component database to be developed by the NJR in 2021/22.