Finalised Patient Reported Outcome Measures (PROMs) in England

Transcription

1 Finalised Patient Reported Outcome Measures (PROMs) in England April 2015 to March Published 10 August 2017 PROMs measures health gain in patients undergoing hip and knee replacement, varicose vein treatment and groin hernia procedures in England, based on responses to questionnaires before and after surgery. This report focuses on the finalised data from these questionnaires between April 2015 to March. Key findings In 2015/16 across all procedures the majority of patients reported that their condition specific problems were much better following their surgery. The average health gain (scored via various condition specific and general measures) is positive for most patients, with the exception of groin hernia procedures (where 49.8% showed an improvement on the EQ-5D TM ). The number of procedures carried out, and subsequent numbers of questionnaires returned has remained relatively stable over the last year, with slight decreases to number of procedures for all but varicose vein procedures, where an increase of 2.3% compared to 2014/15 was reported. An interactive data tool based on Microsoft Power BI, has been introduced and can be accessed from the final 2015/16 report page on the website. Author: Secondary Care Analysis, NHS Digital Responsible Statistician: Jane Winter Copyright 2017 Health and Social Care Information Centre. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital.

2 Contents Key findings 1 Introduction 4 Background 4 Coverage 4 Patient questionnaires and summary health measures 5 Condition-specific measures 5 General health measures 5 Procedure-level summaries 6 Hip replacements 6 Knee replacements 17 Groin hernias 28 Varicose veins 36 Organisation Level Analysis 46 Further information 49 Appendix 1: Score Distributions by measure and procedure, 2015/16 50 Appendix 2: Paired questionnaires with self-reported preoperative health at maximum value, by measure and procedure, 2015/16 51 Appendix 3: Health change by measure and procedure, 2015/16 52 Appendix 4: Readmissions, further PROMs surgery, and complications after undergoing PROMs surgery, 2015/16 53 Appendix 5: Eligible hospital procedures, pre-operative and postoperative questionnaire returns by procedure type, 2009/ /16 54 Appendix 6: Feedback 55 Copyright 2017, Health and Social Care Information Centre. 2

3 This is an Official Statistics publication This document is published by NHS Digital, part of the Government Statistical Service All official statistics should comply with the UK Statistics Authority s Code of Practice for Official Statistics which promotes the production and dissemination of official statistics that inform decision making. Find out more about the Code of Practice for Official Statistics at ISBN: These statistics are used by health care providers and commissioners to improve the quality of health care offered to patients. Academic researchers use this data to inform research on PROMs-eligible procedures. Patients, carers, and other organisations that support patients (including GP practices and charities) may also find these statistics helpful in making informed decisions about elective procedures and providers. Copyright 2017, Health and Social Care Information Centre. 3

4 Introduction Background From April 2009 onwards, patients undergoing one of four common elective inpatient surgical procedures (hip replacement, knee replacement, groin hernia and varicose vein surgery) have been invited to complete pre- and post-operative questionnaires on their general and condition-specific health. Patient participation in PROMs is on a voluntary basis. Responses to these questionnaires are analysed to assess the outcomes of the surgical procedures based on patients self-reported health. PROMs publications and data can be used by patients to inform their choice of hospital provider and are used to by hospital clinicians to inform decisions about individual patients direct care. The data have also been used in medical research studies to improve outcomes by comparing scores across different types of treatments. For further information on the background to PROMs, including user feedback and how the statistics are used, see Appendix 6. Coverage Analysis in this report is based on: Pre-operative patient questionnaires completed between 1 April 2015 and 31 March and any associated in-patient hospital episodes and post-operative questionnaires; Episodes of inpatient hospital care where the episode started between 1 April 2015 and 31 March and included a PROMs-eligible surgical procedure (groin hernia, hip replacement, knee replacement or varicose vein surgery) and any associated pre- and post-operative questionnaires. A small number of episodes recorded more than one eligible procedure; each procedure is treated independently for purposes of analysis. The data source of these episodes is the Hospital Episode Statistics data warehouse ( HES ), where possible, PROMs questionnaires have been linked to records of hospital inpatient activity in order to deliver a richer dataset for analysis and to provide key variables necessary for casemix adjustment. Copyright 2017, Health and Social Care Information Centre. 4

5 Patient questionnaires and summary health measures Condition-specific measures Patients receiving hip replacements, knee replacement and varicose vein surgery are asked to complete questions that are specifically tailored to their condition: The Oxford Hip Score (OHS) The Oxford Knee Score (OKS) The Aberdeen Varicose Vein Questionnaire (AVVQ) No condition specific measure exists for groin hernia procedures General health measures All patients are also asked to complete two general measures, the EQ- 5D TM Index and the EQ VAS, both before and after their surgery: EQ-5D TM Index is a five item measure that asks patients about their: ability to pursue their usual activities; current experience of anxiety and/or depression, if any; current experience of pain and discomfort, if any; mobility, and; ability to wash and dress themselves (self-care). EQ Visual Analogue Scale (EQ VAS) is a single-item thermometer - style measure which asks patients to rate their general health at the time of completion on a linear scale from 0 to 100, with 100 representing the best possible state of health. Within their post-operative questionnaires, all patients are also asked: how they would describe the results of their operation (satisfaction), and; how their problems are now, compared with before the operation (success). Copyright 2017, Health and Social Care Information Centre. 5

6 Procedure-level summaries Hip replacements Key Findings For hip replacement procedures in 2015/16: Health gain Almost all patients (96.5%) showed improvement on the Oxford Hip Score (scored between 0 and 48). This is in line with previous years. There has been a slight improvement in the average health gain over six years, from 19.7 in 2009/10 to 21.0 in 2015/16. Most patients (88.4%) showed improvement on the EQ-5D TM Index (scored from to 1). This is in line with previous years. There has been a slight year-on-year improvement in the average health gain, from in 2010/11 to in 2015/16. Patient Profile Hip replacement rates per 100,000 population were higher among women (187.3) than men (133.2). This is in line with 2014/15. Surgical Success and Satisfaction Almost all hip replacement patients (95.0% of all responding) stated that the problems in the hip on which they had surgery were now much better (86.3%) or a little better (8.8%). More than nine in ten (92.5%) described the results of their surgery as good, very good, or excellent, with 76.0% describing their surgery as very good or excellent. Surgical Complications, Re-admissions and Further Surgery Among patients who returned post-operative questionnaires: Around three in ten (27.5%) of patients experienced one or more post-surgical problems; around one in fifteen (6.7%) said they had been readmitted to hospital following their procedure; around one in forty-five (2.2%) said they have had further surgery on their hip since their original procedure. Patient Engagement There were 77,159 hip replacement procedures carried out in hospitals, a slight decrease of 1.3% compared to 2014/15. Patients completed 67,076 pre-operative questionnaires, giving a headline participation rate of 86.9%, a little higher than the 2014/15 rate (85.8%) and higher than the corresponding rates for previous years. Patients returned 76.7% of the post-operative questionnaires they were sent, lower than the 2014/15 response rate of 78.2%. Response rates have fallen in each year since 2010/11 (85.5%). Copyright 2017, Health and Social Care Information Centre. 6

7 Oxford Hip Score Almost all hip replacement patients with paired pre- and post-operative questionnaires reported improvement on the Oxford Hip Score in 2015/16 (96.5%) and very few (2.9%) reported that their condition had worsened. This result is in line with those from previous years. The average health gain on the Oxford Hip Score in 2015/16 was 21.0 points 1 for this group of patients, with around half of patients gaining between 14 and 28 points on the scale. Figure 1: Distribution of health gain for the Oxford Hip Score, 2015/16 Hip replacement patients with paired questionnaires 2000 Average health gain (21.0) Around 50% of health gains are within the dotted lines Improved 500 Worsened No change Oxford Hip Score: Change between pre- and post-operative questionnaires Base: All patients with paired pre- and post-operative Oxford Hip Scores. An average health gain of 21.0 points on the Oxford Hip Score (scored from 0 to 48) indicates a substantial improvement in aspects of quality of life that are affected by hip conditions. Item completeness for the Oxford Hip Score is very high. In 2015/16: 98.7% (66,230) of pre-operative questionnaires had complete responses to this score; 97.6% (48,566) of pre- and post-operative questionnaire pairs had complete responses. Figure 2 (below) shows the proportions of patients with complete preand post-operative Oxford Hip Scores who reported the most severe scores on the individual questions that form the measure. The proportions of patients reporting the most severe scores in pursuing Oxford Hip Score 96.5% reported improvement. 1 Please note that although average health gains are given to 1 decimal place, an individual s pre- and post-operative scores on this measure can only ever be whole numbers, and subsequently individual health gains can only be whole numbers. Copyright 2017, Health and Social Care Information Centre. 7

8 activities is markedly lower among post-operative patients for all individual items on the Oxford Hip Score. The reported improvement in pain from the hip during the past four weeks is particularly striking. Although 17.5% of patients report moderate or severe pain post-operatively, this is a substantial reduction on the 93.1% of patients who reported moderate or severe pain before their procedure. Conversely, 1.8% of patients reported mild or no pain from their hip before their procedure, compared to 70.7% after. Copyright 2017, Health and Social Care Information Centre. 8

9 Figure 2: Proportions of pre- and post-operative patients reporting the most severe scores for individual items on the Oxford Hip Score, 2015/16 Self-care and Pre-operative questionnaire (% of patients) mobility in the past four weeks Limping when walking most or all of the time 83.4% Post-operative questionnaire (% of patients) 12.3% Extremely difficult or impossible to put on a pair of socks, stockings, or tights 50.4% 11.2% Extremely difficult or impossible to do household shopping on your own 37.7% 10.9% Extremely difficult or impossible to climb a flight of stairs 34.8% 6.2% Extremely difficult or impossible to use car or public transport 31.8% 2.5% Extremely difficult or impossible to wash and dry yourself 19.8% 2.2% Pain in the past four weeks Usually moderate or severe pain from hip 93.1% 17.5% Troubled by pain in hip when in bed on most nights or every night 69.4% 7.2% Great or total interference with work from pain in hip 60.1% 5.5% Sudden severe pain on most days or every day 53.5% 4.2% Very painful or unbearable to stand up from a chair 45.2% 2.9% Can walk around the house only or not at all before hip pain becomes severe 31.3% 6.3% Base: All hip replacement patients with complete pre- and post-operative Oxford Hip Scores Copyright 2017, Health and Social Care Information Centre. 9

10 Primary and revision procedures Where patients questionnaires are linked to hospital episodes, it is possible to report separately on outcomes for patients undergoing primary (91.9% of all hip replacements) and revision procedures (8.1%). This shows that patients undergoing primary procedures generally have better Oxford Hip Score outcomes than those undergoing revisions: The average health gain on the Oxford Hip Score for patients undergoing primary procedures was 21.6, broadly in line with that for all patients with paired pre- and post-operative questionnaires. Almost all patients (97.4%) in this group reported improvement; few reported no change (0.5%) or deterioration (2.1%). The average health gain for patients undergoing revision procedures was Most patients reported improvement (85.8%); few reported no change (2.6%) or deterioration (11.5%). EQ-5D TM Index Figure 3 summarises the distribution of pre- and post-operative scores on the EQ-5D TM Index for all patients with paired scores. The chart shows that: Overall, hip replacement patients make substantial gains on the EQ-5D TM Index following their procedure; More than one in four post-operative respondents reported a score of 1.0 on the Index the best score possible on this measure (this is why there is no narrow bar showing the 75 th - 95 th percentiles for the post-operative scores). The post-operative mean and median are close together, indicating that the spread of scores is relatively even; comparatively, the pre-operative mean is much lower than the median, indicating that a small proportion of very negative scores are skewing the overall distribution. Quartile 2 is comparatively larger than the left tail (5 th to 25 th percentile) for pre-operative scores, and much shorter for postoperative scores. This indicates that although pre-operative scores are more evenly distributed, most patients report very high post-operative scores; 75% of scores fall between and 1, with 20% of post-operative scores falling between and Copyright 2017, Health and Social Care Information Centre. 10

11 Figure 3: Distribution of pre- and post-operative health scores on the EQ-5D TM Index, 2015/16 Quartile 2 Quartile 3 Median Mean 5th to 25th percentile/ 75th to 95th percentile Postoperative Preoperative Worst possible score ( ) Best possible score (1.000) Base: All hip replacement patients with paired pre- and post-operative EQ-5D TM Index scores As would be expected, patients undergoing a primary hip replacement procedure reported higher average health gains on the EQ-5D TM Index (0.440) than those undergoing revision procedures (0.279) 2. Item completeness for the EQ-5D TM Index is very high. In 2015/16: 93.9% (63,017) of pre-operative questionnaires had complete responses to the Index; 90.2% (44,890) of pre- and post-operative questionnaire pairs had complete responses. EQ-Visual Analogue Score (EQ-VAS) Overall, two thirds of hip replacement patients (65.6%) for whom change on the EQ-VAS could be calculated reported improvement on this measure. The average health gain reported was 12.1 points, on a scale running between 0 and 100 (with 100 being the best possible score). As with the other measures, average health gains were higher for those undergoing primary procedures (12.6) than for those having a revision procedure (6.4). Item completeness for the EQ-VAS, although lower than for other measures, is very high. In 2015/16: 90.0% (60,365) of pre-operative questionnaires had completed this question; 2 Average health gains for primary and revision procedures can only be calculated for patients whose paired questionnaires have successfully linked to a hospital episode. Copyright 2017, Health and Social Care Information Centre. 11

12 86.6% (43,077) of pre- and post-operative questionnaire pairs had completed this question. Hip replacements over time Analysis of change over time suggests that patient outcomes for hip replacement procedures are largely stable at England level. The average health gain reported on the Oxford Hip Score has increased very slightly year on year over six years (from 19.7 in 2009/10 to 21.0 in 2015/16), but the proportion of patients reporting improvement is largely unchanged. Similarly, average health gains on the EQ-5D TM Index have increased very slightly over time but the overall proportion of patients reporting improvement has remained relatively static. The EQ-VAS has shown a slightly larger increase in average health gain during this time period from 8.9 in 2009/10 to 12.1 in 2015/16. It is however not possible to determin the specific reason why this is the case due to the very general nature of the measure. Table 1: Health outcomes for hip replacement patients by outcome measure, 2009/ /16 England a, 2009/ /16 percentages and numbers Oxford Hip Score % of patients reporting improvement Average health gain EQ-5D TM Index % of patients reporting improvement Average health gain EQ-VAS % of patients reporting improvement Average health gain a Some patients resident in U.K. countries other than England undergo PROMseligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episodes were they carried out in England) are not included in these statistics. Patient Profile In total, there were 77,159 PROMs-eligible hip replacement procedures in 2015/16: Around six in ten (59.4%) were female and four in ten (40.6%) were male, consistent with women living longer and experiencing more bone density problems, such as osteoporosis, than men. As may be expected given the age composition of those undergoing hip replacement surgeries, almost all patients (86.0%) are recorded as White or White British; only 1.8% of those receiving hip replacement surgery in 2015/16 reported that they were from non-white BME backgrounds. Ethnic group information Copyright 2017, Health and Social Care Information Centre. 12

13 was not known, not stated or not given for 12.2% of hip replacement patients. Few (6.4%) patients were aged under 50 years and of these the majority were male; more than four in ten (43.6%) were aged between 50 and 69 inclusive; almost half (49.9%) were aged 70 and over. For both men and women, rates per 100,000 people peaked among those aged 70-84, with the highest rates being seen among those aged Around 0.82% of women aged had a hip replacement in 2015/16, as did around 0.57% of men in this age band 3. Figure 4: Hip replacement procedures per 100,000 people a aged 10 and over by age b and sex c, 2015/16 Age group Female Male to to to to to to to to to to to to to to to 14 a Rates are calculated using the ONS Mid-2014 Population Estimates in England by Single Year of Age and Sex, using the population aged 10 years and over. b Hip replacement patients for whom gender was known but age was not recorded (96) are included in the calculation of all-ages rates by gender. c Hip replacement patients whose sex was not recorded (5) are excluded from this analysis. All ages (females), All ages (males), , Hip replacement procedures per 100,000 people aged 10 and over Surgical satisfaction and success Patients were asked to rate the success of their hip replacement postoperativley by responding to the following question: 3 For in depth analysis of patient demographics please refer to the CSV data pack: Copyright 2017, Health and Social Care Information Centre. 13

14 Overall, how are the problems now in the hip on which you had surgery, compared to before your operation? Patients were asked to respond using the following categories: Much better ; A little better ; About the same ; A little worse ; Much worse. Figure 5: Hip replacement success and satisfaction score rates, 2015/16 Success Satisfaction Much Better Excellent Little Better Very Good About the Same Good Little Worse Fair Much Worse Poor 0% 50% 100% 0% 50% 100% Almost all hip replacement patients (95.0% of all responding) stated that the problems in the hip on which they had surgery were now much better (86.3%) or a little better (8.8%); Patients were also asked to indicate their level of satisfaction with their surgery, by rating the results of their operation as Excellent, Very good, Good, Fair or Poor. More than nine in ten (92.5%) hip replacement patients described the results of their surgery as Good, Very good or Excellent, with 76.0% of patients describing their results as very good or excellent. Complications and further surgery Around three in ten (27.5%) 4 hip replacement patients experienced one or more post-surgical problems. Among those who experienced one or more complications: around four in ten (44.2%) experienced urinary problems; more than one in three (36.2%) reported experiencing an allergy and/or reactions to drugs; around three in ten (27.4%) experienced problems with their wound; around one in seven (13.7%) experienced problems with bleeding. 4 As a proportion of all patients who returned a post-operative hip replacement questionnaire. Copyright 2017, Health and Social Care Information Centre. 14

15 Patients were also asked whether they had been readmitted to hospital since their operation, or had further surgery on their hip. Among patients who returned post-operative hip replacement questionnaires, around one in fifteen (6.7%) patients said they had been readmitted, and around one in forty-five (2.2%) of patients said that they had further surgery on their hip since their original procedure. Patient Engagement This section provides background information about participation, linkage and response rates for patients undergoing hip replacement procedures. There were 77,159 NHS funded hip replacement procedures carried out in hospitals, a decrease of 1.3% compared to 2014/15. Patients completed 67,076 pre-operative questionnaires giving a headline participation rate of 86.9%, a little higher than the 2014/15 rate (85.8%) and higher than all previous years. Of the 67,076 questionnaires, 55,028 successfully linked to a PROMs-eligible episode giving a linkage rate of 82.0%, lower than 2014/15 (84.0%) but higher than in previous years. Patients returned 76.7% of the post-operative questionnaires they were sent, lower than the 2014/15 response rate of 78.2%. Return rates decreased between 2011/12 and 2012/13. Of the total number of episodes, 43,522 successfully linked to both a pre- and post-operative questionnaire, giving an overall rate of 56.4%, a small decrease compared to the previous year 2014/15 (58.2%). Among patients undergoing hip replacements in 2015/16, response rates 5 : were lower among patients living in more deprived areas (46.5% in the most deprived quintile on IMD 2010 and 60.1% in the least deprived quintile); increased with age to the age band (60.8%), decreasing again thereafter; were much higher among white patients (56.0%) than BME patients (37.2%). 5 Response rates in this instance refer to the number of episodes linked to both preoperative and post-operative questionnaires returned as a percentage of eligible episodes. Copyright 2017, Health and Social Care Information Centre. 15

16 Figure 6: PROMs engagement among hip replacement patients, 2009/ /16 (thousands) Episodes Pre-operative questionnaires returned Post-operative questionnaires returned / / / / / / /16 Copyright 2017, Health and Social Care Information Centre. 16

17 Knee replacements Key Findings For knee replacement procedures in 2015/16: Health gain Almost all patients (93.6%) showed improvement on the Oxford Knee Score (scored from 0 to 48), with an average health gain of A figure slightly higher than last year 2014/15 where the average health gain was Most patients (80.7%) showed improvement on the EQ-5D TM Index (scored from to 1), with an average health gain of Again this figure is marginally higher than last year 2014/15 where the average health gain was Patient Profile Knee replacement rates per 100,000 population were higher among women (196.6) than men (153.9). This is in line with previous years. Surgical Success and Satisfaction Around nine in ten knee replacement patients (89.3% of all responding) stated that the problems in the knee on which they had surgery were now much better (73.1%) or a little better (16.2%). Over eight in ten (85.7%) knee replacement patients described the results of their surgery as Good, Very good or Excellent, with 61.4% of patients describing their results as very good or excellent. Surgical Complications, Re-admissions and Further Surgery Among patients who returned post-operative questionnaires: Around a third (31.2%) of patients experienced one or more postsurgical problems; around one in twelve (8.2%) said they had been readmitted to hospital following their procedure; and around one in thirty (3.3%) of patients said that they had further surgery on their knee since their original procedure. Patient Engagement There were 84,300 knee replacement procedures carried out in hospitals, a modest increase of 1.0% compared to 2014/15. Patients completed 81,240 pre-operative questionnaires, a headline participation rate of 96.4%, an increase on the 2014/15 rate (95.0%) and higher than previous years. Patients returned 74.9% of the post-operative questionnaires they were sent, lower than the 2014/15 response rate of 76.4%. Response rates have decreased since 2010/11. Copyright 2017, Health and Social Care Information Centre. 17

18 Patient reported outcomes for knee replacements Three measures are used to assess patients self-reported outcomes following knee replacement surgery: The Oxford Knee Score, which focuses on aspects of pain, mobility and quality of life that are likely to be improved by a successful knee replacement; The EQ-5D TM Index, which is a general measure of patients quality of life The EQ-VAS which provides a simple snapshot of patients selfreported health. Oxford Knee Score Almost all knee replacement patients with paired pre- and postoperative questionnaires reported improvement on the Oxford Knee Score in 2015/16 (93.6%) and very few (5.4%) reported that their condition had worsened. This result is in line with those from previous years. The average health gain on the Oxford Knee Score, (scored from 0 to 48) in 2015/16 was 16.1 points 6 for this group of patients, with around half of patients gaining between 10.0 and 23.0 points on the scale. Figure 7: Distribution of health gain for the Oxford Knee Score, 2015/16 Knee replacement patients with paired questionnaires 2500 Average health gain (16.1) Around 50% of health gains are within the dotted lines Improved 1000 No change 500 Worsened Oxford Knee Score: Change between pre- and post-operative questionnaires Base: All patients with paired pre- and post-operative Oxford Knee Scores. 6 Please note that although average health gains are given to 1 decimal place, an individual s pre- and post-operative scores on this measure can only ever be whole numbers, and subsequently individual health gains can only be whole numbers. Copyright 2017, Health and Social Care Information Centre. 18

19 Item completeness for the Oxford Knee Score is very high. In 2015/16: 98.7% (80,144) of pre-operative questionnaires had complete responses to this score; 97.5% (57,249) of pre- and post-operative questionnaire pairs had complete responses. Figure 8 shows the proportions of patients with complete pre- and postoperative Oxford Knee Scores who reported the most severe scores on the individual questions that form the measure. The proportions of patients reporting the most severe scores in pursuing activities is markedly lower among post-operative patients for all individual items on the Oxford Knee Score. Oxford Knee Score 93.6% reported improvement. There is a comparatively smaller difference for the question During the past four weeks, could you kneel down and get up again? preoperatively, 77.9% experienced found it difficult or impossible to kneel down and get up again, compared to 49.9% after. In contrast, for the question How would you describe the pain you usually have from your knee?, 94.0% of patients experienced moderate or severe pain before their procedure, compared to 21.9% after. Copyright 2017, Health and Social Care Information Centre. 19

20 Figure 8: Proportions of pre- and post-operative patients reporting the most severe scores for individual items on the Oxford Knee Score, 2015/16 Self-care and mobility Pre-operative questionnaire (% of patients) in the past four weeks Limping when walking most or all of the time 77.6% Post-operative questionnaire (% of patients) 13.1% Felt that your knee might suddenly give way or let you down most or all of the time 42.1% 5.0% Extremely difficult or impossible to climb a flight of stairs 38.1% 9.5% Extremely difficult or impossible to do household shopping on your own 36.8% 12.3% Extremely difficult or impossible to use car or public transport 22.8% 4.9% Extremely difficult or impossible to wash and dry yourself 8.9% 2.2% Pain in the past four weeks Usually moderate or severe pain from knee 94.0% 21.9% Extremely difficult or impossible to kneel down and get up again 77.9% 49.9% Troubled by pain in knee when in bed most nights or every night 60.5% 16.4% Great or total interference with work from pain in knee 54.7% 9.0% Very painful or unbearable to stand up from a chair 45.8% 6.5% Can walk around the house only or not at all before knee pain becomes severe 24.9% 7.2% Base: All knee replacement patients with complete pre- and post-operative Oxford Knee Scores Copyright 2017, Health and Social Care Information Centre. 20

21 Primary and revision procedures Where patients questionnaires are linked to hospital episodes, it is possible to report separately on outcomes for patients undergoing primary (93.9% of all knee replacements) and revision procedures (6.1%). This shows that patients undergoing primary procedures generally have better Oxford Knee Score outcomes than those undergoing revisions: The average health gain on the Oxford Knee Score for patients undergoing primary procedures was 16.4, broadly in line with that for all patients with paired pre- and post-operative questionnaires. Almost all patients (94.2 %) in this group reported improvement; few reported no change (1.0%) or deterioration (4.9%). The average health gain for patients undergoing revision procedures was Most patients reported improvement (87.0%); 2.0% reported no change and 11.1% reported deterioration. EQ-5D TM Index Figure 9 summarises the distribution of pre- and post-operative scores on the EQ-5D TM Index for all patients with paired scores. The chart shows that: Overall, knee replacement patients make substantial gains on the EQ-5D TM Index following their procedure; More than one in four post-operative respondents reported a score of 1.0 on the Index the best score possible on this measure (this is why there is no narrow bar showing the 75 th - 95 th percentiles for the post-operative scores). The mean is much closer to the median post-operatively, indicating that there were patients with particularly negative preoperative scores that were skewing the mean value. Conversely, a large proportion of patients scoring the maximum possible score (1.0) post-operatively have brought the mean nearer to the median, although the length of the left tail post-operatively indicates that there is still a small number of patients with comparatively much lower scores on the Index. Copyright 2017, Health and Social Care Information Centre. 21

22 Figure 9: Distribution of pre- and post-operative health scores on the EQ-5D TM Index, 2015/16 Quartile 2 Quartile 3 Median Mean 5th to 25th percentile/ 75th to 95th percentile Postoperative Preoperative Worst possible score ( ) Best possible score (1.000) Base: All knee replacement patients with paired pre- and post-operative EQ-5D TM Index scores As would be expected, patients undergoing a primary knee procedure reported higher average health gains on the EQ-5D TM Index (0.321) than those undergoing revision procedures (0.270). 7 Item completeness for the EQ-5D TM Index is very high. In 2015/16: 93.8% (76,173) of pre-operative questionnaires had complete responses to the Index; 90.1% (52,875) of pre- and post-operative questionnaire pairs had complete responses. EQ-Visual Analogue Score (EQ-VAS) Overall, almost two thirds of knee replacement patients (56.4%) for whom change on the EQ-VAS could be calculated reported improvement on this measure. The average health gain reported was 6.3 points. As with the other measures, average health gains were higher for those undergoing primary procedures (6.5) than for those having a revision procedure (2.7). Item completeness for the EQ-VAS, although lower than for other measures, is very high. In 2015/16: 89.2% (72,491) of pre-operative questionnaires had completed this question; 7 Average health gains for primary and revision procedures can only be calculated for patients whose paired questionnaires have successfully linked to a hospital episode. Copyright 2017, Health and Social Care Information Centre. 22

23 86.0% (50,467) of pre- and post-operative questionnaire pairs had completed this question. Knee replacements over time The average health gain reported on the Oxford Knee Score has increased very slightly year on year apart from 2014/15 which saw a very slight drop (from 15.9 in 2013/14 to 15.8 in 2014/15), but the proportion of patients reporting improvement is largely unchanged. Similarly, average health gains on the EQ-5D TM Index have increased very slightly over time, as has the proportion of patients reporting improvement. As with hip procedures we can see the EQ-VAS has increased at a faster rate than the other measures, however due to the general nature of the measure it is not possible to state why this increase has occurred. Table 2: Health outcomes for knee replacement patients by outcome measure, 2009/ /16 England a, 2009/ /16 percentages and numbers Oxford Knee Score % of patients reporting improvement Average health gain EQ-5D TM Index % of patients reporting improvement Average health gain EQ-VAS % of patients reporting improvement Average health gain a Some patients resident in U.K. countries other than England undergo PROMseligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episodes were they carried out in England) are not included in these statistics. Patient Profile In total, there were 84,300 PROMs-eligible knee replacement procedures in 2015/16, of which: More than half (57.0%) were female and fewer than half (43.0%) were male. Approximately seven in eight (83.1%) knee replacement patients were from White or White British backgrounds, with 5.9% of knee replacement patients reporting that they were from a non-white BME background. Patients identifying their ethnic group as Indian were the second largest group, accounting for 2.3% of PROMseligible knee replacement episodes in 2015/16. Ethnic group Copyright 2017, Health and Social Care Information Centre. 23

24 information was missing or not stated for 11.0% of patients undergoing knee replacement surgery. The age structure of patients receiving knee replacements was broadly similar to that of patients undergoing hip replacements. Very few knee replacement patients (2.2%) were aged under 50; just less than half (46.6%) were aged between 50 and 69 (inclusive) and around half (51.1%) were aged 70 years or over. Overall, rates for women (196.6) were higher than those for men (153.9). For both men and women, knee replacement rates peaked among those aged 70-79, with around 0.88% of women aged and 0.74% of men aged having a knee replacement in 2015/16. Figure 10: Knee replacement procedures per 100,000 people aged 10 and over a by age b and sex c, 2015/16 Age group Female Male to to to to to to to to to to to to to 24 All ages (females), All ages (males), to to a Rates are calculated using the ONS Mid-2014 Population Estimates in England by Single Year of Age and Sex, using the population aged 10 years and over. b Knee replacement patients for whom gender was known but age was not recorded (56) are included in the calculation of all-ages rates by gender. c Knee replacement patients whose sex was not recorded (17) are excluded from this analysis. 1, ,000 Knee replacement procedures per 100,000 people aged 10 and over Surgical satisfaction and success Patients were asked to rate the success of their knee replacement post-operatively by responding to the following question: Copyright 2017, Health and Social Care Information Centre. 24

25 Overall, how are the problems now in the knee on which you had surgery, compared to before your operation? Patients were asked to respond using the following categories: Much better ; A little better ; About the same ; A little worse ; Much worse. Figure 11: Knee replacement success and satisfaction score rates, 2015/16 Success Satisfaction Much Better Excellent Little Better Very Good About the Same Good Little Worse Fair Much Worse Poor 0% 50% 100% 0% 50% 100% Around nine in ten knee replacement patients (89.3% of all responding) stated that the problems in the knee on which they had surgery were now much better (73.1%) or a little better (16.2%); Patients were also asked to indicate their level of satisfaction with their surgery, by rating the results of their operation as Excellent, Very good, Good, Fair or Poor. Nearly nine in ten (85.7%) knee replacement patients described the results of their surgery as Good, Very good or Excellent, with 61.4% of patients describing their results as very good or excellent. Complications and further surgery Around a third (31.2% 8 ) of knee replacement patients experienced one or more post-surgical problems. Among those who experienced one or more complications: more than one in three (36.0%) reported experiencing an allergy and/or reactions to drugs; more than one in three (34.8%) experienced problems with their wound; around a third (34.5%) experienced urinary problems; around one in five (20.5%) experienced problems with bleeding. 8 As a proportion of all patients who returned a post-operative knee replacement questionnaire. Copyright 2017, Health and Social Care Information Centre. 25

26 Patients were also asked whether they had been readmitted to hospital since their operation, or had further surgery on their knee. Among patients who returned post-operative knee replacement questionnaires, around one in twelve (8.2%) patients said they had been readmitted, and around one in thirty (3.3%) of patients said that they had further surgery on their knee since their original procedure. Patient Engagement This section provides background information about participation, linkage and response rates for patients undergoing hip replacement procedures. There were 84,300 knee replacement procedures carried out in hospitals, an increase of 1.0% compared to 2014/15. Patients completed 81,240 pre-operative questionnaires, a headline participation rate of 96.4% a slight increase on the previous year 2014/15 (95.0%), and higher than the corresponding rates for previous years. Of the 81,240 questionnaires, 59,603 successfully linked to a PROMs-eligible episode giving a linkage rate of 73.4%, slightly less than 2014/15 (75.1%). Patients returned 74.9% of the post-operative questionnaires they were sent, slightly less than the 2014/15 response rate of 76.4%. Return rates decreased since 2010/11 (85.5%). Of the total number of episodes, 47,078 successfully linked to both a pre- and post-operative questionnaire, giving an overall rate of 55.8%, a small decrease on the previous year 2014/15 (57.3%). Among patients undergoing knee replacements in 2015/16, response rates: were lower among patients living in more deprived areas (47.7% in the most deprived quintile on IMD 2010 and 60.1% in the least deprived quintile); increased with age to the (59.4%) age band, decreasing again thereafter; were higher among white patients (56.7%) than BME patients (38.4%) Copyright 2017, Health and Social Care Information Centre. 26

27 Figure 12: PROMs engagement among knee replacement patients, 2009/ /16 (thousands) Episodes Pre-operative questionnaires returned Post-operative questionnaires returned / / / / / / /16 Copyright 2017, Health and Social Care Information Centre. 27

28 Groin hernias Key Findings For groin hernia procedures in 2015/16: Health gain Around half of patients (49.8%) showed improvement on the EQ- 5D TM Index (scored between and 1), with an average health gain of This is in line with previous years. Patient Profile Groin hernia procedure rates per 100,000 population were much higher among men (267.0) than women (25.9). This is in line with previous years. Surgical Success and Satisfaction Almost all groin hernia patients (93.8% of all responding) stated that their groin hernia problems were now much better (84.9%) or a little better (8.9%); More than nine in ten (92.4%) hip replacement patients described the results of their surgery as Good, Very good or Excellent, with 74.0% of patients describing their results as very good or excellent. Surgical Complications, Re-admissions and Further Surgery Among patients who returned post-operative questionnaires: Around one in five (21.1%) patients experienced one or more post-surgical problems; around one in eighteen (5.7%) said they had been readmitted to hospital following their procedure; and around one in six (16.1%) patients said that they had further surgery on their groin since their original procedure. Patient Engagement There were 69,222 groin hernia procedures carried out in hospitals, a decrease of 4.8% from 2014/15. Patients completed 39,706 pre-operative questionnaires, a headline participation rate of 57.4%, slightly lower than in each of the last few years, but higher than the rates for 2010/11 (55.7%) and 2009/10 (55.0%). Patients returned 63.6% of the post-operative questionnaires they were sent, below the 2014/15 response rate of 64.2%. Response rates have decreased since 2010/11 (74.1%). Copyright 2017, Health and Social Care Information Centre. 28

29 Patient reported outcomes for groin hernia procedures Two measures are used to assess patients self-reported outcomes following groin hernia surgery (there is no condition-specific measure for this procedure): The EQ-5D TM Index, which is a general measure of patients quality of life The EQ-VAS which provides a simple snapshot of patients selfreported health. EQ-5D TM Index Figure 13 summarises the distribution of pre- and post-operative scores on the EQ-5D TM Index for all patients with paired scores. The chart shows that: Overall, groin hernia patients make comparatively smaller gains on the EQ-5D TM Index following their procedure than do hip and knee replacement patients; For pre-operative scores, the mean and median are close together, but the long left tail indicates that a number of particularly low scores are skewing the overall distribution. It should also be noted that there is no right tail in the preoperative chart, indicating that at least one in four patients recorded a maximum score on the Index before their procedure. For post-operative scores the median is at the maximum value (1.0), indicating that over 50% of all patients scored the maximum possible value on the Index. The comparatively low mean indicates that there are some scores at the lowest end of the left tail that are skewing the average. More than half of post-operative respondents reported a score of 1.0 on the Index the best score possible on this measure (this is why there is no narrow bar or third quartile showing the upper 50% of data for the post-operative scores). Copyright 2017, Health and Social Care Information Centre. 29

30 Figure 13: Distribution of pre- and post-operative health scores on the EQ-5D TM Index, 2015/16 Quartile 2 Quartile 3 Median Mean 5th to 25th percentile/ 75th to 95th percentile Postoperative Preoperative Worst possible score ( ) Best possible score (1.000) Base: All groin hernia patients with paired pre- and post-operative EQ-5D TM Index scores Item completeness for the EQ-5D TM Index is very high. In 2015/16: 97.0% (38,504) of pre-operative questionnaires had complete responses for the Index; 91.9% (22,806) of pre- and post-operative questionnaire pairs had complete responses. EQ-Visual Analogue Score (EQ-VAS) Overall, slightly more than a third of groin hernia patients (37.6%), for whom change on the EQ-VAS could be calculated, reported improvement on this measure; the average change reported was -0.9 points. Item completeness for the EQ-VAS is very high. In 2015/16: 95.8% (38,506) of pre-operative questionnaires had complete responses for the Index; 94.8% (23,511) of pre- and post-operative questionnaire pairs had complete responses. Groin hernia procedures over time Analysis of change over time suggests that patient outcomes for groin hernia procedures are largely stable at England level. The average health gains reported on the EQ-5D TM Index and EQ-VAS, as well as the overall proportion of patients reporting improvement on each measure, have remained static. Copyright 2017, Health and Social Care Information Centre. 30

31 Table 3: Health outcomes for groin hernia patients by outcome measure, 2009/ /16 England a, 2009/ /16 percentages and numbers EQ-5D TM Index % of patients reporting improvement Average health gain EQ-VAS % of patients reporting improvement Average health gain a Some patients resident in U.K. countries other than England undergo PROMseligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episodes were they carried out in England) are not included in these statistics. Patient Profile In total, there were 69,222 PROMs-eligible groin hernia procedures in 2015/16: More than nine in ten (90.8%) patients were male (267.0 per 100,000 males aged 10 and over). 9 Most groin hernia patients were from a White or White British background (78.5%) with much smaller proportions (5.9%) of patients from other ethnic backgrounds. Ethnicity was not known or not stated for almost one in six (15.6%) patients. Around one in four patients (25.9%) were aged under 50. More than four in ten patients (42.7%) were aged between 50 and 69 (inclusive); a further three in ten (31.3%) were aged 70 or over. As expected, the age structure of patients undergoing groin hernia surgery was more youthful than that of patients receiving hip replacements or knee replacements. Among male patients, the proportion of groin hernia surgeries carried out on patients aged between 50 and 69 (43.6%) was considerably higher than that for men aged 70 and over (30.5%). The groin hernia surgery rate per 100,000 males aged 10 and over, however, was generally higher among older male populations, peaking at per 100,000 men aged This means that approximately 0.7% of all men aged underwent a PROMseligible groin hernia procedure in 2015/16. 9 Throughout this report, England-level male and female all-ages rates per 100,000 episodes are based on the ONS 2014 Mid Year Estimates of the England population aged 10 years and over. Episodes where sex was not recorded (15) are excluded from the calculation of all-ages rates for males and females. Copyright 2017, Health and Social Care Information Centre. 31

32 Figure 14: Groin hernia procedures per 100,000 people a aged 10 and over by age b and sex c, 2015/16 Age group Female Male to to to to to to to to to to to to to to to All ages (females), All ages (males), a Rates are calculated using the ONS Mid-2014 Population Estimates in England by Single Year of Age and Sex, using the population aged 10 years and over. b Groin hernia patients for whom gender was known but age was not recorded (127) are included in the calculation of all-ages rates by gender. c Groin hernia patients whose sex was not recorded (8) are excluded from this analysis Groin hernia procedures per 100,000 people aged 10 and over Surgical satisfaction and success Patients were asked to rate the success of their groin hernia procedure post-operatively by responding to the following question: Overall, how are your hernia problems now, compared to before your operation? Patients were asked to respond using the following categories: Much better ; A little better ; About the same ; A little worse ; Much worse. Copyright 2017, Health and Social Care Information Centre. 32

33 Figure 15: Groin hernia success and satisfaction score rates, 2015/16 Success Satisfaction Much Better Excellent Little Better Very Good About the Same Good Little Worse Fair Much Worse Poor 0% 50% 100% 0% 50% 100% Almost all groin hernia patients (93.8% of all responding) stated that their groin hernia problems were now much better (84.9%) or a little better (8.9%); Patients were also asked to indicate their level of satisfaction with their surgery, by rating the results of their operation as Excellent, Very good, Good, Fair or Poor. More than nine in ten (92.4%) groin hernia patients described the results of their surgery as Good, Very good or Excellent, with 74.0% of patients describing their results as very good or excellent. Groin Hernia 93.8% Patients stated their problems were much better or a little better. Complications and further surgery Around one in five (21.1%) groin hernia patients experienced one or more post-surgical problems. Among those who experienced complications: Nearly half (47.1%) experienced problems with their wound; just over a third (37.1%) experienced urinary problems; around one in four (22.5%) experienced problems with bleeding; around one in six (16.5%) reported experiencing an allergy and/or reactions to drugs. Patients were also asked whether they had been readmitted to hospital since their operation, or had further surgery on their groin. Among patients who returned post-operative groin hernia questionnaires, around one in eighteen (5.7%) patients said they had been readmitted, and around one in six (16.1%) of patients said that they had further surgery on their groin since their original procedure. Copyright 2017, Health and Social Care Information Centre. 33

34 Patient Engagement This section provides background information about participation, linkage and response rates for patients undergoing groin hernia procedures. There were 69,222 groin hernia procedures carried out in hospitals, a decrease of 4.8% from 2014/15. Patients completed 39,706 pre-operative questionnaires, a headline participation rate of 57.4%, slightly lower than in preceding years, but higher than the rates for 2010/11 (55.7%) and 2009/10 (55.0%). Of the 39,706 questionnaires 28,750 successfully linked to a PROMs-eligible episode giving a linkage rate of 72.4%, slightly lower than in the previous year 2014/15 (74.7%). Patients returned 63.6% of the post-operative questionnaires they were sent, below the 2014/15 response rate of 64.2%. Return rates have decreased from 2010/11 (74.1%). Of the total number of episodes, 20,060 successfully linked to both a pre- and post-operative questionnaire, giving an overall rate of 29.0% a decrease on last year s figure of 30.5%. Among patients undergoing groin hernia procedures in 2015/16, response rates: were lower among patients living in more deprived areas (21.5% in the most deprived quintile on IMD 2010 and 34.5% in the least deprived quintile); increased with age to the (36.8%) age band, decreasing again thereafter;l were higher among white patients (30.2%) than BME patients (16.2%). In 2015/65 39,706 pre-operative questionnaires were received for groin hernia procedures, with post-operative questionnaires subsequently received for 24,812 of these. Copyright 2017, Health and Social Care Information Centre. 34

35 Figure 16: PROMs engagement among groin hernia patients, 2009/ /16 (thousands) Episodes Pre-operative questionnaires returned Post-operative questionnaires returned / / / / / / /16 Copyright 2017, Health and Social Care Information Centre. 35

36 Varicose veins Key Findings For varicose vein procedures in 2015/16: Health gain Around eight in ten patients (82.1%) showed improvement on the Aberdeen Varicose Vein Questionnaire (scored from 0 to 100), with an average health gain of 8.4. This is in line with previous years. Around half of patients (52.5%) showed improvement on the EQ- 5D TM Index (scored between and 1), with an average health gain of This is in line with previous years. Patient Profile Varicose vein procedure rates per 100,000 population were higher among women (79.4) than men (59.6). This is in line with 2014/15. Surgical Success and Satisfaction Around nine in ten varicose vein patients (88.9% of all responding) stated that the problems with the varicose veins on which they had surgery were now much better (67.8%) or a little better (21.2%); More than eight in ten (85.0%) patients described the results of their surgery as Good, Very good or Excellent, with 58.4% of patients describing their results as Very good or Excellent. Surgical Complications, Re-admissions and Further Surgery Among patients who returned post-operative questionnaires: Around one in five (21.1%) of patients experienced one or more post-surgical problems; around one in twenty-one (4.7%) said they had been readmitted to hospital following their procedure; and around one in seven (15.5%) of patients said that they had further surgery on their varicose veins since their original procedure. Patient Engagement There were 33,439 varicose vein procedures carried out in hospitals, an increase of 2.3% compared to 2014/15. Patients completed 10,962 pre-operative questionnaires, a headline participation rate of 32.8%, lower than the 2014/15 rate (39.5%) and the lowest rate since 2009/10 (43.4%). Patients returned 54.2% of the post-operative questionnaires they were sent, slightly less than the 2014/15 response rate (55.1%) and below the 2012/13 response rate of 58.2%. Copyright 2017, Health and Social Care Information Centre. 36

37 Patient reported outcomes for varicose vein procedures Three measures are used to assess patients self-reported outcomes following varicose vein surgery: The Aberdeen Varicose Vein Questionnaire, which focuses on pain and skin irritation, the impact on regular activities, and the location of their varicose veins. The EQ-5D TM Index, which is a general measure of patients quality of life The EQ-VAS which provides a simple snapshot of patients selfreported health. Aberdeen Varicose Vein Questionnaire Over eight in ten varicose vein patients with paired pre- and postoperative questionnaires reported improvement on the Aberdeen Varicose Vein Questionnaire in 2015/16 (82.1%) and very few (17.2%) reported that their condition had worsened. This result is in line with those from previous years. The average health gain on the Aberdeen Varicose Vein Questionnaire in 2015/16 was 8.4 points for this group of patients, with around half of patients gaining between 2.3 and 14.3 points on the scale. Figure 17: Distribution of health gain for the Aberdeen Varicose Vein Questionnaire 10, 2015/16 Varicose vein patients with paired 350 questionnaires 300 Average health gain (8.4) No change Around 50% of health gains are within the dotted lines Worsened Improved Aberdeen Varicose Vein Questionnaire: Change between pre- and post-operative questionnaires Base: All patients with paired pre- and post-operative Aberdeen Varicose Vein Questionnaire scores. 10 Please note that although the range of potential scores is -100 to 100, this has been condensed in the chart to reflect that no data fall beyond this range in 2015/16. Copyright 2017, Health and Social Care Information Centre. 37

38 An average health gain of 8.4 points on the Aberdeen Varicose Vein Questionnaire (scored from 0 to 100) indicates a substantial improvement in aspects of quality of life that are affected by varicose veins. Item completeness for the Aberdeen Varicose Vein Questionnaire is very high. In 2015/16: 96.5% (10,578) of pre-operative questionnaires had complete responses to this score; 94.7% (5,464) of pre- and post-operative questionnaire pairs had complete responses. Figure 18 (below) shows the proportions of patients with complete preand post-operative Aberdeen Varicose Vein Questionnaire scores who reported the most severe responses on the individual questions that form the Aberdeen Varicose Vein Questionnaire 11. The proportion of patients reporting severe score(s) is lower amongst post-operative patients for all dimensions. Aberdeen Varicose Vein Score 82.1% reported improvement. The proportion reporting that their varicose veins caused pain or ache for between 6 and 10 days or for more than 10 days in the past two weeks is particularly notable; pre-operatively, 49.6% reported this score, compared to 18.3% post-operatively. Conversely, 82.6% said they had purple discolouration of the skin before surgery, and 69.5% reported this post-surgery. 11 Please note that the question Please draw in your varicose veins in the diagrams shown is coded differently and is subsequently not included in this analysis. For more information, see the PROMs Data Dictionary, p Dictionary/pdf/Proms_Data_Dictionary.pdf Copyright 2017, Health and Social Care Information Centre. 38

39 Figure 18: Proportions of pre- and post-operative patients reporting the most severe response(s) for individual items on the Aberdeen Varicose Vein Questionnaire, 2015/16 Pain and discomfort Pre-operative questionnaire (% of patients) in the past two weeks Had itching below the knee or both below and 55.7% above the knee¹ Post-operative questionnaire (% of patients) 29.2% Varicose veins caused pain or ache for between 6 and 10 days or for more than 10 days¹ 49.6% 18.3% Moderate or severe ankle swelling 30.7% 15.1% Have taken painkilling tablets on between 6 and 10 days or on more than 10 days 15.5% 8.3% Rash or eczema in ankle area that requires treatment from a doctor or district nurse¹ 7.8% 3.7% Have a skin ulcer associated with your varicose veins¹ 6.2% 4.4% Daily life and cosmetic aspects in the past two weeks Had purple discolouration of the skin¹ 82.6% 69.5% Appearance of varicose veins causes moderate or a great deal of concern 57.6% 25.5% Varicose veins often or always influence choice of clothing 50.5% 31.7% Worn support tights or stockings prescribed by a doctor occassionally or every day¹ 26.8% 23.5% Leisure activities have been moderately affected or have been unable to take part in leisure activities 25.9% 11.3% Daily activities have been moderately affected or have been unable to carry out daily activities 19.0% 8.3% 1 This question is answered separately for the left and right leg. For this analysis, patients who have recorded the relevant score(s) for either leg, or both, are included in the numerator. Base: All varicose vein patients with complete pre- and post-operative Aberdeen Varicose Vein Questionnaire scores Copyright 2017, Health and Social Care Information Centre. 39

40 EQ-5D TM Index Figure 19 summarises the distribution of pre- and post-operative scores on the EQ-5D TM Index for all patients with paired scores. The chart shows that: Overall, varicose vein patients comparatively smaller gains on the EQ-5D TM Index following their procedure; More than one in four post-operative respondents reported a score of 1.0 on the Index the best score possible on this measure (this is why there is no narrow bar showing the 75 th - 95 th percentiles for the post-operative scores). The box area of the pre-operative scores chart is much smaller than those for other procedures; this shows that 50% of preoperative varicose vein scores were between and The pre-operative mean average is lower than the median, indicating that a proportion of relatively poorer scores were affecting the average. Figure 19: Distribution of pre- and post-operative health scores on the EQ-5D TM Index, 2015/16 Quartile 2 Quartile 3 Median Mean 5th to 25th percentile/ 75th to 95th percentile Postoperative Preoperative Worst possible score ( ) Best possible score (1.000) Base: All varicose vein patients with paired pre- and post-operative EQ-5D TM Index scores Item completeness for the EQ-5D TM Index is very high. In 2015/16: 94.7% (10,382) of pre-operative questionnaires had complete responses to the Index; Copyright 2017, Health and Social Care Information Centre. 40

41 91.5% (5,284) of pre- and post-operative questionnaire pairs had complete responses. EQ-Visual Analogue Score (EQ-VAS) Overall, around four in ten varicose vein patients (41.0%) for whom change on the EQ-VAS could be calculated reported improvement on this measure, the average health gain reported was 0.0 points. Item completeness for the EQ-VAS is very high. In 2015/16: 91.8% (10,062) of pre-operative questionnaires have completed this question; 90.6% (5,232) of pre- and post-operative questionnaire pairs have completed this question. Varicose vein procedures over time Analysis of change over time suggests that patient outcomes for varicose vein procedures are largely stable at England level. The average health gain reported on the Aberdeen Varicose Vein Questionnaire had increased very slightly year on year (from 7.4 in 2010/11 to 8.4 in 2013/14). After a slight drop to 8.2 for 2014/15, the score this year 2015/16 is 8.4. The proportion of patients reporting improvement is largely unchanged. Average health gains on both the EQ-5D TM Index and the EQ-VAS, and the overall proportion of patients reporting improvement, have remained largely static. Table 4: Health outcomes for varicose vein patients by outcome measure, 2009/ /16 England a, 2009/ /16 percentages and numbers Aberdeen Varicose Vein Questionnaire % of patients reporting improvement Average health gain EQ-5D TM Index % of patients reporting improvement Average health gain EQ-VAS % of patients reporting improvement Average health gain a Some patients resident in U.K. countries other than England undergo PROMseligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episodes were they carried out in England) are not included in these statistics. Copyright 2017, Health and Social Care Information Centre. 41

42 Patient Profile In total, there were 33,439 PROMs-eligible varicose vein procedures in 2015/16, of which: Almost six in ten (58.0%) were carried out on female patients and around four in ten (42.0%) were male. Most patients receiving an eligible varicose vein procedure were identified as White or White British (77.8%), of whom 5.3% were patients from white backgrounds other than British or Irish. Patients from (non-white) BME backgrounds accounted for 7.5% of all patients, of whom the largest group were identified as Indian (1.8%). Ethnic group information was not stated or missing for 14.6% of all episodes. The age structure of patients undergoing PROMs-eligible varicose vein procedure was more youthful than that for patients undergoing any other PROMs procedure. More than four in ten patients (40.1%) were aged under 50; around four in ten (40.7%) were aged between 50 and 69 (inclusive), and almost one in five (19.1%) were aged 70 or over. As the number of PROMs-eligible varicose vein procedures was much lower than for any other PROMs-eligible procedure, rates per 100,000 people aged 10 and over are much lower than those for the other procedures reported on within this publication. Overall, rates per 100,000 people were higher for women (79.4 per 100,000) than for men (59.6 per 100,000). Among men, rates per 100,000 people peak between ages 60-79, with the highest rate being among year olds (107.4 per 100,000 people, or just over 0.1% of all men aged 75-79). The distribution of female scores is different from males, with a higher rates amongst younger age groups. Female rates peak among year olds (128.5 per 100,000, or just over 1 per 100 women in this age group). Copyright 2017, Health and Social Care Information Centre. 42

43 Figure 20: Varicose vein procedures per 100,000 people aged 10 and over a by age b and sex c, 2015/16 Age group Female Male to to to to to to to to to to to to to to to 14 All ages (females), All ages (males), 59.6 a Rates are calculated using the ONS Mid-2014 Population Estimates in England by Single Year of Age and Sex, using the population aged 10 years and over. b Varicose vein patients for whom gender was known but age was not recorded (38) are included in the calculation of all-ages rates by gender. c Varicose vein patients whose sex was not recorded (2) are excluded from this analysis Varicose vein procedures per 100,000 people aged 10 and over Complications and further surgery Around one in five (21.1%) varicose vein patients experienced one or more post-surgical problems. Among those who experienced complications: Just over half (54.6%) experienced problems with bleeding; just over half (54.4%) experienced problems with their wound; around one in ten (11.2%) reported experiencing an allergy and/or reactions to drugs; around one in sixteen (6.1%) experienced urinary problems. Patients were also asked whether they had been readmitted to hospital since their operation, or had further surgery on their varicose veins. Among patients who returned post-operative varicose vein questionnaires, around one in twenty-one (4.7%) patients said they had been readmitted, and around one in seven (15.5%) of patients said that they had further surgery on their varicose veins since their original procedure. Copyright 2017, Health and Social Care Information Centre. 43

44 Surgical satisfaction and success Patients were asked to rate the success of their varicose veins postoperatively by responding to the following question: Overall, how are the problems now with your varicose veins on which you had surgery, compared to before your operation? Patients were asked to respond using the following categories: Much better ; A little better ; About the same ; A little worse ; Much worse. Figure 21: Varicose vein success and satisfaction score rates, 2015/16 Success Satisfaction Much Better Excellent Little Better Very Good About the Same Good Little Worse Fair Much Worse Poor 0% 50% 100% 0% 50% 100% Around nine in ten varicose vein patients (88.9% of all responding) stated that the problems with the varicose veins on which they had surgery were now much better (67.8%) or a little better (21.2%); Patients were also asked to indicate their level of satisfaction with their surgery, by rating the results of their operation as Excellent, Very good, Good, Fair or Poor. More than eight in ten (85.0%) patients described the results of their surgery as Good, Very good or Excellent, with 58.4% of patients describing their results as very good or excellent. Patient Engagement This section provides background information about participation, linkage and response rates for patients undergoing varicose vein procedures. There were 33,439 varicose vein procedures carried out in 2015/16 which is an increase of 2.3% over 2014/15. This keeps activity at a similar level to that seen in 2010/11 (32,271) following a steady decline over the years. Copyright 2017, Health and Social Care Information Centre. 44

45 Patients completed 10,962 pre-operative questionnaires, a headline participation rate of 32.8%, lower than the 2014/15 rate (39.5%) and the lowest the participation rate has been since PROMs have been recorded at a national level. Of the 10,962 questionnaires, 9,262 successfully linked to a PROMs-eligible episode giving a linkage rate of 84.6%, higher than in 2014/15 (83.3%). Patients returned 54.2% of the post-operative questionnaires they were sent, the lowest figure since PROMs started in 2009/10 (65.2%). Of the total number of episodes, 5,259 successfully linked to both a pre- and post-operative questionnaire, giving an overall rate of 15.7%, lower than the 18.9% of 2014/15 and that of previous years. Among patients undergoing varicose vein procedures in 2015/16, response rates: were lower among patients living in more deprived areas (12.4% in the most deprived quintile on IMD 2010 and 18.2% in the least deprived quintile); increased with age to the age band (19.9%), decreasing again thereafter; were higher among white patients (16.3%) than BME patients (10.2%). Figure 22: PROMs engagement among varicose vein patients, 2009/ /16 (thousands) Episodes Pre-operative questionnaires returned Post-operative questionnaires returned 2009/ / / / / / /16 Copyright 2017, Health and Social Care Information Centre. 45

46 Organisation Level Analysis Key findings In 2015/16, based on 99.8% statistical control limits: Seventeen providers were positive outliers on at least one measure, of whom six were positive outliers on two or more measures. Twenty-eight providers were negative outliers on at least one measure for one or more PROMs procedures, of which six were negative outliers on two or more procedures and nine were negative outliers on two measures for a single procedure (for at least one procedure type). Eight providers were positive outliers for the same procedure in both 2015/16 and in 2014/15, whilst nine providers were negative outliers for the same procedure in both years. Outlying Organisations Adjusted average health gains have been calculated for each provider of PROMs eligible surgery an NHS trust or independent sector hospital based on statistical methods 12 which take account of the fact that provider organisations deal with patients with differing case-mixes. These scores can be explored in the interactive Score Comparison tool, released as part of this publication. The health gains recorded for each provider of PROMs procedures have been compared to all-england averages using statistical models 13 which take account of the differing case-mix seen by each provider. The models identify as outliers those providers having overall outcomes that are significantly different from the national average: positive outliers have significantly better outcomes than the national average; negative outliers have significantly worse outcomes than the national average. A provider identified as a 99.8% outlier has roughly a 1 in 500 chance of their results being so far from the England average merely because of random variation in their patients, giving a good indication that there was something within that provider's control to have caused so substantial a difference. It does not mean that the provider was 12 Casemix adjustment methodology developed by the Department of Health, with the aid of independent contractors, in conjunction with NHS Digital. Further information is available from 13 Statistical models developed by the Department of Health / NHS England in conjunction with NHS Digital. Further information is available from Copyright 2017, Health and Social Care Information Centre. 46

47 necessarily doing something 'good' or 'bad', but it might warrant further investigation. Both the EQ-5D TM Index and the condition specific measures are used to identifying outliers. Although adjusted scores are calculated for the EQ-VAS, this measure is not used in line with Department of Health Policy Patient Reported Outcome Measures (PROMs) in England: A Methodology for Identifying Potential Outliers 14. Table 5: Outlier providers (99.8% control limits) for EQ-5D TM Index and condition-specific measures, by procedure and measure, 2013/ /16 England, 2013/ /16 a All procedures 14 numbers 2013/ / /16 EQ-5D Conditionspecific EQ-5D Condition- EQ-5D Condition- Index Index specific Index specific +ve -ve +ve -ve +ve -ve +ve -ve +ve -ve +ve -ve All Hip Replacements of which: Primary Revision All Knee Replacements of which: Primary Revision Groin Hernia Varicose Vein a Some patients resident in U.K. countries other than England undergo PROMseligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episode were they carried out in England) are not included in these statistics. - = Not applicable Full tables of adjusted scores and identified outliers are available in the Provider and Commissioner-level data files that form part of this publication. Results by Sector Whilst the national PROMs programme collects data for NHS funded activity only, patients can be treated at either NHS or independent sector organisations. This may be due to patient choice or subcontracting arrangements between organisations. Copyright 2017, Health and Social Care Information Centre. 47

48 Figure 23 below shows the average adjusted health gain for each of the four PROMs procedures by sector (NHS, independent) compared to the England average. Figure 23: Average adjusted health gain by sector 2015/16: straight line represents the national average The charts for all but varicose veins have had the axis shortened in order to show a clear illustration of the difference, which whilst small is statistically significant for most procedures. For hips, knees and varicose veins when comparing the condition specific measures we can say that on average patients have a slightly higher adjusted health gain when the procedure is carried out at an independent provider. For groin hernia procedures as measured by the EQ-5D TM we can see a slightly higher average health gain, however this is not statistically significant. Results by Clinical Commissioning Group (CCG) Analysis by CCG is now included in the interactive tool accompanying this publication based on Microsoft Power BI. Copyright 2017, Health and Social Care Information Centre. 48

49 Further information PROMs Guide For more details on the background to the PROMs programme and an overview of data collection, processing, scoring and linking, refer to A Guide to PROMs Methodology, which is available at Data Quality Important information about the quality of the data from which these statistics are derived is set out in the accompanying Data Quality Note, available at Hospital Episode Statistics For more information about Hospital Episode Statistics, and to access the many published analyses and datasets, please visit the HES homepage at Acknowledgements Any and all copyrights in the EQ-5D questions, their order, layout and images vest in the EuroQol Group 15. The EuroQol Group reserves all rights EuroQol Group. EQ-5D is a trademark of the EuroQol Group. Any and all copyrights in the Oxford Hip Score and Oxford Knee Score questions, their order and layout vest in Oxford University Innovation Limited 16, previously Isis Innovation Limited. Oxford University Innovation Limited reserves all rights. Except where expressly stated to the contrary, the Department of Health PROMs questionnaires are protected by Crown copyright. Crown Copyright and Copyright 2017, Health and Social Care Information Centre. 49

50 Appendix 1: Score Distributions by measure and procedure, 2015/16 England 2015/16 Numbers and percentages Hip replacement Knee replacement Groin hernia Varicose veins Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Condition-specific scores a Mean First quartile Median Third quartile EQ-5D TM Index Mean First quartile Median Third quartile EQ-VAS Mean First quartile Median Third quartile a There is no condition specific score for groin hernia. The following condition-specific measures are used: for hip replacements, the Oxford Hip score ranges from 0 (worst) to 48 (best); for knee replacements, the Oxford Knee score uses the same range as the related Oxford Hip score; for varicose vein surgeries, the Aberdeen Varicose Vein Questionnaire (AVVQ) ranges from 0 (best) to 100 (worst). Copyright 2017, Health and Social Care Information Centre. 50

51 Appendix 2: Paired questionnaires with self-reported pre-operative health at maximum value, by measure and procedure, 2015/16 England a, 2015/16 numbers and percentages Hip replacement Knee replacement Groin hernia Varicose veins no. % no. % no. % no. % Condition-specific scores b 48, , , of which: pre-operative scores at maximum value pre- and post-operative scores at maximum value EQ-5D TM Index paired scores c 44, , , , of which: pre-operative score at maximum value (1.0) , , pre- and post-operative scores at maximum value (1.0) , EQ-VAS paired scores d 43, , , , of which: pre-operative score at maximum value (100) , , pre- and post-operative scores at maximum value (100) a Some patients resident in U.K. countries other than England undergo PROMs-eligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMseligible episodes were they carried out in England) are not included in these statistics. b There is no condition-specific measure for groin hernia. The following condition-specific measures are used: for hip replacements, the Oxford Hip score ranges from 0 (worst) to 48 (best); for knee replacements, the Oxford Knee score uses the same range as the related Oxford Hip score; for varicose vein surgeries, the Aberdeen Varicose Vein Questionnaire (AVVQ) ranges from 0 (best) to 100 (worst). c The EQ-5D TM Index ranges from to 1.0, with 1.0 being the best possible score. d The EQ VAS ranges from 0 to 100, with zero being the worst and 100 being the best state of health. Copyright 2017, Health and Social Care Information Centre. 51

52 Appendix 3: Health change by measure and procedure, 2015/16 England 2015/16 Numbers and percentages Hip replacement Knee replacement Groin hernia Varicose vein no. % no. % no. % no. % Condition-specific scores a : All pre- and post-operative questionnaires for which changed can be calculated 48, , , Improved 46, , , Unchanged Worsened 1, , EQ-5D TM Index: All paired pre- and post-operative questionnaires for which change can be calculated 44, , , , Improved 39, , , , Unchanged 2, , , , Worsened 2, , , EQ-VAS: All paired pre- and post-operative questionnaires for which change can be calculated 43, , , , Improved 28, , , , Unchanged 4, , , Worsened 10, , , , a There is no condition-specific measure for groin hernia. The following condition-specific measures are used: for hip replacements, the Oxford Hip score ranges from 0 (worst) to 48 (best); for knee replacements, the Oxford Knee score uses the same range as the related Oxford Hip score; for varicose vein surgeries, the Aberdeen Varicose Vein Questionnaire (AVVQ) ranges from 0 (best) to 100 (worst). Copyright 2017, Health and Social Care Information Centre. 52

53 Appendix 4: Readmissions, further PROMs surgery, and complications after undergoing PROMs surgery, 2015/16 England a 2015/16 Numbers and percentages Hip replacement Knee replacement Groin hernia Varicose vein no. % no. % no. % no. % All patients b 49, , , , of whom: Experiencing one or more post-surgical problem(s) 13, , , , of which: Allergy c 4, , Bleeding c 1, , , Urinary c 6, , , Wound c 3, , , Readmitted 3, , , Further surgery 1, , , a Some patients resident in U.K. countries other than England undergo PROMs-eligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMseligible episode were they carried out in England) are not included in these statistics. b All patients returning post-operative questionnaires are included in this table. c Percentages for specific problems are given as a proportion of all those experiencing one or more problems. Copyright 2017, Health and Social Care Information Centre. 53

54 Appendix 5: Eligible hospital procedures, preoperative and post-operative questionnaire returns by procedure type, 2009/ /16 England a, 2009/ /16 Numbers and percentages Eligible hospital procedures b (no.) Pre-operative questionnaires returned (no.) Pre-operative (headline) participation rate (%) Post-operative questionnaires sent (no.) Post-operative questionnaires returned (no.) Post-operative questionnaire response rate (%) All procedures 2015/16 264, , , , /15 267, , , , /14 255, , , , /13 241, , , , /12 247, , , , /11 245, , , , /10 239, , , , of which: Hip replacement 2015/16 77,159 67, ,834 49, /15 78,195 67, ,449 51, /14 76,576 65, ,767 50, /13 72,285 60, ,429 43, /12 72,354 59, ,561 47, /11 69,818 55, ,291 44, /10 63,625 48, ,527 39, Knee replacement 2015/16 84,300 81, ,365 58, /15 83,450 79, ,361 59, /14 79,769 74, ,697 55, /13 76,220 68, ,500 50, /12 77,457 69, ,068 54, /11 75,307 63, ,324 50, /10 72,563 56, ,182 45, Groin hernia 2015/16 69,222 39, ,030 24, /15 72,709 42, ,950 26, /14 73,229 43, ,060 28, /13 68,668 42, ,785 27, /12 70,786 42, ,088 29, /11 68,120 37, ,281 26, /10 68,640 37, ,533 26, Varicose vein 2015/16 33,439 10, ,646 5, /15 32,692 12, ,652 6, /14 26,201 10, ,264 5, /13 24,260 10, ,312 5, /12 27,102 13, ,661 8, /11 32,271 15, ,718 9, /10 34,855 15, ,632 9, a Some patients resident in U.K. countries other than England undergo PROMs-eligible hospital episodes in England and are included in these statistics. Conversely, patients resident in England who undergo surgical procedures in other U.K. countries (which would be PROMs-eligible episode were they carried out in England) are not included in these statistics. b There are slightly more inpatient procedures than episodes in each year as some episodes were eligible for more than one PROMs procedure. Copyright 2017, Health and Social Care Information Centre.

55 Appendix 6: Feedback Where possible, NHS Digital has collated information on the extent to which different aspects of regularly published data are used. This analysis shows: Our finalised data release is the most regularly accessed publication within the yearly cycle, followed by quarterly releases of full year provisional data for the latest available year; Before data are finalised, the latest available data are consistently viewed more than the previous year s data; There is a substantial reduction in the number of views for part-year data publications once they have been superceded by a more recent publication; Special Topic publications continue to be viewed over time, even where they relate to less recent data; The interactive score comparison spreadsheet is the most regularly downloaded file within quarterly publications, followed by the CSV file pack. Consultations NHS England consulted on the future content of the national PROMs programme during the 2015/16 financial year in order to understand more about how, when and why national PROMs data is used, and what benefits are provided to the NHS, both nationally and locally. The findings are due to be published 17. NHS Digital consulted on changes to NHS Digital Statistics / /19, including proposals to stop publishing the monthly PROMs national headline figures and to cease production of the regular quarterly special topics in favour of more targeted and collaborative topics. The consultation ended on 27 June and the results have now been published 18. User feedback NHS Digital is keen to gain a better understanding of the users of this publication and of their needs; feedback is welcome and can be sent by: ing enquiries@nhsdigital.nhs.uk, citing PROMs in the subject; Copyright 2017, Health and Social Care Information Centre.

56 telephoning our customer contact centre on There has been user feedback on a range of topics related to PROMs publications in the last 12 months. Broadly: Enquiries about the PROMs data, including usage and data quality (approximately 50 enquiries); Enquiries about the finding the relevant provider level PROMs data, including data held on the PROMs data quality dashboard and via the provider extract service (approximately 60 enquiries); Seeking information on the processing of PROMs data including the methodology for Casemix adjustment, as well as information on data suppliers and PROMs policy (approximately 15 enquiries); Enquiries about the updates to the PROMs framework agreements (approximately 30 enquiries) Use of data in responses to parliamentary questions (approximately 5 enquiries). Improvements to publications There have been a number of changes to PROMs publications in previous years as a result of feedback. This year the changes include: Addition of an interactive reporting tool based on Microsoft Power BI set of visual analytics data to support the data previously only shown at a national level on an annual basis; this will now be updated on a quarterly basis. Change to the public-facing web page. The PROMs homepage has been developed to make it easier to find our publications in a relevant and user friendly order. Copyright 2017, Health and Social Care Information Centre.

57 ISBN This publication may be requested in large print or other formats. Published by NHS Digital, part of the Government Statistical Service NHS Digital is the trading name of the Health and Social Care Information Centre. Copyright 2017 You may re-use this document/publication (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence visit or write to the Information Policy Team, The National Archives, Kew, Richmond, Surrey, TW9 4DU; or Copyright 2017, Health and Social Care Information Centre.