NJR 2009 NJR Activity 2008 Keith Tucker Survivorship Analysis Martyn Porter Outliers Paul Gregg Clinician Feedback Peter Howard

NJR 2009 NJR Activity 2008 Keith Tucker Survivorship Analysis Martyn Porter Outliers Paul Gregg Clinician Feedback Peter Howard

NJR ACTIVITY 2008-9 A few highlights Keith Tucker NJR Steering Committee

NJR Activity 2008-9 NJR database now stands at > 742,706 entries 160,227 uploads, the busiest year so far Compliance (registrations as % of levies) 92.5% Consent 87.4% Linkability 92.5% (Overall NJR linkability 77.4%)

Operations 2003-9

KNEES

2008 KNEES

KNEE BRANDS

HIPS

2008 HIPS

Cemented stems

Cementless stems

Cemented cups

Cementless cups

Resurfacing

Head Size

ASA & BMI We seem to be operating on less fit patients

Hips? Less fit patients

Knees?Less fit patients

BMI Hips

BMI Knees

ODEP 10A Benchmark 76% Cemented Stems 77% Cementless Stems 49% Cemented cups 11% Cementless cups 45% Surface Replacements (BHR 10A)

Acknowledgements Claire Newell NJR Data quality manager (Northgate public services) Martyn Porter Peter Howard Paul Gregg

THANK YOU

Survivorship Analysis 2003-2008 Martyn Porter Wrightington Hospital Chair NJR Editorial Board NJR Steering Committee

Methodology Changes Linkage to HES and NJR to identify revisions Changes in methods to identify revisions in HES Capture of revision hip increased by 200% Capture of revision knee increased by 300% Reporting period for linked data extended to Oct 2008 ( was June)

Linkage Mechanism

Revision Following Primary THR 1 year 1% (0.9-1.1%) 3 years 2% (1.9-2.1%) 5 years 2.8% (2.6-3.0%)

Three Year Revision According to Hip Type Cemented 1.3% (1.2-1.4%) Hybrid 1.9% (1.7-2.1%) Cementless 2.8% (2.6-3.0%) Resurfacing 4.4% (4.0-5.0%)

Three Year Revision According to Hip Type

Age and Sex Risk Stratification Males< 55yrs Cemented 2.5% (1.7-3.7%) 1,384 1 Cementless 3.3% (2.6-4.2%) 3,407 1.5 Hybrid 1.8% (1.1-2.9%) 1,284 0.8 Resurfacing 3.7% (3.0-4.7%) 3131 1.8

Age and Sex Risk Stratification Females> 65yrs Cemented 1.1% (1.0-1.2%) 41,701 1 Cementless 2.5% (2.2-2.9%) 14,52 0 2.7 Hybrid 1.6% (1.3-2.0%) 8,474 1.8 Resurfacing 8.5% (5.3-13.6%) 266 10.1

Revision and Cemented Stems Exeter 1.3% (1.2-1.4%) 49,213 1 Charnley 1.3% (1.1-1.8%) 10,740 1 CPT 1.5% (1.2-1.9%) 7,177 1.3 C Stem 1.4% (1.1-1.8%) 7,128 1.1 Stanmore 1.4% (0.9-2.3%) 2,212 0.9

Revision and Cemented Cups Contemporary 1.3% (1.1-1.6%) 16,193 1 Ogee 0.9% (0.7-1.2%) 10,979 0.7 Charnley 1.3% (1.0-1.6%) 6,719 0.9 Duration 1.5% (1.2-1.9%) 6,408 1.2 Opera 0.8% (0.5-1.3%) 3,616 0.6

Revision and Cementless Stems Corail 2.8% (2.3-3.0%) 18,905 1 Furlong 2.7% (2.3-3.1%) 10,071 1.2 SL Plus 2.8% (1.9-3.8%) 2,588 1.1 Accolade 2.8% (1.8-4.3%) 2,379 1.1 Taperlock 2.9% (1.9-4.4%) 2,008 1.3

Revision and Cementless Cups Pinnacle 2.2% (1.9-2.7%) 14,902 1 Trident 1.8% (1.5-2.2%) 10,437 0.9 CSF 2.7% (2.3-3.1%) 9,047 1.4 Trilogy 2.3% (1.9-2.7%) 8,378 1.1 Duraloc 2.2% (1.8-2.8%) 3,084 1.1

Revision and Resurfacing BHR 3.3% (2.9-3.9%) 6,748 1 Cormet 6.0% (4.7-7.5%) 1,807 1.8 ASR 7.5% (5.9-9.5%) 1,332 2.2 Adept 4.2% (2.4-7.2%) 791 1.3 Durom 4.9% (3.3-7.3%) 683 1.4

Revision and Bearing MoP 1.6% (1.5-1.7%) 94,012 1 CoP 1.7% (1.5-2.0%) 15,743 0.8 CoC 2.2% (1.8-2.6%) 9,928 0.9 MoM 1.9% (1.2-3.0%) 1,304 0.8

Revision Following Primary TKR 1 year 0.7% (0.6-0.8%) 3 years 2.5% (2.4-2.6%) 5 years 3.7% (3.5-3.9%)

Three Year Revision According to Knee Type Cemented 2.1% (2.0-2.2%) Cementless 2.4% (2.1-2.9%) Hybrid 2.9% (2.2-3.9%) Unicondylar 7.2% (6.6-7.9%) PFR 8.3% (6.6-10.5)

Revision and Type of Knee

Revision and Sex

Three Year Revision and Brand of Knee PFC 1.7% (1.6-1.9%) 52,793 1 Nexgen 1.8% (1.6-2.1%) 20,259 1 AGC 2.1% (1.8-2.3%) 19,490 1.2 Scorpio 2.2% (1.9-2.6%) 12,133 1.3 Kinemax 2.5% (2.2-3.0%) 7,140 1.5

Summary Hips Cemented fixation superior at five years Cementless fixation has now overtaken cemented Age and sex stratification has an important effect Resurfacing results best in males < 55yrs but still infrerior There is variation in survivorship of types of THA within its fixation category There is less variation in survivorship in terms of bearing surface

Summary Knees Cemented fixation most popular and best results at three years (2.1%) Unicondylar revision 7.2% at three years Age and sex stratification are important Results very similar to Australian Register

Conclusions The NJR is work in progress We are aware that data quality issues need to be addressed But NJR Compliance stands at over 90% Clinician feedback reports should further improve data quality HES interrogation, linkage and statistical analysis are likely to improve

THANK YOU

OUTLIERS Prof P J Gregg The James Cook University Hospital, Middlesbrough Vice-Chairman NJR Steering Committee

POTENTIAL OUTLIERS arise from the need to measure outcome of total hip and knee replacement surgery

NATIONAL JOINT REGISTRY Primary objective is to provide information to all those involved in the management of joint replacement surgery with regard to surgical and implant performance and clinical best practice. Central to the provision of this information is the aim of improving patient outcomes and safety.

SIXTH NATIONAL ADULT CARDIAC SURGICAL DATABASE REPORT Significant improvements in survival despite increasing complexity of case mix and increasing patient age Methodologies for predicting operative risk and adjusting for case mix essential if comparisons are to be made about differing outcomes between hospitals or surgeons

DARZI DIMENSIONS OF QUALITY! Safety! Clinical effectiveness! Patient experience Backed up by metrics and backed up by regulation using metrics.

OUTCOME MEASURE The outcome measure used is implant survivorship Expressed as Revision Rate Calculated for individual hospitals, surgeons, and implants

REVISION RATE Revision rate = Total revisions Patient time (years) 1 (Expressed as revisions per 100 patient years) 1 Time elapsed from primary operation to revision, death or end of follow-up, whatever comes first.

REVISION RATE Surgeon-specific revision rates are presented in a funnel plot and compared against a target revision rate, that is defined as the average rate observed in England and Wales. Target rate (National Benchmark) is defined as total number of revisions divided by the total sum of patient time for all surgeons data in registry.

EXPECTED NUMBER OF REVISIONS Expected number of revisions for a surgeon is equal to the target rate multiplied by the patient time summed up over all patients for this surgeon.

HIP REPLACEMENT WITH NJR REVISIONS Funnel plot: 95% and 99.8% limits 5 4.5 revision rate / 100 pat years 4 3.5 3 2.5 2 1.5 1.5 0 0 5 10 15 20 25 expected number revisions

HIP REPLACEMENT WITH NJR FIRST REVISIONS 2003 TO 2008 Funnel plot: 95% and 99.8% limits CEMENTED CEMENTLESS 5 5 4.5 4.5 4 4 revision rate / 100 pat years 3.5 3 2.5 2 1.5 revision rate / 100 pat years 3.5 3 2.5 2 1.5 1 1.5.5 0 0 0 5 10 15 20 25 expected number revisions 0 5 10 15 20 25 expected number revisions HYBRID RESURFACING 5 4.5 5 4 4.5 revision rate / 100 pat years 3.5 3 2.5 2 1.5 revision rate / 100 pat years 4 3.5 3 2.5 2 1.5 1 1.5.5 0 0 0 5 10 15 20 25 expected number revisions 0 5 10 15 20 25 expected number revisions

PROBLEMS Poor compliance artificially lowers the national benchmark. NJR NJR linkage seriously underestimates number of revisions. Anomaly of resurfacing surgeon can have higher revision rate than non-resurfacing but not be seen as outlier.

PROBLEMS Funnel plots are based on assumption that the revision rate remains constant with time from surgery which is not the case. Further work needed to investigate which statistical method represents best the timedependent revision rates and how this can be used to estimate expected number of revisions.

PROBLEMS Revision rates for surgeons with expected numbers of revisions of less than 1 are not displayed in the funnel plot because the calculations are too imprecise.

POTENTIAL OUTLIERS An adequate system for detecting potential outliers cannot be developed quickly and will require continuous refinement and updating with a growing understanding of it s functioning.

POTENTIAL OUTLIERS It is not acceptable to ignore evidence of outlying performance even if the evidence is imperfect BUT results could reflect differences in data quality, completeness and case mix rather than quality of joint replacement surgery.

POTENTIAL OUTLIERS Given current stage of development, the identification of outlying revision rates should first trigger a detailed examination of the data in the NJR and HES databases and cross-checked with data from the hospital concerned.

FUTURE Compliance must be made mandatory Compliance part of Health Commission s Annual Health Check PBR linked to NJR compliance Compliance part of GMC revalidation process

FUTURE Case-mix/complexity assessment and adjustment essential Risk-adjusted funnel plot Prosthesis Age Sex Diagnosis

THANK YOU

Clinician Feedback Peter Howard Consultant Orthopaedic Surgeon, Derby Chair Regional Clinical Co-coordinators committee

Clinician Feedback Significant progress in last 12 months Much more to come Funnel plots difficulties/issues resolved Data accuracy issues persist consent NHS number needed for optimal Great for appraisal folder & departmental audit (if on correct side of the plot)

NJR Clinician Feedback

Available Reports

Data Quality

NHS Number Submission

Revision Rate at One Year - TKR

3 Year Revision Rate Unicondylar Knee

Revision Rate 3 Years All Knees - SHA Level

Patient Time Incidence Rate - All Hips

Patient Time Incidence Rate - Hips Cementless

Patient Time Incidence Rate - All Knees

Patient Time Incidence Rate - Unicondylar Knee

Latest format of PTIR plots

NJR Clinician Feedback - Getting Access Username and Password for Data Entry System will work. If you don t have any log on credentials you must email the NJR Service Desk. The email you send must: Be from an NHS/Hospital email account Include a specific request for access to Clinician Feedback Include a contact telephone number Health_servicedesk@northgate-is.com The Service Desk will contact you with the necessary details. Failing that, visit the NJR Stand in the Exhibitors Hall

Consenting to Share Data - Step 1 Select System Functions once logged into the Data Entry System

Consenting to Share Data - Step 2 Select Modify Surgeon Profile

Consenting to Share Data - Step 3 Select Personal Options

Consenting to Share Data - Step 4 Check Consent Box

Consenting to Share Data - Summary Log in to Data Entry System Select System Functions then Select Modify Surgeon Profile Select Personal Options Check Consent Box Click Save All too difficult? Call the Service Desk on 0845 345 9991!

The future? Including HES data on PE etc will give much more data availability Consent, NHS number & mandation of the NJR essential for accuracy What else do we need?

THANK YOU DISCUSSION