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20 Years of the National Joint Registry: who benefits? Part one: patients and hospitals
Elaine Young, Gillian Coward, Robin Brittain and Timothy Wilton
The National Joint Registry (NJR) was founded in 2002, and started collecting data to monitor the performance of hip and knee replacement surgery in England and Wales in 2003. Since then, we have expanded both our scope of joints and territories covered. In this three-part series, we describe the value of the NJR, its data resource and its outputs to our key stakeholders. In this first part, we focus on the benefits of the NJR to patients and hospitals; in part two, we outline the benefits to surgeons and implant suppliers; and in part three, we describe the benefits to service commissioners, regulators and policymakers, and the broader benefits to society (including research and innovation).
Benefits to patients
The primary stakeholder for the NJR is the patient. Joint replacement is routine surgery and patients rightly expect that their surgery will improve their quality of life. Evidence from NJR data collected over the last 20 years has demonstrated continuing improvements in core outcomes and generated a significant body of information for patients to use in the shared decision-making process.
Core outcomes
Death following joint replacement surgery is a rare event. In the 20 years since the NJR’s inception and despite patients receiving joint replacement becoming higher risk over time, there has been a sustained reduction in the risk of mortality. Mortality rates 90-days following primary hip replacement reduced from 0.56% in 2003 to 0.29% in 2011 [1]. Mortality following knee replacement shows a similar reduction over time [2]. When the National Institute for Health and Care Excellence (NICE) first issued recommendations on hip replacement surgery, the suggested acceptable revision rate at 10 years was 10%. This has since reduced to 5%, with the best-performing hip replacements in the NJR achieving revision rates that have halved since their peak from over 6% to around 2.5%, and for knees this has fallen from a peak of over 5% to less than 4%. Around 90% of hip and knee replacements now last more than 15 years, and 58% of hips and 82% of total knee replacements are expected to last 25 years [3,4].
Shared decision-making
Patient information and knowledge is vital to ensure understanding, confidence, managing expectations and contributing to shared decision-making. Information on the NJR’s work is shared publicly through its website. This includes our annual report (comprising analysis of surgical data translated into visual presentation formats), patient leaflets on the work of the NJR and guidance on surgery for different joints with what to expect. We publish surgeon hospital and implant-level information about patient outcomes following joint replacement surgery that enables patients to understand what to expect from their treatment, and to inform their decision about where to be treated and what implants are used. We produce guidance from NJR’s Annual Report to provide patients with digestible data on the type and quality of joint replacement surgery undertaken, to increase patient awareness and patient choice.
The NJR, through its publicly available information resource, makes data tangible and meaningful. This can assist patients and surgeons to explore the choices available regarding type of implant and surgery, and consider their options.
For example, the Patient Decision Support Tool (PDST) (https://jointcalc.shef.ac.uk/) is a freely available online tool that was developed using NJR data to help those considering joint replacement surgery, to better understand the risks and benefits [5]. The patient enters simple details, such as age, sex, height, weight, general health and how their joint disease affects them. The tool then uses data from similar patient experiences to calculate how much better they are likely to feel after surgery (Figure 1). The tool also calculates the likelihood of repeat surgery being needed and the risk of death after surgery.
The tool is an example of how the patient benefits from NJR-supported research, enabling both patients and surgeons to make informed decisions jointly as an important part of patient-centred medicine. The tool has now been accessed by many tens of thousands of patients across more than 110 countries, and some of the underlying methodology can be found at the following scientific reference [6].
Shared decision-making relies on NJR evidence, plus information and research outcomes being presented in a clear and understandable way through patient guidance, stories and interviews, quotes, infographics, and in easily accessible formats and locations. Patients with better understanding of their surgical procedure, their own risk level, and what will be happening to them are likely to be better prepared and to thereafter have better outcomes.
Recognising the importance of the patient perspective, a pre-op PROMs questionnaire is collected by the NJR for shoulder replacement and around a quarter of elective patients return these within the required timescale. Around a third of patients complete a further six-month PROMs, but engagement is poor beyond that. At six months following surgery, 5.3% of all patient responders reported a score worse than they did preoperatively. Patients with a high pre-op score – over 40 on the Oxford Shoulder Score – had an equal chance of being better or worse at six months. NJR-supported research has examined the use of these shoulder PROMs and a paper examining the Floor and ceiling effects in the Oxford Shoulder Score found that the score does not exhibit a ceiling effect at six months, but does at three years and five years, which may influence the sampling and timing of NJR PROMs moving forward [7].
Benefits to hospitals
The NJR has invested in the development of a wide range of interactive reporting tools for both hospitals and surgeons over the years, most of which can now be accessed through the sophisticated new software platform: NJR Connect – Data Services (Figure 2).
Supporting best practice
We support local clinical governance through the provision of hospital and surgeon-level reports, providing an independent assessment of the safety and effectiveness of local practice compared to national benchmarks. We alert hospital medical directors of any adverse patterns in patient outcomes attributable to their hospital, and provide data and analysis to support local investigation of root causes for raised alerts. Recently, we also launched the NJR implant scanning app to support implant checking during the operation, to prevent the occurrence of ‘never events’ where incompatible implants are inadvertently used in patients. Twice a year a comprehensive analysis is undertaken of the performance of all surgical units undertaking joint replacement in the NJR’s operational areas. Each unit, regardless of their performance, receives a comprehensive in-depth analysis of their practice, including a list of all revisions and deaths, and this regular reporting mechanism enables units to reflect on best practice and address any issues relating to worse outcomes.
Annual Clinical Reports (hospital-level reports)
NJR Annual Clinical Reports are supplied to all hospitals submitting data to the registry, providing detailed analysis of activity and outcomes across joint replacement services. This also provides medical directors with a summary of the performance outcomes for each surgeon operating in their units. Outcomes data is supplemented by analyses that show the indications for revision across their unit so that trends can be identified, as well as a summary of how individual surgeons are contributing to a unit’s overall outcomes. This summary data is now supplemented by customisable reporting tools within our NJR Connect platform, as well as a detailed appendix of individual patient outcomes, which means that that data can be analysed locally.
• ‘Never events’ (a clinical incident eg, surgery performed on the wrong body part, or incorrect implant used). We can monitor and identify ‘never events’, and increasingly prevent them from happening with the scanning interface.
• Poorly performing units and surgeons are identified and supported to improve.
• Poorly performing implants are identified and this information is escalated to regulators
Price benchmarking
With a view to improving the cost-effectiveness of joint replacement surgery, NJR’s implant price-benchmarking service gives hospitals the information they need to benchmark the price they pay for hip, knee, ankle, elbow and shoulder implants against the ‘best’ national prices achieved across all hospital implant procurement services. Since 2017, the NJR’s enhanced implant price-benchmarking service EMBED (Figure 3) has been included as part of the standard NJR subscription charge for all NHS trusts. This service enables the hospital to drill down into their pricing data, including the additional capability to give surgeons individual reports relating to their own implant use. EMBED provides the tools to enable hospitals to understand in greater detail their use of joint replacement implants in the context of cost, evidence and trends, in comparison to the national picture.
The service provides clinicians, management, procurement and finance teams with an objective set of data and analysis to inform their decision-making. This activity, with a focus on cost and value alongside procedure outcomes, underpins the Getting It Right First Time (GIRFT) and NHS England’s Model Hospital initiatives.
Summary
In this part one of our NJR benefits article, we hope we have given a flavour of some of the benefits the NJR delivers to patients and hospitals. A fuller picture of these benefits can be found in the relevant sections of the NJR website (www.njrcentre.org.uk). In the next part of this series, we will cover the benefits of the NJR to clinicians and implant suppliers.
References
1. Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, et al 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013;382(9898):1097-104.
2. Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, et al. 45-day mortality after 467 779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet. 2014.
3. Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019;393(10172):647-54.
4. Evans JT, Walker RW, Evans JP, Blom AW, Sayers A, Whitehouse MR. How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019;393(10172):655-63.
5. Zotov E, Hills AF, de Mello FL, Aram P, Sayers A, Blom AW, et al. JointCalc: A web-based personalised patient decision support tool for joint replacement. Int J Med Inform 2020;142:104217.
6. de Mello FL, Wilkinson JM, Kadirkamanathan V. Metaparametric Neural Networks for Survival Analysis. IEEE Trans Neural Network Learn Systems. 2021;pp.
7. Singh HP, Haque A, Taub N, Modi A, Armstrong A, Rangan A, et al. Floor and ceiling effects in the Oxford Shoulder Score: an analysis from the National Joint Registry. Bone Joint J. 2021;103B(11):1717-24.
Elaine Young is the Director of Operations for the NJR, with responsibility for its overall management, as well as strategic direction and leadership of the NJR management team in supporting the work of the NJR and its committees.
Gillian Coward has been a patient member of the NJR Steering Committee for over six years and also volunteers with Versus Arthritis. Gillian has wide experience of joint replacement surgery due to living with rheumatoid arthritis for 40 years.
Robin Brittain is a patient representative for the NJR and has lived experience of musculoskeletal conditions, having been diagnosed in 1991 with ankylosing spondylitis and subsequently osteoarthritis and hip impingement to both hips. He volunteers for various organisations across a range of activities including patient support, advocacy and research.
Timothy Wilton is a Consultant Orthopaedic Surgeon at Department of Orthopaedics, Royal Derby Hospital, Derby, with specialist interests in knee and hip replacement surgery. He is Medical Director of the NJR.
