Following a meeting of the NJR Steering Committee in 2018, it was agreed to establish a PROMs working group, led by the Chair of the NJR’s Research Committee, Professor Mark Wilkinson. This group oversees a number of workstreams that involve the collection, analysis and reporting of patient reported metrics.
Assessment of PROMs data quality: As the NJR increasingly uses PROMs metrics from the national PROMs programme (undertaken by NHS Digital) alongside revision and mortality endpoints, an examination of the quality and representativeness of national PROMs for the population of patients in England who have hip and knee replacement surgery is now being undertaken. This important work that is being carried out by the University of Bristol on behalf of the NJR will aim to ensure that clinicians, hospital managers, and regulators can have confidence in using patient reported metrics to assure quality.
Use of PROMs in implant reports: The NJR now routinely includes reporting of PROMs metrics in implant reports made available to manufacturers via the NJR Supplier Feedback platform. This means that patient reported metrics can be considered alongside revision rates when examining the performance of an implant or construct. Increasingly, regulatory bodies internationally are requiring PROMs to be included as part of submissions to support device assurance. The NJR is currently developing a system that will make a library of these implant reports available to clinical teams – it is hoped to launch that platform in 2021/22.
Shoulder PROMs: For shoulder replacement joint surgery, the NJR commenced regular six-month follow-up in April 2017 for patients who had undergone surgery after 1 October 2016. The disappointingly low rate of pre-operative submissions is being addressed by the British Elbow and Shoulder Society, in conjunction with the NJR and the Getting It Right First Time (GIRFT) programme. Response rates to questionnaires sent directly to patients at their home addresses post-surgery averages at just over 80%.
Identifying and Preventing Never Events
In 2018, the NHS Healthcare Safety Investigation Branch identified a requirement to reduce the number of ‘Never Events’ associated with joint replacement surgery. The NJR was identified as a means by which this could be achieved.
For hip surgery, Never Events are where there is a mismatch in size between the acetabular cup/liner and the head or where different brands of head and stem are used in modular components. For knees, a Never Event relates to side, e.g. a left-sided component being put into a right knee.
The data entry system was changed to detect potential Never Events and to warn the data entry user. At the same time as warning the user, the system generates emails to NJR Centre staff so that this can be investigated. If an alert is confirmed as a genuine Never Event, the Consultant in Charge is contacted by a surgeon member of the NJR Steering Committee to confirm what action, if any, will be taken.
A very small number of Never Events are identified in this way each year but the number of ‘false alarms’ is considerably higher. These alarms are most often likely to be due to mistakes in data entry, such as selecting the wrong side for the operation or using the wrong label detail for recording the implants.
As part of this focus on never events, the NJR has been working to deliver the validation rules that the NJR applies in data entry to an external environment, so that it can be used in support of intra-operative checks. An Application Programming Interface (API) has been developed so that hospital theatre systems can interface with NJR’s checking rules. A smartphone application is also being developed so that clinical teams can carry out validation checks even if their hospital does not have a compatible front-end system.
In 2019, the NJR commissioned the development of a cloud-ready, platform-based application framework for provision of future NJR services. The rationale for the implementation of the NJR IT Platform includes a focus on developing a modern, unified environment with the ability to move to cloud-based infrastructure. The platform development will include developing reusable services that will transfer across user groups, so that functionality and developments can be shared across all systems on the platform. Optimisation of modules for accessing on mobile devices will also be included.
The first phase of development (iteration 1) transfered clinician feedback services into the new environment along with a more interactive reporting service. This included the following modules:
• Consultant Level Report (CLR)
• Annual Clinical Report (ACR)
• Clinical Outcomes Publication Preview (COP)
• Clinician Profile Edit
• Interactive NJR activity count tool
• Contacts Database
Iteration 2 of development has taken place following the successful completion of iteration 1 and this added interactive management feedback. Further development work during 2022/23 will gradually include our other NJR services:
• Component Database
• Implant Supplier feedback, including interactive reporting services
• New availability of implant data library
• New semantic layer to aid researcher access to NJR data
• Data entry for hospitals
• Data quality audit tools
• Secure data access portal