NJR Medical Advisory Committee (MAC)
Chair’s report 2022/23 – Mr Tim Wilton
The Medical Advisory Committee (MAC) continues to provide invaluable advice and professional context to the functioning of the NJR. I thank all of the specialist society presidents and representatives, the BOA President and our core members for the contributions to these many discussions.
The change in outlier analysis method from using ‘All Knees combined’ as a metric to using ‘Total Knee Replacement’, ‘Unicondylar Knee Replacement’ and ‘Patello-femoral replacement’ as separate metrics has inevitably caused some further discussion in the orthopaedic community since, as expected, the change caused some surgeons and hospitals to reach ‘alarm’ status where previously they were not at that level. It is comforting that the change also enabled some surgeons and hospitals to no longer be considered to be at ‘alarm’ level. The MAC members have discussed this matter further retrospectively after the changes and are generally very satisfied with the overall outcome.
There have been some concerns expressed over the years that surgeons whose outcome data show them to have a relatively high revision rate could suffer consequent mental health issues and that this might be something which we might alleviate by modifying the outlier notification process. This matter was discussed amongst MAC members and some very helpful suggestions were made about modifying the language within letters sent to surgeons and Medical Directors, in order to be sure that such issues were being appropriately considered by the local personnel and processes. The possibility of changing the protocol so that Medical Directors were notified of the issues earlier in the process was discussed and rejected on the grounds that surgeons do need and appreciate the advanced warning they currently receive, as it allows proper collection of the relevant audit data. It was therefore felt that to remove that advance warning might actually increase the possibility of causing anxiety and distress for the surgeon.
This year MAC members have also discussed the introduction of the Minimum Data Set version 8 (MDSv8) for the collection of data and have contributed input for additional procedures to be collected, in particular relating to the data which might be necessary to support the developing regional revision network systems for hips and knees. It was agreed that adding this as data collected by the registry would be a far better solution rather than collecting much of the information again in a separate database, as this will limit duplication of effort and minimise the risk of undermining data input into the existing registry system.
Discussions that the NJR has about governance considerations, access to other datasets through NHSE and the many other matters involved in the regular NJR/NHSE/HQIP accountability meetings occurred regularly during the year in order to keep the BOA and specialist societies abreast of these conversations and where necessary seek their assistance in both communicating and effecting the requisite changes to practice. There remains a serious problem with the supply of PROMs data to the NJR from NHSD (now incorporated into NHSE) which is responsible for the collection and management of the national Hip and Knee PROMs programme. It is very clear that PROMs are an increasingly important outcome measure and essential to supplement the registry information on outcomes relating to mortality, revision surgery and re-operation. Discussion in MAC has left no room for doubt that, without the PROMs data to link to other outcomes in the NJR, the profession would feel the value of the data provided about both implants and surgeons would be seriously diminished. These feelings have been regularly represented to NHSE and GIRFT in a forthright fashion and we trust that NHSE will soon find a solution to reinstating PROMs.
I am particularly grateful to the presidents of the BOA and BASK for their help with the issue of communicating to knee surgeons the problems surrounding a knee implant that was identified as having a high revision rate. This problem produced, understandably, a great deal of concern and potential confusion about how to deal with existing recipients of the devices. Urgent meetings were held with BOA and BASK presidents at very short notice, and this enabled a suitably measured and considered response to be developed that was subsequently shared with the MHRA and the manufacturer. This experience has also been very useful in guiding how the process can be modified for the future to allow such issues with implant ‘recalls’ to be dealt with more swiftly and appropriately.