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Scottish Arthroplasty Project Annual Report 2019

FOREWORD

The members of the Scottish Arthroplasty Project Steering Group would like to thank colleagues from across Scotland for their ongoing support of this valuable audit. The 2019 report continues to show that across Scotland patients undergoing joint replacement procedures receive high quality care. Surgeons are now able to access “live” personal data on complication rates and numbers of arthroplasties through Tableau.

We have received 44 individual CUSUM outlier responses for 2018 and we hope that the process has provided an opportunity to reflect on practice and where thought necessary change practice. The SAP is required, as a National Audit, to monitor complication rates on a Health Board level. Health Boards between 2 and 3 Standard deviations above the mean complication rates are sent a letter for information. Health Boards 3 or more standard deviations above the mean are required to reflect and respond to the data. After discussion with the Orthopaedic consultant leads across Scotland we decided to monitor hip arthroplasty mortality at 90 days, infection at one year and reoperation at 3 years. For knee arthroplasty the chosen complications are mortality at 90 days, infection at 1 year and knee revision at 3 years. This is a new process as required by the Scottish National Audit Programme Governance Policy and we expect that the Orthopaedic Community will engage with it in the hope that it will improve patient care.

The SAP has an established fellowship programme. The incumbent is a trainee who is usually on time out of programme and studying for a Higher degree. The fellowship involves some clinical work at the GJNH (RMO level) and research at their chosen institute. It provides the trainee with a salary and adequate opportunity to pursue research. Further information can be obtained from the Committee, in particular the SAP member for the GJNH Mr Jon Clarke.

We remain a member of the International Society of Arthroplasty Registries. The Scottish Government continues to work to develop an implant registry and this will be a very valuable resource when it is operational. The SAP committee have been involved since the inception of the Knee Revision Consensus meetings and look forward to working further with colleagues in future meetings.

Mr Matthew Moran

Consultant Trauma & Orthopaedic Surgeon

Royal Infirmary of Edinburgh

Chairman

Scottish Arthroplasty Project

Introduction

The Scottish Arthroplasty Project Annual Report 2019 continues to present data relating to arthroplasty procedures including hip, knee, shoulder, elbow and ankle replacements. We hope that the data is more accurate than ever having provided surgeons with electronic access to their own data over the course of the few years, and a simple route to correct any obvious errors. High quality and accurate data is clearly very important to maintain standards and we thank the Orthopaedic community for their ongoing support and engagement with the Scottish Arthroplasty Project.

Scottish Arthroplasty Steering Committee 2018 – 2019

  • Clinical Mr Matthew Moran (Chairman)
  • Dr Karen Cranfield
  • Mr William MacLeod
  • Mr James Bidwell
  • Mr Ben Clift
  • Mr Ken Hay
  • Mr Martin Paton (Senior Info. Analyst)
  • Mr Martin O’Neill (Principal Info. Analyst)
  • Mr Stuart Baird (Service Manager)

Members who left in 2019

  • Mr Sandy Shirra (Lay member)
  • Mr Robert Frame (Lay member)
  • Mrs Kate James
  • Mr Martin Sarungi

Key highlights

Key Points - Scottish Arthroplasty Project Annual Report 2019

Scottish Arthroplasty Project outliers

Arthroplasty patients who died within 90 days

Percentage of 2018 arthroplasty patients with Hip mortality within 90 days
The review of the patients who died within 90 days has shown that there are no concerns regarding this indicator. Two of the patients had the procedure for palliative reasons only; one patient was high risk and fully consented with input from relevant other specialists prior to surgery. Only one patient was an unexpected death, and there was nothing within this patient’s care pathway that raised concern. In addition, one patient has been miscoded and therefore the number of deaths within 90 days should be 3. (Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde)
Percentage of 2018 arthroplasty patients with Knee mortality within 90 days

Arthroplasty patients with infection within 1 year

Percentage of 2017 arthroplasty patients with Hip infection within 1 year
Percentage of 2017 arthroplasty patients with Knee infection within 1 year

Arthroplasty patients with revision within 3 years

Percentage of 2018 arthroplasty patients with Hip revision within 3 years
The orthopaedic service is concerned about this outcome and has instituted a number of quality improvement measures to address performance in this area. A significant amount of work is ongoing this year to achieve the intended delivery of a dedicated elective orthopaedic unit at Hairmyers Hospital in the summer of 2020. This will improve separation of elective and trauma patients which is known to reduce prosthetic infection rates. This will be combined with continued investment in the ERAS team to improve early mobilisation and shorten length of stay which should also improve outcomes for our arthroplasty patients. (NHS Lanarkshire)
Percentage of 2018 arthroplasty patients with Knee revision within 3 years
Our high revision rate in this year was surgeon related. One surgeon using PSI for routine cases. Our own database picked this up and surgeon stopped from doing it. Only 2 specialist surgeons now use this technique on cases that cannot be done by conventional surgery and we have not had any further problem. Any change in technique needs to be discussed and agreed with the department before changes made. Its always good to have a thorough review of our practice so we can prevent early failures. With our new protocols of subspecialisation of our knee surgeons should prevent future problems. Our data from 2017 and 2017 looks very encouraging. We hope to publish our 5 year data on attunes later this year. NHS Fife now have 7 high volume knee surgeons doing routine knee replacements. (NHS Fife)
No comment (NHS Western Isles)

Number of low volume surgeons (10 or fewer) by hospital in 2017 and 2018

Independent (Private) Hospitals

Independent sector hospitals in Scotland are represented by the Independent Healthcare Provider Network (Scotland). Within this network, there are seven acute hospitals in Aberdeen, Ayr, Edinburgh, Glasgow and Stirling. The independent hospitals are fully supportive of the aims and objectives of the Scottish Arthroplasty Project (SAP) and have a representative on the steering committee. At present however the hospitals are prevented from submitting data directly to the Scottish Arthroplasty Project (SAP) and this is somewhat restrictive in enabling the hospitals to contribute fully to the workings of the project.

Activity undertaken in independent sector hospitals on behalf of Health Boards is fully recorded in SAP and this data is coded within Health Boards for inclusion in the report. However, the data for patients funded privately either through medical insurance or through self-funding is omitted as the methodology which would allow it to be included is not currently in place. The steering committee continue to explore ways of enabling the inclusion of this data.

Given the increasing activity in the independent sector and in the absence of a methodology for formal inclusion in the register, data is gathered separately by the independent hospitals for inclusion in the report. At present, the data gathered in the independent sector is limited to hip and knee arthroplasty procedures; these procedures making up the vast majority of arthroplasty activity in the independent sector. In future the sector will submit data for the SAP report which will also include ankle and elbow replacement activity.

Arthroplasty activity continues to increase in independent hospitals and in 2018 there were a total of 1,218 and 884 primary hip and knee procedures performed, in comparison with 1,142 and 861 respectively in 2017. Of this activity, those procedures funded privately by the individual patient either through medical insurance or self-funding continues to increase at 84% of the total number undertaken for 2018 compared to 75% in 2017. The remaining activity is funded through Health Board waiting list initiatives.

To provide assurance, all complication rates for activity is tracked through the individual hospital’s clinical governance mechanisms, and is not available within individual surgeon’s data in SAP. This data continues to demonstrate low complication rates across Scotland in the independent sector. Low volume activity consultants are also reviewed within the independent sector, although it is noted that it may be the case that the surgeon’s activity in the sector is low compared to their activity overall.

Moving forward, the independent sector remains fully committed to SAP and will continue to seek ways of working more closely with the project to both increase and improve the data available, ideally through direct access to the register to enter data at source.

K Hay, Steering Committee Member

More data

For more data please see our online report.

Contact

Martin O’Neill

Principal Information Analyst

martin.o’neill@nhs.net

0131 275 6244

Martin Paton

Senior Information Analyst

martin.paton1@nhs.net

0141 207 1867

Email: nss.isdarthroplasty@nhs.net