Orthopaedic Outcome Collection MDOR/Registries

Since EA Codman¹ introduced the end result concept, Orthopaedic surgeons have led the way measuring outcomes and setting standards. It is important that we produce evidence of our success to promote and support our practice locally and nationally. This also needs to include “Patient Reported Outcome Measures”. 

We regard it as essential that patients are followed up and data is collected both in terms of appropriate clinical measurements and what matters to the patients.

The routine recording and monitoring of adverse events (e.g. infection, dislocation, fixation failure, DVT and death) must be in place in all departments. Attendance records and meaningful discussions at regular departmental Mortality and Morbidity meetings are now included for our appraisal standards as part of national patient safety improvement programmes. 

National programmes such as the Confidential Enquiry into Patient Outcome and Death² and Confidential Reporting System for Surgery³ are integrated into our working life for good reason.

However, further detail beyond any basic adverse event data is necessary to describe and detail our success and support our continued practice. There are a multitude of specific scoring systems, of increasing complexity, currently in use.

A “PROM” is any measure of outcome reported by the patient. In general, a body region specific score, which has been validated, gives a reliable indicator of success.

If publication is considered, more detail will be required on top of that from the PROMs scores alone (range of movement, angle of correction, etc.). Again there are a multitude of well-tried systems available; however, their increasing complexity requires time and personel for data acquisition and management. Your association and specialist society will have a view as to the most appropriate scores to use for practice monitoring and for publication. Submitting data to some registries is mandated.

We operate on a wide variety of patients so, if we wish to compare our effectiveness and population against others, we also require a general, age appropriate, health measure. These will be insufficiently specific to detect differences between treatments but allow evidence of healthcare benefit from your treatment, for general use. These are often difficult to deliver as a routine unless intended for a specific research project.

Patients’ experience⁴ of healthcare delivery is increasingly important (Patient Reported Experience Measures). You are expected to have some measure of individual experience in outpatients as part of your GMC revalidation portfolio. However, we encourage a more general assessment of any hospital episode to try to identify common themes in your department.

In regard to registries, the orthopaedic profession has a justifiable reputation for being very forward thinking. The largest registry is the National Joint Registry (NJR) and was set up to collect information on all hip, knee, ankle, elbow and shoulder replacement operations in England, Wales and Northern Ireland. In Scotland the Scottish Arthroplasty Project is in place. In 2013, surgeon level outcomes data for hip and knee replacement were published for the first time as part of an NHS England initiative using NJR data, and is now standard.  Each consultant should be reviewing their data on an annual basis at least, as part of their appraisal. 

Expansion of this practice into other specialties is vital and should be welcomed by clinicians to support their practice.

There are a range of other registers and audits already established (including the National Hip Fracture Database (NHFD) and National Major Trauma Registry . The BOA is also aware that there is a strong desire among Specialist Societies to create further new registries, and is engaging in a project to support the development of these and encourage its members to contribute to them.

Surgeons should comply with the Data Protection Act⁵ and, if considering publication, any local ethics committee requirements to store and report on data. Permission for an ethics committee is not required for service evaluation as part of routine care.

Your management team have a duty to support your endeavours in regular quality initiatives and the routine gathering of a basic dataset is easier to implement and more meaningful than intermittent short term audits.

We recommend:

• A  comprehensive system to record adverse events (M&M meetings)- To include participation in CEPOD and CORESS
• Participation in national registries (e.g. NJR, NHFD)
• Participation in your specialty specific registry programme
• A measure of patient experience for both outpatient and in-patient episodes

We have to put our outcomes in the context of patient expectations.

References

^{1. Codman EA. The classic: registry of bone sarcoma: part I.--Twenty-five criteria for establishing the diagnosis of osteogenic sarcoma. part II.--Thirteen registered cases of "five year cures" analyzed according to these criteria. 1926. Clin Orthop Relat Res 2009;467(11):2771-82.}

^{2. National Confidential Enquiry into Patient Outcome and Death. Secondary National Confidential Enquiry into Patient Outcome and Death 2013. http://www.ncepod.org.uk}

^{3. Confidential Reporting System for Surgery. Secondary Confidential Reporting System for Surgery 2013. http://www.coress.org.uk}

^{4. de Silva D. Measuring patient experience. London: The Evidence Centre, The Health Foundation, 2013:1-50.}

^{5. Data Protection Act. London: UK Government, 2003.}