Presidents Review of the Year John Timperley MB ChB FRCS (Ed) DPhil (Oxon)

Transcription

1 Presidents Review of the Year John Timperley MB ChB FRCS (Ed) DPhil (Oxon)

2 Mission for 2013/14 Improve quality of care to patients Protect the Profession Protect our Members

3 Transparency Data Revolution The Year s themes Non Arthroplasty Hip Register (NAHR) The future Umbrella with other orthopaedic Registers Commissioning Guidelines Payment By Results NICE Consultation on hip arthroplasty Responding to the Media

4 After Bristol: 2013 BHS motion on NJR The British Hip Society (BHS) supports transparency of outcomes and wishes to contribute to the preparation and interpretation of clinical outcome data. Relevant NJR data must be validated and specialist professional bodies, including the BHS, must be engaged in the analysis and reporting of NJR data. Publication of Inappropriate or misinterpreted data may distort the provision of clinical care and harm patients.

5 Result: BHS motion on NJR

6 BHS correspondence with Keogh and meetings with Bridgewater r.e. The Transparency Agenda The BHS believes it is essential to clearly deline the constitution of the group holding the mandate to make decisions concerning the Registry data released into the public domain. The Profession (BHS for hip data) must be involved in the interpretation of published data and setting the context in which it is presented.

7 A successful collaboration Commentary: Surgeons should not be ranked by their mortality rate as there is a risk that they will be wrongly criticised and patients misled. The mortality rate after hip and knee replacement surgery is inlluenced by many factors outside the control of the operating surgeon. Case- mix adjustment is a useful tool but as with any methodological approach it cannot account for all differences including those that may be due to random events.

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9 HQIP are emphasising to all stakeholders the importance of selecting additional outcome measures that are relevant to their particular speciality where possible, and of supporting the analyses with an appropriate narrative explaining what the data do and do not show and why. NHS England seem to to be firm in their belief that outcomes data, not process measures alone, are key to driving up the quality of clinical care and maintaining patients trust.

10 The Data Revolution It will change your practice in hip surgery

11 Data Sources Hospital Episode Statistics RightCare Atlases of variation National Registries Quality Observatories RCS Quality Dashboards Patient Reported Outcomes Measures (PROMS) Mandatory Quality Accounts Individual Trusts Private Healthcare Information Network (PHIN)

12 Data, data everywhere! Issues: Access and Interrogation Validity Context and Interpretation Ownership (Mandate)

13 Hospital Episode Sta.s.cs HES is a data warehouse containing details of all admissions, outpa9ent appointments and A&E a<endances at NHS hospitals processing over 125 million records each year. Standard aggrega9on tables are free and anonymous to access on HESonline. A monthly managed service and bespoke extract service is used by government and public bodies, private companies, manufacturers and the media.

14 HES to CES

15 NHS England is working closely with the Health and Social Care Information Centre (HSCIC) and other stakeholders to design a modern data service for the NHS known as "care.data".

16 Trust the Government/DoH? A major UK insurance society disclosed that it was able to obtain 13 years of hospital data covering 47 million patients in order to help companies reline their premiums.

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21 Individual Hospitals

22 SHA Quality Observatories: 2008: Quality Care for All

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29 The availability of data will now define the culture surrounding hip surgery Data to measure the problem Data to measure the procedures Data to measure performance Data to measure outcomes

30 The surgeon is now at risk - Unit Performance - Personal Performance

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33 Surgeon x Coming soon into Public Domain?

34 With respect to the NJR and orthopaedics, surgeon level reporting could be approached through: 1. An NJR Group 2. A professional Orthopaedic Group (rep BOA, Specialist Societies, NJR) 3. A Pan- Specialty Professional Group (e.g. FSSA)

35 The BHS needs to be pro- active in demining the datasets to be released: Engage in efforts to validate NJR data DeLine what (validated) metrics will improve patient care Formalise the mechanism by which the Professional Orthopaedic Group drives the publication Agenda each year. (Presently the Board of Specialist Societies but this is not the correct forum)

36 From now on a surgeon is at personal risk: Implants performing poorly on NJR Introduc9on of new implants Beyond Compliance Ini9a9ve New techniques (e.g. DAA)

37 2014 Report: - Requires PMIs to inform patients that they will be able to obtain quality information on consultants and hospitals from the website of the insuring organisation. - Information about hospitals and consultants (outcomes and quality) will be addressed through PHIN (Private Healthcare Information Network)

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39 We will require all private hospitals to collect and submit patient episode data for all patients treated at its facilities: (a) volumes of procedures undertaken; (b) the hospital and consultant level: (b) average lengths of stay; (c) infection rates, surgical and hospital-acquired; (d) readmission rates; (e) revision rates (where appropriate); (f) information on the frequency of adverse events, such as postoperative DVT and cardiac arrest (where appropriate); (g) relevant information from clinical registries and audits as appropriate and where available (h) for the ten highest-volume, or otherwise most relevant, procedures, a procedure specific measure of improvement in health outcome (i) a measure of patient feedback and/or satisfaction on the service provided.

40 Private hospital operators will be expected to provide data including: (a) GMC number of the consultant (b) NHS number of patient (c) Diagnostic coding (d) be fully comparable with that collected by the NHS to allow the performance measures to be reported for the whole of consultants practices, both NHS and private (to allow risk adjustment where appropriate) (e) Publication to be in stages but all the above information to be submitted by September All data will be made available to the public from April 2017 onwards (f) With suitable data security provisions, data will be provided in a raw format to all relevant interested parties, including the private hospital operators, consultants, insurers, the CQC, Dr Foster and HSCIC from April 2017 onwards.

41 We require consultants practising privately to submit information on their consultation fees and procedure fees to the information organisation by December 2016 Fees to be published on the website of the provider organisation alongside information on consultant performance.

42 The Profession needs a relationship with PHIN

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44 Your practical involvement in Data Revolution: Suggestions: Clinicians would be wise to check that the data being submitted in their name is complete in every institution they work e.g. Each Form, BMI, Consent Take an active interest in the systematic processes within your department to enter data Meet the Coders in your hospital Collect comprehensive data on your activity/outcomes: Registries Risks of not engaging: loss of BPT, institutional risk, reduced Trust income PERSONAL RISK

45 Existing: National Joint Register (NJR) Hip arthroplasty Knee arthroplasty UK Orthopaedic Registers Shoulder/elbow arthroplasty National Hip Fracture Database (NHFD) Trauma Audit and Research Network (TARN) Non Arthroplasty Hip Register (NAHR) British Spine Register (BASS) Knee ligament Register (BASK) Paediatric Register (BSCOS) Hand surgery (BSSH Audit Website) Foot and Ankle surgery index Trauma Register (OTS) In planning?knee osteotomy Register (BASK)?Soft tissue shoulder register?computer assisted surgery (CAOS)

46 The future for NAHR and orthopaedic Registries in UK It could become the normal culture that all orthopaedic procedures are automatically entered onto a Registry There must be collaboration between Registries They can be a vehicle for multi-centre RCTs The BOA can co-ordinate between Specialist Societies and Registries

47 Scoping Registry Umbrella Facilitates National Representation of Profession in strength EMPOWERMENT of the Profession Issues in common Consent/Caldicott issues Governance Policies (e.g.data access) Database structure and duplication of data Functionality Validation of data Interpretation and release of data Opportunities Strategic planning Develop initiatives to improve compliance Through CRGs, NICE, Revalidation, Integration with care.data initiative (upload to HSCIC) Collaboration with PHIN

48 Investment from NHS England January meeting between Bruce Keogh, Tim Briggs, myself and Mike Kimmons. Sir Bruce Keogh has committed 150k over two years to a project to scope the BOA registries work stream It is planned to have someone in BOA offices leading the project by springtime

49 Published November 2013

50 Available for download: BHS website Defines Best Practice Provides Metrics to Measure Performance

51 Assessment in Primary Care HISTORY Pain - site Function - compromising sports, occupation, daily activity EXAMINATION MOVEMENT GAIT INVESTIGATIONS: a plain A- P radiograph of the pelvis may be requested to conlirm diagnosis made after history and examination no further imaging (e.g. MRI or bone scan) is appropriate before referral.

52 Management- offer all people: Mild Symptoms Core treatments: offer verbal and written information about condition (OA guidance NICE 2013 offer information to achieve weight loss if people are overweight or obese (OA guidance NICE 2013), Advise to carry out local muscle strengthening and general aerobic exercise (OA guidance NICE 2013) use of shared decision making tools ( oral simple analgesia and anti- inllammatory medication assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid supervised and evidence based physical therapies after assessment by an appropriate HCPC registered practitioner

53 Management- offer all people: Moderate Symptoms add NSAIDs or stronger analgesics in very elderly patients and those assessed to be unsuitable for surgery consider referral for image guided intra- articular steroids - benelicial for between 3 weeks and 3 months Severe unresponsive Symptoms Refer

54 1. Refer to Intermediate or Secondary care: Refer when unresponsive to UP TO MAXIMUM OF 12 weeks of evidence based non- surgical treatments: Young adults (<40) with persistent hip pain interfering with work or leisure activities All adults with painful irritable and stiff hip interfering with sleep, activities of daily living, work or leisure Referral should be independent of the radiographic grade of arthritis. Refer patients before there is prolonged and established functional limitation and severe pain (NICE OA 2013). The current hip scoring tools are not appropriate for use in prioritisation or deciding on referral thresholds (NICE OA 2103, Dieppe et al., 2009; Judge et al., 2011, Coleman, McChesney, & Twaddle, 2005)

55 2. Refer to Intermediate or Secondary care: age, gender, smoking, obesity should not be barriers to referral Ensure that patients with signilicant co- morbidities [systemic or local] have appropriate investigations and treatment to optimise their condition before referral. Patients who are not suitable for surgery should be referred for a complex care package.

56 Hip Preserving operations Surgery for hip impingement may be considered after: Diagnosis of FAI conlirmed with imaging failure of non- operative management Femoral/pelvic osteotomy may be considered in: failure of non- operative management patients aged <50 years with persistent hip symptoms with abnormalities of femoral and/or acetabular anatomy

57 Total Hip Replacement Consider total hip replacement when: i. pain is inadequately controlled by medication ii. there is restriction of function iii. the quality of life is signilicantly compromised iv. there is joint space narrowing on radiograph Having established the need for surgical intervention the operation should be performed as early as possible (Hajat 2002).

58 Who to refer to? Young adult hip Operations should be carried out by surgeons with a declared specialist interest, and expertise, in young adult hip problems who should contribute data to the Non Arthroplasty Hip Register Degenerate hip in adult In general the outcome of surgery is superior in the hands of surgeons performing high volumes (>70 per year) but this is only true if well- performing implants are chosen

59 Follow up visits Routine follow up in General Practice is not advised. Patients > 75 years at primary THR with ODEP 10A rated implants need not be routinely reviewed after the post operative period. Patients <75 with ODEP 10 A rated implants should be followed up in the Lirst year, once at seven years and three yearly thereafter in asymptomatic patients. Novel or modilied implants have increased follow- up - usually annually for the Lirst Live years, two yearly to ten and three yearly thereafter (Beyond Compliance initiative). Telephone or web- based PROMS may be useful to monitor outcome.

60 Commissioners take home messages: Examination of the joint is essential for diagnosis Unless red Llag : A- P X- ray of pelvis only investigation necessary Refer if no improvement with up to 12 weeks of evidence based non- surgical treatment (NICE) Refer before there is established functional limitation and severe pain (NICE) Scoring tools are not suitable for prioritising or to decide on referral (NICE) There is data available to enable patient choice

61 Best Practice Tariff (BPT)

62 Hip Best Practice Tariff Proposal for PBT by Peter Kay (NCD in MSK) Lirst time ever (not just in the UK but internationally) that an outcome measure will be used to drive tariff price and incentivise improvement. (an example of excellent collaboration between BOA, BHS, BASK) Original Proposal: In order to get best practice tariff you have to: 1) Submit data to NJR 90% compliance 2) Submit data to PROMS 70% compliance 3) Not be an outlier in case adjusted improvement in Oxford hip or Knee scores (bottom 5-10%) 4) Not be an outlier in case adjusted improvement EQ5D (bottom 5-10%) Failure: 10% payments witheld: 1&2 No way back 3&4 Discussion with Commissioners

63 BHS issues/suggestions: Use of EQ5- D problematic For OHS: Use Dx. of OA rather than Case- mix adjust The exercise should be cost neutral When reported good outliers should have equal Press Meeting with Commissioners should be formalised with BOA/BHS/Professional representation Suggestions for money saved: Pay PAs for visiting clinical team inc. from high performing Trusts Fund specilic improvements to address local issues Reward top 5%

64 December 2013: New BPT for primary hip and knee replacement outcomes The aim of the BPT is to reduce the unexplained variation that exists between providers in terms of the outcomes of surgery as reported by patients. Payment of the BPT is conditional on criteria linked to data collected through Patient Reported Outcome Measures (PROMs) and the National Joint Registry (NJR)

65 The criteria for payment of the BPT are: the provider not having an average health gain signilicantly below the national average (3 standard deviations, 99.8% signilicance). Health gain will be measured by the condition- specilic Oxford hip after applying a casemix adjustment for primary joint replacement procedures only. and the provider adhering to the following data submission standards: a minimum PROMs participation rate of 50%; a minimum NJR compliance rate of 75%; and an NJR unknown consent rate below 25%. Where these criteria are not met, providers will receive a price 10% below the best practice price.

66 Proposed variation to BPT Commissioners must pay the full BPT if the provider can demonstrate that the following circumstances apply: 1. Recent improvements Outcomes have improved since data collected 2. Planned improvements Evidence of a credible improvement plan 3. Casemix complexity If a provider has a particularly complex casemix that is not yet appropriately taken into account in the casemix adjustment in PROMs.

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68 November Appraisal Committee s preliminary recommendations 1.1 Total hip replacement and resurfacing arthroplasty prostheses are recommended as treatment options for people with end- stage arthritis of the hip only if the prosthesis has a rate (or projected rate) of revision of less than 5% at 10 years. 1.2 If more than one type of prosthesis meeting the above criteria is suitable for a patient, the prosthesis with the lowest acquisition costs should be chosen.

69 Submission to NICE from the British Hip Society (Review of technology appraisal guidance 2 and 44) [ID540]: 1.1 It is not stated what is acceptable as a source for this evidence. NJR Data see next slide Talk to ODEP! Diagnosis/Case- mix? 1.2 This recommendation is too naïve to be workable, would not necessarily lead to the lowest overall cost of arthroplasty for an institution, may reduce quality of service and ultimately patient safety

70 Submission to NICE from the British Hip Society (Review of technology appraisal guidance 2 and 44) [ID540]: Recommending a 95% survival at 10 years may be too high and be shown to be unachievable as data capture in the NJR becomes more complete. To- date the quality of NJR data collected in key areas has never been validated and the British Hip Society is profoundly concerned that NJR data should be used to demine acceptable revision rates when the quality of the source data is simply not known.

71 (+ ODEP empowered)

72 Dear Laurel, Considering the fact that the NJR has now been running for 10 years at a current annual cost in excess of 1m, it is extraordinary that the Steering Committee has not commissioned work to test the quality of the data they are publishing. More than one member of the Steering Committee has postulated that the NJR may be missing between 30 and 50% of revision operations performed in England and Wales. The BHS fully supports openness and transparency in healthcare and has collaborated to publish consultant level outcomes. The reputations and livelihoods of clinicians are at risk from information released into the public domain using unvalidated NJR data. Please can you write to describe what measure are urgently being taken to validate important areas of NJR data? Kind Regards

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74 Data, data everywhere! BHS Theses: The transparency agenda is to be supported. The profession (and individuals) must be proac9ve to organise, collect and interpret quality outcome data We need a change in culture for data collec9on

75 The Bottom Line 1. Ensure (accurate) data is collected in your name 2. Monitor and act upon the results

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