Scottish Arthroplasty Project

Mr. Gavin C.A. Wood
MBChB, FRCS,
Royal Infirmary Edinburgh

Mr. Colin Howie FRCS
Consultant Surgeon
Royal Infirmary Edinburgh

The Scottish Arthroplasty Project (SAP) was established in 1999 with the following aims.

  • To instigate change through continual feedback.
  • To set individual results in a local and national context.
  • To use outcomes which the public could identify with (death, dislocation, infection, DVT/PE and re-operation).

The SAP is an administrative dataset derived from the Scottish Morbidity Record (SMR01). Each individual in Scotland has a unique Community Health Index number (CHI) used in all patient episodes. All NHS hospitals in Scotland submit an SMR01 return for every patient episode. As well as the patient demographics, this record contains information about the dates of admission and discharge, surgeon, diagnosis, operation and up to five other co-morbid events relating to that admission. Any subsequent admission (or transfer) is similarly coded. These records are submitted to and linked by the Information and Statistics Division centrally (ISD) using the patient's unique identifier. The patient's journey and history can be tracked before and after the index procedure. Thus reporting co-morbidities, complication rates and ensuring patient confidentiality (all data is professionally encrypted).

The data is submitted by the local hospital and "owned" by the local hospital that has to undertake any corrections to the dataset and resubmit it to ISD. Quarterly listings are sent to consultants to verify and amend the data.

The data and the clinical content of the annual report are managed by the Scottish Arthroplasty Project Steering Committee, which is overseen by the Scottish Committee for Orthopaedics and Trauma (SCOT). SCOT is a committee of elected orthopaedic surgeons from each of the regions in Scotland, plus the clinical directors of each of the orthopaedic departments in Scotland (the chairman of which sits on the British Orthopaedic Association council). The SAP steering committee is made up of three orthopaedic nominees, one of whom must chair, a medical director, ISD members including a public health consultant (who is the "Caldicott Guardian" for data security) and two patient representatives. Representatives are elected for three years with an option to renew this term only once. The chair must be a practicing orthopaedic surgeon whose data appears in the report.

Consent is assumed, patients and surgeons are given the option to withdraw and none have done so to date. No patient identifiable data has been produced or reviewed. To respect data protection and inform change, only the originating surgeon (or the patient) can review patient data. Only one member of the ISD staff can identify an individual consultant (to resolve data issues). No other member of the group can access individual surgeon or patient data.

Converting Data to Information
Each Consultant receives a quarterly list of patients recorded as having surgery under their care.

An Annual Report is Produced
The results and new developments are presented at the annual SCOT meeting which over half the surgeons attend.

scottishfig7.jpg

The annual report includes all joint arthroplasties, more recently knee arthroscopy and disc surgery have been reviewed. Analysis includes length of stay, surgeon volume, deprivation category, age, sex, health board, diagnosis, laterality and bilateral procedures. National trends in the overall numbers and complications including subsequent revisions are produced and the data compared with other national registers.

Anaesthetic complications within 30 days are reported (MI, GI bleed and stroke within 30 days of surgery) at a regional level as anaesthetist-specific data is not yet available (Figure 7). Each surgeon receives an individual report plotted against a case mix adjusted (age, sex, social deprivation and diagnosis) mean such that individual's performances can be compared using Shewart charts (Figure 25). Outliers who are more than three "standard deviations" from the mean are highlighted.

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Converting Information to Knowledge
Consultants or the Chief Executive of a health board identified as outliers' are sent a letter from the SAP requesting information on reasons for the apparent anomaly and any action taken. This is done anonymously. Locally a clinical colleague signs off the response, thus converting the information into local knowledge.

The response is submitted to and reviewed anonymously by the steering committee. A simplified scoring system is used to avoid debate as to specifics of technique and management. This response is returned to the individual and the local colleague who confirmed the veracity of the report. The emphasis is on local review and responsibility, not attributing blame. The process of care is being assessed, not just the consultant. E.g. infection rates maybe due to laminar flow, antibiotic policy, CSSD etc.

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To date, the project has recorded reductions in death, dislocation and DVT rates (Figure 14). There has been a 20.5% increase in THR numbers since 1996 with a 28% reduction in total bed stays. The numbers of revisions has remained static. Individual consultants who had outlying levels of hip dislocation have come to lie within control limits. Consultants, even outliers, view the project as supportive, highlighting problems and providing feedback useful for appraisal and revalidation.

http://www.arthro.scot.nhs.uk/index.htm

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