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PROMs clinical case study: data informs clinical practice

Consultant Trauma and Orthopaedic Surgeon Mike Reed is a specialist in trauma, hip and knee arthritis including revision joint replacements, at the Northumbria NHS Healthcare Foundation Trust.

Mike Read Mike is one of several leads across the NHS who has used Patient Reported Outcomes Measures (PROMs) data to inform medical practice across their trust.

The Health & Social Care Information Centre (HSCIC) produces regular PROMs publications that assess patients' health before and after non-emergency treatment for knee and hip replacements, varicose veins and groin hernia. The publications and underlying data are used by trusts across the country to improve the quality of care.

PROMs data for 2009/10 and 2010/11 showed that Northumbria NHS Healthcare Foundation Trust was below the national average for health gains (the difference in PROMs score after treatment compared to before) related to hip and knee replacement surgery. To make improvements to clinical outcomes, they used PROMs data in a variety of ways to make changes in four key areas.

Changing the implant brand

An independent study linked PROMs data with the National Joint Registry (NJR). A clear correlation was found between PROMs scores and various surgical factors, including implant brand.

The study reported that one specific brand had a significantly higher health gain for knee and hip replacement surgery outcomes. Using this finding as a catalyst, in late-2011, Northumbria switched implant brands.

To assess whether the change had delivered improvements to patients, post-change analysis of PROMs data for Northumbria procedures showed that health gains had significantly improved.

Moving away from resurfacing patella during surgery

Another independent study linked PROMs data with NJR data to establish whether there was an early functional benefit to replacing the kneecap surface, otherwise known as resurfacing the patella.

The study reported that, of the 3,400 procedures who had received the implant the trust was now using, and where the patella was not resurfaced and left alone, there was a trend towards better surgical outcomes.

Consultants at the trust were more often than not using this approach anyway so this re-affirmed good working practice.

Circumpatellar electrocautery (diathermy) during surgery

A further independent study took a randomised trial to understand the efficacy of circumpatellar electrocautery, known as making a small burn around the surface of the kneecap during knee replacement surgery.

The study, which was based on the same implant that Northumbria had switched to, reported that those receiving circumpatellar electrocautery had better outcomes with regards to knee pain and function.

Consultants at the trust were more often than not using this approach anyway so this re-affirmed good working practice.

Preservation of infra-patella fat pad during surgery

A further independent study reported that the preservation of the infra-patella fat pad during total knee replacement is associated with improved patient outcomes.

Based on this finding Northumbria linked PROMs data with local data to report for each surgeon, the impact on PROMs scores of excising the fat pad during surgery.

The analysis showed that consultants who routinely preserved the fat pad had significantly better health gain for knee replacement surgery. As a result the majority of Northumbria surgeons now routinely preserve the fat pad.

The 2013/14 PROMs data, as released in May 2015, confirms that Northumbria NHS Foundation Trusts health related benefits for knee surgery is now significantly above the national average (above the 95% control limit).

In 2010/11 the health gain, as measured by the Oxford Knee Score, one of the measures used in PROMs, was 14.68 against a national average of 14.87. In 2013/14, the heal gain increased to 17.13 against a national average of 16.25.

Mike Reed says: "We have used PROMs data to transform the way we deliver knee and hip surgery across the trust.

"This means that patient outcomes have improved as a result of changing the way we operate or re-affirming that our processes and approaches to surgery of this nature are good. Ultimately, this increases the chances of patients being independent following major knee or hip surgery."

Benefits Management Consultant Mohammed Basser says: "This is just one of the case studies that we are doing to raise awareness of how HSCIC's health data can be used to bring benefits to patients.

"In this example, PROMs data has clearly informed clinical practice, which, in turn, has enabled more patients to recover quicker and better after knee replacement surgery. The data has been a catalyst to enabling change in implantation practice and also re-affirmed in a couple of areas that medical practice at the trust is following evidence-based practice."

Other trusts that have also used PROMs data to improve clinical practice include:

  • Barnsley Hospital NHS Foundation Trust replaced a home-based physiotherapy assessment with a hospital-based hip class
  • Derby Hospitals NHS Foundation Trust established a multidisciplinary team to review their knee surgery pathway and adapt their post-operative pain relief protocol
  • Harrogate and District NHS Foundation Trust used PROMs procedure level data to contact patients with worsened PROMs scores to establish key issues affecting their health
  • The Royal Orthopaedic Hospital NHS Foundation Trust linked PROMs data with local information systems, such as patient administration and theatre systems to understand care and treatment patterns where improvements were not reported

This PROMs clinical case study has been informed by the PROMS benefits case study, which describes in more detail how providers (e.g. Northumbria, Barnsley and Derby) and other stakeholders have used PROMs data to initiate local changes and subsequently deliver benefits.

HSCIC are interested to hear how our data are used for the benefit of patients. If you have used PROMs, or any other of our datasets, to improve care, we would like to hear from you. Please call 0300 303 5678 or email enquiries@nhsdigital.nhs.uk to let us know.

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