Noticeboard for surgeons

The question has been raised a number of times as to whether an SAS doctor or trainee could have their own registry report of the record of joint replacements they have performed. There appears, therefore, to be significant uncertainty about this in some quarters and so we would like to confirm that the ability to obtain data about their cases has been available to SAS doctors and trainees for many years. This facility differs in some respects between SAS doctors and trainees.
 
The NJR recognises that some SAS doctors, in particular ‘associate specialists’, have their own practice in joint replacement (and other areas) and that those surgeons conduct that practice with varying degrees of independence. Nevertheless, all patients admitted within the health service for such treatment are under the care of a named consultant. For this reason, since its inception, the NJR has always collected data about not only the lead surgeon but also the consultant-in-charge of the case.
 
The NJR believes that all surgeons should be able to benefit from the monitoring of their own practice, just as consultant surgeons are able to do. Therefore, all SAS and trainee surgeons performing joint replacement as a lead surgeon are able to access their NJR data online through the NJR Connect – Data Services platform and can obtain the appropriate username from the NJR Service desk. All surgeons have access to dynamic activity reports (updated daily/monthly, as appropriate to the report) and outlier analysis funnel plots (updated bi-annually). Data used to analyse outcomes for SAS and trainee surgeons include all procedures where they are the named lead surgeon.
 
In addition to the dynamic reports, SAS surgeons with sufficient eligible procedures in the latest financial year will also receive an annual Surgeon Level Report (SLR). Whilst trainee surgeons do not receive an SLR they can see all the relevant data and funnel plots where they are registered as the lead surgeon, and are able to take screenshots of the data for use in annual reviews.
 
In some circumstances we are aware that a case may be attributed to the incorrect consultant-in-charge but this should not affect the assessment of the lead surgeon (and therefore SAS surgeon) data. Where such incorrect attribution has occurred it is possible for the ‘consultant-in-charge’ (or indeed the ‘lead surgeon’) data to be corrected. It is preferable for this to happen as soon as the error has been identified and on a case-by-case basis. This applies whether the case incorrectly attributed is a primary case or a revision case. Changing the attribution in this way can be actioned by the relevant NJR compliance officer with the agreement of BOTH consultants. Where surgeons are requesting more than one or two such cases are ‘re-attributed’, referral to the NJR management team will generally be required, in order to ensure that no ‘gaming’ of the system is occurring.
 
Occasionally it has been noticed that surgeons reaching ‘outlier’ status (at alarm level for revision rate) may have then identified some of their revised cases where the primary operation has actually been performed by another surgeon (consultant OR SAS doctor). In this situation it would still be possible to correct the mistake, but it is more complicated and should require the agreement of the NJR management team as the surgeon’s whole practice would potentially need to be audited and ‘corrected’.  
 
The reason for this is that simply transferring some revised primary cases from one surgeon to another can cause distortion of the analysis of the ‘Standardised Revision Rate’ for both the surgeon transferring the case AND the surgeon accepting the case. There could have been significant numbers of cases erroneously placed under the wrong surgeon/consultant in these circumstances and it is essential that the relevant data point (ie consultant-in-charge and lead surgeon) is corrected for both the revised cases and the primary cases, so that the denominator as well as the numerator is correct for analysis.  This sort of problem seems particularly likely to affect associate specialists and other more senior SAS doctors as they have many more cases which may be attributed to different consultants-in-charge.
 
Some surgeons have expressed the view that only lead surgeon data are relevant and only those data should be used for analysis. It is the view of the NJR, the BOA and the specialist societies (expressed through the NJR Medical Advisory Committee) that a consultant surgeon who has patients who are operated on by other surgeons, such as trainees and SAS doctors, should be able to audit those cases and monitor the outcomes just as they can for cases performed by themselves. It therefore remains the case that NJR analysis will be performed both on consultant-in-charge and on lead surgeon data.
 
It is essential that all SAS doctors and trainees performing joint replacement ensure that every primary and revision case that they do is correctly attributed, both in consultant-in-charge and lead surgeon data, on the NJR MDS form submitted at the end of each case. In that way they will be able to receive accurate and reliable reports on their practice.
 
We occasionally receive requests to designate an SAS doctor as a ‘consultant-in-charge for the purpose of NJR analysis.  We do not believe this is appropriate.  Full analysis of the SAS doctor’s own cases should be possible using the SLR with the lead surgeon data.  If the surgeon is actually acting as a consultant then we should wish to know why they have not been appointed as a consultant.  If they are still operating ‘under licence’ on other consultants’ cases, then it is in the interests of the SAS doctor, the consultants and the patients, that the doctors concerned are all able to see and monitor the outcomes of their cases. We believe that is best achieved by continuing to register cases under both the consultant-in-charge and the lead surgeon and to analyse these separately.