1. Session 3: Can the Best Practice Tariff and price benchmarking lead to better care? Elaine Young Director of Operations National Joint Registry & Peter Howard Orthopaedic surgeon member, NJR Steering Committee and Chairman, NJR Surgeon Outlier Sub-committee

2. About us The National Joint Registry for England, Wales and Northern Ireland Largest arthroplasty register in the world Hold more than 1.75 million records covering hip, knee, ankle, elbow and shoulder joint replacements Monitor the performance of implants, hospitals and surgeons Collaborating nationally (MHRA, CQC, Monitor) Collaborating internationally – a growing agenda (FDA, EU, international orthopaedic societies)

3. Best Practice Tariff (BPT)

4. New BPT For hip and knee replacement surgery in England Started April 2014 NJR data reported at hospital-level quarterly, on NHS-funded procedures in England Two NJR measures contribute – Compliance – Patient consent National PROMs data also forms part of the tariff requirements

5. BPT leading to better care? Through use of the tariff we hope to see improved: Data completeness – allowing a full picture of activity and performance to be reported Data quality – improving the active consent process to ensure we have patient details to monitor outcomes i.e. linking primary and revision operations together to calculate revision rates Best practice and engagement – organisations given financial incentive for their participation in national audit

6. BPT – learning so far Though it is early days for the NJR: Intention to increase the levels of compliance and patient consent required to drive up standard practice In 2015/16, the requirements for compliance will increase Impact - large number of trusts have already contacted the NJR to enter historical data

7. Price benchmarking

8. Background to price benchmarking Quality, Innovation, Productivity and Prevention (QIPP) Collaboration with the QIPP team at the DH Price benchmarking is one initiative that forms part of the QIPP programme to support clinical teams and NHS organisations to improve the quality of care they deliver while making efficiency savings

9. Background to price benchmarking Overview Initial pilot covering five hospitals, moving to 30 additional organisations across England and Wales Award winning initiative for benchmarking, Best Practice Institute 2013 Following this success, the pilot is now rolling out nationally as a free of charge NJR service – Trusts also have the option to buy enhanced reporting services, dependent on their requirements

10. Price benchmarking Objectives Provide local and national insight into the relative cost effectiveness of joint replacement surgery by individual prosthesis To enable providers to develop action plans around exploitation of this data to improve cost effectiveness of joint replacement surgery

11. Relating price to care Lower Cost Better Outcome Higher Cost Better Outcome Higher Cost Lower Outcome Lower Cost Lower Outcome At the heart of the pilot, was the intent to examine patient outcomes, not just cost.

12. What we set out to look at Measure price of implants Measure outcome (multi-faceted) Visualise this data to attempt to understand relationships between cost and outcome by implant Recognise that ‘comparisons’ need to be cautioned relative to volume and case-mix

13. What data? NJR Patient Reported Outcome HES/SUS Local Prosthesis Price Prosthesis Revision Outcome Hospital Volume of activity at hospital Patient Age and Sex demographic 12 month PROM Pre-operative score 6 month Health gain (PROM) Length of Stay Local Prosthesis Price

14. Implant costs data analysis 35 Trusts/units 5 largest manufacturers Annual spend on implants

15. DistributorCount of Priced ComponentsTotal Price Biomet9,992£4,511,333 DePuy34,273£13,681,324 Smith & Nephew5,125£2,225,748 Stryker17,854£5,999,144 Zimmer6,537£2,708,850 Other125£30,286 TOTAL73,906£29,156,685 Findings: total spend and usage

16. Findings £29m annual spend in hip and knee implants across the 35 organisations with the 5 suppliers included in the pilot Average hip implant cost - £1,368 – averages range from £800 - £2150 Average knee implant cost - £1,395 – average range from £1000 - £1950

17. Findings If all 35 trusts purchased these components paying at most the AVERAGE price, the annual saving across the trusts would be £1.98m at the BEST price the annual saving would be £7.76m

18. Findings Link between volume purchased and cost paid is weak In many cases, prices paid not directly related to volume even to same company In any trust there is a wide variation in the average cost of implants between surgeons – Driven by usage of different implants/manufacturers

19. Trusts Trust Max implant cost Trust Min implant cost Trust Average implant cost No or primary procedures undertaken Variation in Implant Cost – Primary Knees

20. Trusts Procedure Device Costs by Trust - HIPS

21. Findings – Hip Stem Brand Pricing by Trust

22. Findings Wide variation in the average cost of implants between surgeons Wide variation in implant usage within single trusts

23. What did participants say Clinical Can I see my detailed data? Which procedure cost x and why? I wasn’t aware that component x cost more than component y! Can we link with clinical outcomes data / ODEP ratings for products? Procurement Who is paying £x for product y! I have alerted supplier x to the data and asked them to explain. Can we model the cost implications if we migrate to supplier x? Management Why do we pay more for product x? Who is consultant x?

24. What is happening now in Trusts Each Trust has now been invited to submit data to the scheme and receive an individual pricing report

25. How can this contribute to better care? Managing device costs ensures best use of finite healthcare resources Supports trusts and surgical teams in using data to evidence device choice Supports trusts in developing implant usage protocols Enhances evidence-based discipline around implant choice

26. Future study options Correlation with other variables – PROMS – Revision rates – Length of stay – Readmission

27. Thank you Mr Peter Howard Orthopaedic surgeon NJR Steering Committee Elaine Young Director of operations, National Joint Registry