Less Fuss, Greater Value
the CJRR gets an upgrade

Dennis Jeanes
Manager, Communications & Advocacy
Canadian Orthopaedic Association

In a recent COA membership survey about the Canadian Joint Replacement Registry (CJRR), nearly 38% of respondents who perform hip and knee arthroplasties indicated that they never submit data. That may be fewer than the 42% who said they always submit arthroplasty data, but not by much. And it's certainly a far cry from the ideal of every surgeon reporting every arthroplasty.

These contradictory results are more or less in keeping with surgeon-participation rates measured at the Canadian Institute for Health Information (CIHI). "So far, we've got 68% of orthopaedic surgeons submitting data to the CJRR," says Brent Diverty, director of CIHI's Continuing and Specialized Care Information Services, who is overseeing a concerted effort at the Institute to boost surgeon participation in the CJRR. "We'd like it to be 100% or close to it. So we're committed to enhancing the registry - specifically to increasing the value of our information products and decreasing the burden of submitting data."

If all goes according to plan, says Diverty, as of March 2010 the CJRR will begin offering "organizational-level comparative-indicator reports that allow hospitals to compare themselves with others in terms of types of patients, types of procedures used on those patients, revision rates, utilization of in-house rehabilitation, and so on. This is something that we've done in other domains, and it's worked well and been of great value to hospitals in terms of supporting enhanced patient care." He also plans to supplement the CJRR with information from CIHI's acute care database, which houses the discharge abstract database (DAD).

"I think CIHI is headed in the right direction by concentrating on making the CJRR increasingly relevant to individual surgeons and hospitals," says Dr. Eric Bohm, co-chair of the CJRR's advisory committee. "Once you start providing these stakeholders with more useful kinds of information, you will engage them more fully in the project. I'm quite optimistic this will happen."

While the new information products are almost ready for launch, the other half of the strategy calls for reducing the burden of submitting data. "We're all pretty much agreed, I think, that the main barriers to data collection are the CJRR form and the consent issue," says Bohm. Indeed, when members were asked in the COA survey if they supported a simplified CJRR form - one that could be completed and submitted electronically (by nursing or office staff, for example) and that no longer required a patient's signed consent - nearly 90% of respondents endorsed the concept.

Diverty feels they've taken a giant step toward streamlining the process with their new web-based application, developed in-house, that will allow surgeons or hospital staff to submit their cases on-line. If hospitals already collect CJRR data electronically, CIHI has also developed a set of specifications that would allow administrators to send data as batch files. Paper submissions will continue to be supported by increased human resources dedicated to hand-capturing the information. "Even if they submit all their cases on paper, we really hope that all participating surgeons will register with the web application," he says. "That way they can still use its report-generating side to have access to surgeon-specific reports containing all submitted CJRR cases, regardless of method, in real-time."

As to the delicate issue of signed consent from the patient, there may be changes in the offing. In the years since strict privacy legislation was imposed on the maintenance of personal health information, CIHI's unique mandate within that regulatory framework has been increasingly recognized in a number of jurisdictions - notably Ontario, where, says Diverty, the Information and Privacy Commissioner "has designated CIHI as a 'prescribed entity.' That allows CIHI to hold and use personal health information without consent for the purposes of helping manage Canada's health care system. We're currently updating our CJRR Privacy Impact Assessment (PIA), including reviewing the need for patient consent on a jurisdiction-by-jurisdiction basis to see if it is, in fact, required for CJRR data submission to CIHI. We hope to have this clarified over the next several months. But in the end, the need for consent is a jurisdiction's decision, not ours."

In the meantime, Eric Bohm has tasked the CJRR with an analytical project that will test its ability to integrate data from DAD/HMDB: "If we catch the primary joint with the CJRR form, we're now able to depend on the hospital discharge abstract database to capture the revision." The pilot study will compare the rates of infection and revision between knee implants that were cemented with or without antibiotics. "Is it beneficial to use antibiotics in bone cement when doing a total knee? We don't really know. I think some very straightforward clinical questions could be answered - in fact, we may be able to look at revision rates for specific implants - especially if a lot more of us submitted our data. We've put a lot of effort into getting this thing up and running, and the focus now is making it relevant to surgeons and hospitals. I cannot think of a good reason not to participate in the CJRR."

For those surgeons still resisting the allure of the new and enhanced CJRR, consider the following: "One of the more common comments that I hear from members," says COA President Cy Frank, "is that we're losing ground compared to other countries that have national registries. If you look at Sweden, which has a long-established and well-run registry, they have a significantly lower revision rate than we do: 6% compared to our 18%. Is there a direct correlation between registries and revisions? Perhaps. Perhaps not. But clearly, there are patient-safety issues that arise that we need to learn about sooner than later."

What's more, Frank notes, surgeons in those carousel countries that require hospitals to submit data to national registries, such as England and New Zealand, "have come to appreciate the benefits of seeing their own data, plus the compiled data."

Finally, he says, let's not forget the uncertain economic times: "Since elective surgery tends to take the brunt of cost-cutting measures, a national registry would likely give us hard data to show hospital and ministry officials that cutting elective surgeries is not cost-effective."