Hip replacements: do public or private providers do better?BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m362 (Published 19 February 2020) Cite this as: BMJ 2020;368:m362
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When considering hospital-level outcomes after total hip replacement, it must be remembered that serious post-operative complications (e.g. dislocation, periprosthetic fracture, infection, DVT) often present to an NHS hospital, via the Emergency Department, even if the primary procedure was undertaken in the private sector (1). Overall patient-reported outcome measures are largely skewed by this group of patients, and outcome metrics reported by private hospitals (e.g. readmission rates, infection rates, patient satisfaction) may be misleading if they fail to take this into account (2). Whilst the analysis presented shows overall parity between NHS and non-NHS hospitals in EQ-5D scores, without understanding the flow of patients between the two sectors the cost-effectiveness (or indeed clinical effectiveness) of outsourcing care to the private sector cannot be determined.
The author makes the important point that there are very few outliers on the funnel plot after adjustment for case-mix as described by NHS England (3). No case-mix adjustment model is perfect, but the British Orthopaedic Association recommend the collection of Body Mass Index and the American Society of Anaesthesiologists (ASA) grade as potentially important further variables to add to the model (2). This might reduce the number of funnel plot outliers still further. Multilevel modelling is a useful alternative approach to measuring variation between hospitals that helps determine the relative importance of patient-, surgeon-, and hospital-level factors.
Dr Adam M Ali, Professor Alex Bottle
(1) Partridge T, Jameson S, Baker P, Deehan D, Mason J, Reed MR. Ten-Year Trends in Medical Complications Following 540,623 Primary Total Hip Replacements from a National Database. J Bone Joint Surg Am. 2018;100(5):360-367
(2) BOA position statement regarding PHIN’s implementation of CMA’s hospital and consultant performance information remedy. British Orthopaedic Association, 20th April 2017. Available at: https://www.boa.ac.uk/uploads/assets/e3d7524c-31fd-4927-b9a0884a4c845b41...
(3) Patient Reported Outcome Measures (PROMs) in England. Update to reporting and case-mix adjusting hip and knee procedure data. Available at: https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/12...
Competing interests: No competing interests