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cover of episode Medical Registries explained: The hidden key to healthier nation an interview with Prof Richard Page.

Medical Registries explained: The hidden key to healthier nation an interview with Prof Richard Page.

2025/3/27
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@Richard Page : 我认为医疗登记册最重要的作用是提高医疗质量和改善患者预后。通过收集和分析大量患者数据,我们可以识别出哪些手术或治疗方法效果最好,哪些患者群体风险最高,从而改进医疗实践,减少不必要的手术或并发症。澳大利亚国家关节置换登记册就是一个很好的例子,它在过去20多年里为澳大利亚医疗系统节省了数十亿美元,并显著改善了患者预后。 此外,医疗登记册还能帮助我们及早发现潜在问题,例如特定植入物或手术技术的缺陷。这使得我们可以及时采取措施,避免更多患者遭受不必要的痛苦和风险。 未来,随着人工智能和可穿戴设备技术的进步,医疗登记册将发挥更大的作用。我们可以利用这些技术对患者进行实时监测,预测潜在风险,并为患者提供个性化的治疗方案。 总的来说,医疗登记册是改善医疗质量和患者预后的重要工具,它不仅能帮助我们改进现有的医疗实践,还能为未来的医疗创新提供宝贵的数据支持。 @Gavin Nyman : 作为一名骨科医生,我亲眼目睹了医疗登记册对医疗实践的积极影响。通过登记册收集的数据,我们可以更深入地了解不同手术方法的有效性和安全性,从而做出更明智的临床决策,改善患者预后。 此外,医疗登记册的数据分析结果可以为医疗政策的制定提供依据,帮助我们优化医疗资源的配置,提高医疗服务的整体效率。 我相信,随着技术的不断发展,医疗登记册将在未来发挥越来越重要的作用,为我们提供更全面、更精准的医疗数据,帮助我们更好地为患者服务。

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Medical registries, like the Australian Orthopaedic Association National Joint Replacement Registry, track surgical outcomes to improve patient care. They collect large amounts of national population data to improve patient outcomes by providing the right information for making the right decisions.
  • Medical registries improve patient outcomes by tracking surgical results and identifying trends.
  • The primary purpose is quality improvement through data collection and analysis.
  • Registries are cost-effective, saving healthcare systems significant amounts of money.

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I'd like to let you know that Aussie Med Ed is supported by HealthShare. HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of HealthShare products are Better Consult, a pre-consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, as well as HealthShare's Specialist Referrals Directory, a specialist in allied health directory helping GPs find the right specialist.

Medical registries are transforming healthcare, silently working behind the scenes to track outcomes, refine surgical technique and influence policy. In orthopaedics, registries like the Australian Orthopaedic Association National Joint Replacement Registry have revolutionised the way we understand joint replacement surgeries, improving patient care by identifying trends, successes and areas for improvement. But how exactly do these registries work?

What impact have they had on orthopaedic practice, particularly in shoulder and joint arthroplasty? And with the rise of AI and predictive analytics, what does the future hold for these powerful databases?

Today we're diving deep into the world of registries, exploring their origins, challenges and future developments. Whether you're a medical student, general practitioner or surgeon, this episode will shed light on a critical yet often overlooked aspect of modern medicine. G'day and welcome to Aussie Med Ed, the Aussie-style medical podcast. Our pragmatic and relaxed medical podcast designed for medical students and general practitioners, where we explore relevant and practical medical topics with expert specialists.

Hosted by myself, Gavin Nyman, an orthopedic surgeon, this podcast provides insightful discussions to a hunch of clinical knowledge without unnecessary jargon.

I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders both past, present and emerging and recognising their ongoing connection to land, waters and culture. This podcast is for educational purposes only and does not constitute medical advice. Always refer to clinical guidelines and consult a qualified healthcare professional before making medical decisions. Joining me is Professor Richard Page, a Rwanda orthopaedic shoulder and upper limb surgeon based in Geelong, Victoria.

He's in the Foundation Chair of Orthopaedics at Deakin University, Director of Orthopaedic Research at Bar 1 Health, and has played a significant role in the AOA National Joint Replacement Registry. With over 150 publications, leadership roles in multiple orthopaedic research organisations, and extensive contributions to arthroplasty registries, Richard is the perfect guide to help us navigate this fascinating topic.

Well, it gives me great pleasure to introduce Professor Richard Page. Richard is a professor in orthopaedics at Deakin University. He's the president of the Shoulder and Elbow Society, and his accolades would need another podcast just to read out. But most importantly, I would describe him as one of the most pleasant and humble surgeons I know.

Richard, it's great to have you on board on Aussie MedEd and talk about this really important topic. Thanks, Gavin. It's a pleasure to be here. Very generous introduction. Appreciate it. No worries. I'd say that you do have a bit of interest in this, in that you're actually the past Deputy Director to the Australian Orthopaedic Association National Joint Replacement Registry, and also on the committee for the Victorian Orthopaedic Trauma Outcome Registry. So you've got a bit of experience in registries and talking about the importance of them.

Perhaps we could start off by asking, what's the primary purpose of a registry for? Yeah, good question. I guess that's the fundamental question is the why, because there's a lot of time, effort, energy involved in running registries, and there's obviously costs as well. But the principal point of having them and why we have developed them and thrown our weight into them in Australia is for quality improvement. So at the end of the day, to collect large amounts

national population data sets that can improve patient outcomes. That's what it's all about, giving people that need the information the right information to make the right decisions to do the right thing by patients. And that covers a whole range of registries. Obviously our area of interest is orthopaedics, in particular joint replacements, but there's a range of registries both in Australia and globally that have been shown to be very effective and in fact very cost-effective.

Perhaps you could actually go through the type of registries that you're aware of. Yeah, okay. Maybe if I start with the ones that I'm involved in and I can talk, because obviously that's an outline of what I know best, but I'm certainly aware of others, as you've suggested. So the big one for us is Orthopaedic Surgeons National in Australia, and Jewel in the Crown, as it's often referred to, is the National Joint Replacement Registry. And that's been running for over 25 years now and has had a major impact on

both our practice as surgeons and our measured outcomes in terms of revision rates. So that's probably the big one. There are a number of other registries. You alluded to the trauma outcome registry, which is a sentinel registry looking at orthopedic trauma outcomes in Victoria. And there's been some smaller regional ones. We've got a regional joint replacement registry in Geelong, which has also been running for over 25 years now.

It collects similar but some different data. So these are all complementary. They're not competing. They sit well together because they have slightly different flavours or look, in some instances, different attributes. And then we've got an even smaller but soft tissue registry that looks at the outcomes of my and your Gavin area of interest around the shoulder and upper limb. It looks at particular things like rotator cuff injuries

problems, shoulder instability, other painful shoulder conditions like frozen shoulders. No one registry can do everything and different registries have a slightly different favour. So that's probably the orthopedic ones that are well known to me and us but then there's the really other important ones

Things are like other device registries in the country that have picked up problematic things like breast implants, cancer registries, both soft tissue and musculoskeletal, and they're really important, particularly when you're looking at rare and uncommon events where no one surgeon or no one centre may have enough data to be able to provide sensible interpretation of outcomes. So these are the sort of things that we see, and then there's respiratory ones, there's

renal disease ones, there's urology ones, there's general surgical ones. So they've grown hugely. And this mirrors really what's happening globally. So Australia is not the only country that's doing it. It's all around the world. Yeah, look, it is. And obviously you need to have good infrastructure for them to work. You need to have some support.

For data collection, ideally government, local or national government support because there is a cost in running these. It has actually, it's a bit of a classic line now, it's not can we afford to run a registry, but if you look at our national joint replacement registry and significant savings over 20 years, the question is can you afford not to?

Because it's in the order of about $1.2 billion that have been saved from the Australian health budget by reducing outlier surgery or reducing revision surgery. So it's got benefits for both the surgeon, the patient, and the government who are funding the implants. Are they the main benefits at all? Obviously, there's a range of other flow of benefits. The patient benefit's huge, and then there's the social benefit.

But there are, shall we say, academic and collaboration benefits. And this is good for growing both expertise, also for building relationships, sharing information across different domains. If you look at our national registry, that's led to a range of collaborations with the Nordic countries, which are great.

Sweden, for example, had some of the earliest registries and they've got a very well-structured registry ethos. America, other European countries, Great Britain, the National Registry, New Zealand. New Zealand were early adopters of a National Joint Registry. So there's...

Interpersonal collaboration is academic collaboration. And what that does is, and you've got to remember that registries are not static. They evolve and change over time. That sharing of information refines the processes, improves the analysis, gives us better understanding of both the strengths but also the weaknesses of registries, where the gaps might be. So it has improved how registries operate and also made them more efficient. And so they actually help contribute to improving patient outcome overall as well?

Yeah, they do. And again, if you stick to the joint replacement registries, then, and particularly our national registry, both through the action of collecting data, it's a well-known phenomena that once you start measuring something,

particularly in medicine, you automatically start improving its outcomes because people become more aware of what they're doing and they start using that information to measure and test and refine their practice. So that's a part of the process of how it happens. By the

promoting the findings. So clearly it's not just the collective data. That's not the end point. It's what you do with it, what we think of as this audit cycle. You collect data, you measure, you then have to report feedback findings or changes and then try and improve.

And by that circle of providing information, firstly to surgeons where we have a better understanding of what's going well and perhaps what's not going well or having such a good outcome. And at the end of the day, it's about choosing

reducing either unnecessary or revision surgery for patients and reducing patient morbidity, improving the quality of care. How do you think they influence the practice apart from the surgeons being aware of their actual outcomes? What other ways can help influence practice? Yeah, first of all, as we get information, huge amounts of information, in fact,

about both types of surgeries and how they're performing for different diagnoses around arthritic conditions and our domain around shoulder conditions. So what's working well, what the risks are, who the at-risk patients might be. Obviously,

Of great interest is whether we can modify any of those factors, whether it's either the technical side of surgery or more, particularly in patient selection, whether certain things do better in certain patient cohorts than others. And really importantly is what we call early signal detection. So early detection of when there might be a problem

with a particular operation or a particular implant. So without this early monitoring and this early measurement and then early assessment of the data, it can take five or 10 years before you realise that a particular component or particular type of operation is not doing so well. So this is a way of

having some early feedback about and signals about something that might require closer monitoring. I presume it's also helped by the fact you're pooling all the numbers together. Absolutely. It's a sheer weight of numbers. You or I can only do so much in a week, a month, and a year, and we may not be doing enough to actually uncover an area of our own practice or an area of a particular prosthesis, a particular implant that's actually not going so well. It's got

complications, particularly for newer implants. And just by measuring that, we are also able to determine which implants and grade them according to how well they've performed and what their risk of revision is over time, whether that be one to two years, five to 10 years. Now we're getting into 10 and 15 and 15 and 20 year data sets for the

shall we say, the more classic style implants that have been around that long. Clearly not all implants that we're using have been around that long. And that's one of the, shall we say, weaknesses, that there is things that come and go. But that early detection of or early information about how they're going gives us either the confidence to keep going or makes us have a closer look. And sometimes we just have to earmark and say, we need to have a closer look at this next year when we've got more numbers. As you said, there's a numbers there.

So obviously you've mentioned the importance of having numbers, but what challenges are there in maintaining a registry and actually setting up a registry? I mean, it's not for the faint heart to start up. You have to have funding. You have to be able to pay for the staff because it is, even with current digital data collection, there's still staff members, statisticians, data managers who need to make sure the data is accurate. We still input some of our data, in fact, a lot of our data manually.

because it works. Because one of the challenges is, particularly in a country like Australia, we're like six different countries and two different territories. Each jurisdiction has its IT infrastructure, uses different software. So getting those to talk to each other is very difficult. Having said that, in Australia, because we're an island essentially,

particularly in orthopaedics, it's very difficult for a patient to have their first operation here and to have a subsequent operation elsewhere. Now, I wouldn't say it never happens, but it rarely happens. So if people are having meager follow-up surgery, they generally have it at home or in Australia. And because of the way the funding system works, it makes it much easier and more attractive for them. Therefore, we know what the denominator is.

So if somebody has a revision operation, we're able to detect that. But going to the challenges, that requires a mechanism to tap in and detect that's happened because that clearly could happen across states. And that's a bit like sometimes happening in a different neighbouring country. But you have to have mechanisms, therefore, to data check and to do data linkage to check if this patient that we've identified has had this operation and that

Hello, they went to another state two or three years later, they've had it operated on again. So you've got to have a mechanism to be able to link the data sets and check that on a regular basis. The other strengths we have are that you can do data linkages with different data sets like

the pharmaceutical prescribing so you can look at what their disease patterns are. I wouldn't say these things are straightforward, they're quite complicated, but they can be done, about what other operations they've had or what other medical treatment they have through the MBS schedule. It's done in a way in the background they identify, the privacy is preserved, but you're able to link certain patient identifiers so you know a bit more about those patients. The weakness or the limitation is that you can't

say things about outcomes or patient profiles or treatments that you're not measuring. So they're what we call the confounders. You have confounders, which are known. Otherwise, things we know about patients, like we collect data about their age, their BMI, for example, their general health status, which is their ASA. So that gives us some indication of how well or not they are. But we can't, for example, necessarily know if they've had

surgery or other treatment on that joint or that particular body part before the registry started. So there's stuff that's happened in the background, the unknown confounders that we can't adjust for. But on the whole, what we know in Australia, with the Australian registry, we know with a high level of accuracy because their data integrity is high. In other words, their data accuracy is high.

And the pickup rate is essentially 99 plus percent. There's very little data we miss out. So we've got great confidence in the things that we can interpret from our data set. And that gives us a huge strength. There's only a few other countries in the world that are able to do that with a high level of accuracy. I'd like to let you know that Aussie MedEd is sponsored by AVAD, Medical Legal Indemnity Insurance.

They tell me they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever-changing regulatory environment. They have a specialist medical indemnity team located here in Australia and have access to medical legal experts 24-7 in emergencies.

And this is all done on the background of de-identified data. So for the person listening as a layperson, there's no way that we know who that person is or where they live or anything. We just know the scores they've been given. We can make some assumptions about their health and their body mass index and things like that. Privacy protection is of paramount importance and it's to have the confidence in that data being accurate but at the same time not...

No one individual can be identified. No one surgeon can be identified. And this has got an overarching protection as a quality and national quality assurance activity, which has got approval under the federal or parliament. In fact, it's in that by parliament and under the jurisdiction of the federal minister for health. Those features are protected. And so...

Somebody could come in and say, oh, they're dark, but they can't have it. Perhaps you can go through the history of the Australian Orthopaedic National Joint and Placement Registry and the people that are involved in that. Yeah, look, the great thing about the registry, the great strength, it was set up by surgeons, by the Australian Orthopaedic Association, and some very, I shouldn't say forefathers, but they're mostly still around, but who had great insight and a great vision specifically

to what could happen. And this was whilst observing what had already been started in other companies, as I said, particularly Sweden was the first one, the first registry that really got known. The Swedish HIPAA registry got known in this space. So obviously there was a period of looking at how they did it and then trying to work out how that would work in our system. Clearly no two cultures and health systems are quite the same, so you have to be able to adapt it for that.

But there was a group of people who got together and started setting this up. And one of the early people involved was David Davidson, and then it was led for a long time by Stephen Graves. And there were other well-known surgeons, highly respected surgeons involved in it.

Richard De Sida was the next person in, and he'd been involved for a very long time from Melbourne. I won't list everybody, but there's a range of people. And there's been both a maturity in the registry. It's certainly bigger now. We've got something in the order of 2.2. We'll be soon getting up to 2.5 million joints in the registry. So it's a huge data set, and there's a lot of data management involved. And clearly the management of that has got more complex.

So that's the sort of history of how it started. And when it started, it was very basic. It really was just measuring what was done, what was used, what the diagnosis was, and then almost figuring out the outcome later. But they were able to do that by matching surgical activity across each of the individual states.

If you go to our area of practice, Gavin, there were a couple of us, a few of us, I was one of the pesky young surgeons who knew Stephen and two or three meetings I kept on saying to him, because first of all, it was hip and knee. I'm going to add shoulders to this. Shoulders are...

It's going to be important. We should be able to. It's not very common. I don't know if there would be enough data, et cetera, et cetera. So it was a bit of resistance. And also it required some additional funding. So what some of us were doing was taking the data collection sheets for knee replacements and I was just crossing it out and writing shoulder and putting all the shoulder data on it.

which they didn't know what to do because the database wasn't set up for that. But to the team's credit, they didn't throw them out. They just kept them all in a pile. And there was a few of your colleagues in South Australia that were doing the same. We'd talk at meetings and sort of the word spread. It was just like...

Just keep doing it. They'll get it. They'll get that they were interested in this as shoulder surgeons. And anyway, it grew. Long story short, I started doing that in about 2004. In fact, the first joint entry was 14th of April 2004. But that grew, and eventually it was like, you know what, there's something in this. Because there wasn't really much idea of how much shoulder replacement had been done. But in that first year that there was approval that we included it, it wasn't all the states either. We couldn't include all states at the same time.

because you have to get approval from both the hospitals, the government, ethics committees to do it in every individual hospital. So you can imagine that's very time-consuming. So very quickly, it became apparent that we were doing a measurable amount of shoulder replacements, nowhere near as much as hip and knee, but that grew. And in the first incomplete year, it was about 1,000, and then soon it was clearly close to 2,000. Last year, we did nearly...

12,000 shoulder replacements nationally. So it has been the fastest growing joint replacement, not just in Australia but globally, which probably says two things. It was under service, and this happened to knee replacements if you go back a couple of decades. It was a large unmet need. And also I think in the general practice setting, so going to GP colleagues who tune into this, Gavin,

There was this kind of perception that the shoulders, they're no good. They don't work. If you go back 20 years before, that was the same ethos around knee replacements. Now, yes, there are some that are not brilliant, but it's certainly the shoulders perform in terms of revision rates and improvement in patient function and pain relief.

Very close to hips. The satisfaction level for patients, if you look at their shoulder registry data, is very close to hips. So I think from an efficacy point of view and a patient satisfaction point of view, it rates very highly.

And our GP colleagues are really starting to see that now because they see patients. There's a lot more shoulders being done. So anyway, that's a bit of the history and a bit of the now we're up to. How has the data evolved over those years too? It's an interesting question. When I first started as a young surgeon, I had this idea that you have this

like for most researchers, those of you have this really well-defined set of data that you're going to collect, and it's quite rigid and you can't change it. You don't want to muck it up and you need to be able to compare what you're doing now to later, so it's got to be the same.

Certainly when we started, that's what it was like. But registries are like a slowly evolving organism in that it has changed a lot over time because you realise like some of the implants, for example, that we were using are no longer available or have been shown not to do so well or have been improved on. So they're different in their chain. So clearly that's data that you're not going to collect anymore because it's not happening. It's not being done. Similarly, you realise that there are

additional data points, additional features around either the operation or the patient that have changed. And a good example is the introduction of some new technology. And you don't want to miss that. We want to be able to evaluate and measure that. So you've got to work out a way to effectively capture that

activity, whether it's use of navigation, digital technology, robotic-assisted surgery. We want to be able to measure that so we can capture those patients, those operations where it's done, and measure the outcomes.

So that's an example of how it's expanded. I can't quantify for you off the top of my head what volume it is, but it almost feels like a doubling, I would say that, even in that shoulder domain. And there are moves to add more data, to have more granular laser data. We're collecting information about...

bony abnormalities of your bony wear that's very different from the hip and knee. We're collecting information about the rotator cuff. Similarly, we collect technology information. Some of that is less used in the shoulder than it is elsewhere. So probably the big one in Australia, which, you know, to be fair, was being collected in New Zealand and to a couple of the offshore registers like England and Scandinavia, is PROM, so Patient Reported Outcomes.

So, again, that adds a significant level of complexity about both the collection and the storage of the data. That gives you a lot more information. And what we've grown to appreciate is it is not possible to collect that data off everybody. But in actual fact, you don't need it off everybody. You just need it off a liable, reproducible sample that represents, it's got the same sort of spread of patient features as the whole data set. And that gives us...

huge insights into, as I mentioned before, this is where the satisfaction comes in. You ask patients, patient expectations before or after surgery, has that been met?

But we also look at functional things, pain scores. That's international. In our local registry, we've got a bit more flexibility, so we're able to collect a few other features about the comorbidities, about the other diseases and treatments, and also things like anxiety and depression scales because we know that influences outcomes in a range of areas of medicine, but also particularly surgery, and it also influences pain experience, for example.

What we do is that's a whole different podcast because, you know, that's where the science, that's where the exciting bit is, to work out other things that we can modify that will help the patients do better. That's a different topic. I won't say we're there yet, but I think that's emerging is where we're going to have great interest in the future.

On that point, do you think AI will actually have some influence in helping you work that out? Yeah, certainly we think about Spectrum AI, looking for data trends that are not apparent because there is now so much data that it's really hard to even write code for the statisticians to analyze it. They can do that, but only on the attributes that they select to do it, if that makes sense.

Whereas if you use digital machine learning, it can look for trends or associations that we may miss. And there's work being done on that. Again, a lot of this sort of new technological approaches to data management or using data also needs to be validated. So you've got to say, how do we validate those findings in the real world much or not just the spurious statistical anomaly? The limitation is you can only analyse what you're measuring. You can't

Although it's tempting, you can't extrapolate that to things that you're not measuring. But there's some imputational things that you can do, for example, about

knowing about their patient's ASA and their BMI, for example, it gives you some idea about the health status in the patients. Often it will come up with a proposal, which is actually a hypothesis, which is another research project, if that makes sense. I think we've got huge potential. For example, we know that BMI is an association with

variability in outcomes. It's not linear and it's not across all operations diseases, but there are some areas where it makes a big difference in outcomes and or a lot of these patients start lower, but they don't get as much improvement. They're certainly more at risk of complications. And I think looking at some of the attributes we do and looking at, say, some of the other complications, which don't always result in a revision or even a reoperation, it's going to be really important for us as well.

and that will involve linking to other data sets. But I think using some of these technologies will help us refine and look at things more specific for clinical trials. For example, the unsolved question or the unsolved problem we still have is infection. We're going to look at attributes that...

can diagnose it earlier or look at alternative treatment pathways, look at high-risk patients. Are there things that we can do in high-risk patients? Same with BMI. Are there things that we should do at the front end before they have surgery? Now, in the past, that was very difficult. This is slightly getting off registries, but the registry data, I think, is going to be crucial in helping us answer these. For example, there's a

whole classes of new drugs that GP colleagues would know and be using almost daily practice. Is preconditioning patients who are at high risk with those to reduce their weight, is that going to help outcomes? Is it going to reduce risks, complications? Or is it actually...

putting them at risk of something else. So these are questions that could have studies embedded in the registry or in registries to make them more easy to answer. And that's another relatively new tool. It's been around for probably nearly 10 years now, but using registries to doing research because they have all the linkages and the data structure that

to do research. And one of the studies I'm doing, and there's several other studies that hip and knee colleagues are doing, are embedded in the registry using the registry infrastructure to run randomized controlled trials. That's a very powerful way to do it because you can actually do it a lot more efficiently. I wouldn't say it's simple, but it has some advantages of doing it

compared to a traditional way. It's more cost-effective and you can use some of those data linkages and you've got the population that's already sitting within the registry as a comparator in some of these to see how people outside the study, how did they go? Is this representative? So that's a now but a growing era of potential use.

How is our registry perceived overseas then? What do people think of the Australian setup? Yeah, it's world class. In fact, it's hard to, shall we say, measure competitively, but it's got a very strong reputation as being world leading. And the other registrars I've mentioned are also up there. But in terms of

the structure, the design, particularly the data completeness, and that reflects, again, the intent, the people who set it up, and how it's grown, and the people who are now involved in it. They're doing a great job, and they've got bringing new ideas. Like any organisation or like a business or a company, you need fresh ideas coming into it, and as they come in and new people come in, the whole process

the whole thing can evolve and have a fresh face and new ideas looking at new questions. Can the registries be joined together to make an even larger data group for which you can do research on as well? I've been lucky to be involved in a number of projects like that with the Cusper Minto Group in the US with the Nordic Registry doing one at the moment with the Danish Registry. And the answer is yes. And because we each look at slightly different things, you can...

should we say combine the two parts, sometimes it's greater than the sum of one plus one. There are some challenges because sometimes we measure or define things slightly differently. So that requires some funded work. So it's not just as simple as,

getting two big spreadsheets and joining them together and analysing it. Because we have different time points, for example, or we might do different operations. And certainly, as you know, there may be different prostheses available for 1 plus 7, but that's also a strength. So you can compare different things.

So yes, quite apart from the collaboration and having international connections and developing and growing a network of people who've become really good friends is hugely satisfying. So that's one of the, shall we say, the human elements of working in this space is that collaboration builds friendships and networks. That's great on a personal level, but it grows really good, strong ideas and improves the way we do something. And you may see a way that they've approached a problem

and how they've dealt with it in terms of managing some data or a new device is coming, how they've defined it, that can influence how you do it locally here. And it's a big project. In fact, we just had what's called the ISAR meeting in New Zealand a few weeks ago, which is an annual international meeting. So there's a great learning experience. And unlike most of the professional meetings that we go to as surgeons or clinicians, we

This is actually a meeting with surgeons, but there's statisticians, there's data managers, regulators, all these people in the same room. Fascinating. It's one of the best meetings I go to, and very little is discussed around actually how you do an operation. There's not a lot of that. So it's high class, high tech, very smart people in the room, but...

Out of that, you have the opportunity to network and grow, develop new projects or ideas, but also come home with ideas about they're doing this, maybe we should look at that or think about how that might work here. What about looking at other medical specialties and their registries? Does that have any influence on our arthroplasty registry? That's a good question. Certainly, I won't say specialties per se,

But collaborating and working with the different people, and some of it, for example, allied health physios and things like that who are academics, you see a different approach to what to measure or things that may be important or of interest. You see it for a different lens, and that's hugely important to inform how you do something and also asking questions.

questions about things that you and I might just assume, oh, it's always been like that. Or somebody turns around and says, why? I actually don't know. So actually shining a light on things that we should be looking at or questions that should be asked or studies we should do. So that's really important. I find it fascinating even when you're operating, you've got up shoulders with peers, but also people from that cross-pollination for different specialties. There's heaps of stuff that I use in my practice that

that I would never have been aware of if I didn't bump into a vascular surgeon or a plastic surgeon or even a hip or knee surgeon. There's a whole range of new medications that come out that you and I wouldn't be aware of if we weren't talking and interfacing with somebody else. Because all of us tend to...

narrow down our lane a bit and stick in our lane because we're comfortable, but it's also what we're good at and what we're interested in. But you need to be aware of what's going on around you. And that's the same with registry. So you need to then collaboration, communication, knowing what's going on around you, what new ways of doing things is crucial, particularly with some of the statistical analyses that are being done, which again, I'm not going to do, but...

know what some of the new potentials are. So I think really helpful. If we look at National Joint Replacement Registry, it's all online, it's for public knowledge. There's the data that's there. There's also a layperson's 30-page document too for people to look at, which gives a few summaries. But if we look at this registry perhaps on the shoulder joint replacements, perhaps you can tell me what sort of information that's been useful that's come out of the registry on that scenario. Yeah, right. This is an area where I've got a huge amount of personal information

satisfaction and pride in having been involved in it for that long. I think the lay summary is really important because just digesting the reports is not for the faint-hearted. It took me a couple of years to get my head around what a lot of this data meant and how to interpret it. But to answer your question about informational things we've learnt, right at the top, that total shoulder replacements...

in Australia function better for osteoarthritis than partial shoulder replacements. Okay, and that's been reflected in our practice. You can see that the revision rates are hugely low and partial shoulder replacements are seldom used now. You never say never because there are some situations where through deformity or because it's a revision, I think you might need to

That's a big one. Another positive, which was, I think, for some of us when we saw this trend, this huge uplift year in, year out in the early days of reverse shoulder replacements. I don't mind saying there were a few of us, I was one of them, a bit nervous about this because we'd seen some of the complications overseas and particularly because it was early in the Australian experience. Reality is, and this is where the data is really helpful, it's demonstrated that, in fact, it actually performs well.

really well on the whole. There's a few exceptions and that's where you've got to get into brain. You can't just look at the high level and say, yeah, okay, it performs well, but what about in this group and what about in that group? Young men, perhaps not. And by younger men under 50, they're at risk compared to some of the other options.

But I think that that's a reassuring one. They better than expected. And also that implant or that design has evolved a lot over time. So we're able to track it and track incremental improvements and how that's changed. So that's been a winner. Looking at it, it's I guess not a surprise because it was shown the same in the hip, but we looked at the different types of polyethylene. So the different bearing surfaces showed if it's modern treated, highly cross-linked, so more stable polyethylene that's stable against oxidation.

that has a huge downward push on revision rates compared to non-crossing. In fact, this is where it's important for surgeons looking at the register or anybody else of interest, GPs, you can't just look at the front page and see the first graph that shows, because that one makes reverses look like it's much lower revision rate than that. But that's because it's comparing all comas and all types and everything. Then you go down and look at, okay, what about if we use

best in class or the best polyethylene and stuff, then it has a big difference of results. So these have been some of the big things, certainly in the early days, that have had an impact. Things like technology, that's been shown to have a positive impact. Knee, in some settings, we don't have that data yet in shows, but we will in due course. It's a time and numbers game. Where do you think the actual registry data is going to go down the track? How do you think it's going to progress for the future? Yeah.

Yeah, good question. It already is being used to inform surgeons, but maybe using that in a bit more specific one-on-one way to, again, improve not just surgeons, but improve practice. And I have to say, if you look at the revision rates in Australia, they have come down significantly, not quite year on year out, but over that whole journey. And I'm really pleased and

proud of the Australian surgical scene is that our colleagues have taken the data on board really proactively as a collective group. And you could look at our revision rates of shoulder surgery have come down like three and a half percent, nearly getting close to four percent, which doesn't sound huge, but that's hundreds and hundreds of patients who've avoided surgery.

revision operation just because surgeons are able to have access to that data because we access it. So that's a big one. Going to the future, the use of improved digital technology to make more efficient data capture, more efficient dashboarding through you and I to look at what's happening closer to real time, us compared to the rest of the population, and more efficient capture of other data

attributes around the patients their things like their activity level linking it to their smart device like that so that this talks to talks to the registry and you have an app on there and it talks to the patient's profile so we could really measure things that we can only dream of now

The technology is actually there to do that, but to do it on a large scale or a national scale, that's, you can imagine the amount of computing and data capture, how you need, but that's the sort of stuff that's there linking it to, shall we say, other disease profiles. So we have better understanding of things that we need to improve periopathy. So it

it helping us as surgeons to manage and prepare our patients for surgery. Equally, that information being available for patients earlier so they can actually plug their parameters in and it can give them a perioperative plan until it really gives them a better idea about the expectation. So there is potential for some of this now, but aspirationally to do that, if we take that from theory to practice, I think that's the mid-term.

mid-term. I think in the longer term, this will actually tell both the patient and the surgeon, this patient's gone off a bit, their walking distance has changed, or they're no longer able to reach the top shelf. Perhaps they should come in for a review. So it will help interface in a proactive way

and help guide review. So Richard, really interesting hearing about these registries. Perhaps you could just summarise what the registry is made to use for, how it's done, and the main advantage that you see for it. So in a contemporary setting, all the registries that I'm involved in, both in trauma, soft tissue, but particularly the joint replacement registries, are about taking the information around a patient, their operation or their journey, and their outcome,

and tracking that. And whilst it can't necessarily tell you or predict what's going to happen for an individual patient, if you add thousands of patients, it can give a pretty good idea, a pretty good picture about how things are going and how things are going to likely go for a whole group of patients. And that knowledge and that is very powerful in improving the quality of care.

and improving the outcome, not just for those patients, but for the future patients, which may be that patient's next operation, or maybe a relative or a grandchild. This has been going long enough now, for 25 years, that we're getting into whole generations of people, whole household of people. So in a way, collecting and allowing the collection of that data on a big social level is paying forward to the next generation.

As has we all benefited from all the data about medicines being collected that's improved and refined treatment to reduce complications, identify things that are risky or don't work or have got complications, eliminating those and identifying

focusing on the treatments, the operations, the procedures, the implants that are doing well reliably and doing very well, in fact. So that's what a registry is all about. It's about, and that's what our National Joint Placement Registry is all about, it's about providing data to improve the quality of the outcomes for our patients. And that's the core business. The great thing about, Gavin, about our registry is it was set up by surgeons for surgeons and their patients.

And it's still run that way and it's still owned that way. So it's independent and it can give independent outcomes on actually what's happening and how we can best treat our patients with what we've got. So we can give the best outcome for our patients...

because we then get the best reward for us, which is the excitement of seeing a patient do well for a long time. Yeah, it certainly sounds like it's the same for you, but certainly the thing that puts the biggest smile on my face is seeing your patients happy. Well, thank you very much, Richard, for coming on Aussie Med Ed. It's been great to hear your perspective on these arthroplasties and other registries and your involvement in them. It's a really important topic and certainly the data is out there for public access for people.

I really appreciate your time this evening. Thank you. Thanks, Gavin. It's been a pleasure and an honour to be able to join you on this. All the best. Thank you. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways to treat all medical conditions. It's just general advice and may vary depending upon the region in which you are practising or being treated. The information may not be appropriate for your situation or health condition and you should always seek the advice from your health professionals in the area in which you live.

Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organisations such as Lifeline in Australia. Thanks again for listening to the podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.

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