Which English Hospital is Best at Hips?

Prof Nancy Devlin Prof Nancy Devlin


Earlier this month, the first set of data on post operative patient reported outcomes (PROMs) was published by the Department of Health (DH). For the first time, this has provided a patient-based assessment of changes in patients’ health related quality of life following hip replacement.  The data also cover surgery on knees, varicose veins and groin hernias.

Between April 2009 and April 2010, over 14,000 hip patients from over 200 English NHS and private hospitals completed PROMs questionnaires both before and after surgery.  Data collection is continuing and will soon build up to be one if the world’s largest sets of PROMs information.  While the Department emphasise that the figures are ‘experimental’ -- released to encourage comment, debate and suggestions for improvement -- the initial headline figures are fascinating.

So, which hospital is best at hips?

We have looked at the EQ-5D, which provides a patient’s rating of their own health on five key questions.  This is then summarised as an overall index score and adjusted to take account of differences in each Trust’s case mix.  It turns out that Whipps Cross Hospital manages to produce the largest increase in patient reported health, though when case mix is taken into account the overall winner is Mid Essex Hospital Services NHS Trust.  The difference between the best and worst performers is large -– a 49% improvement versus 31% -- although the numbers of patients aren’t yet big enough for us to identify statistically significant differences.   Further details of other hospitals are available here.

Just to be clear how important these data are, they don’t measure patients’ experience of their care or their satisfaction with it; rather they measure outcomes in terms of patients’ own assessments of pain, mobility, mental state and ability to function normally.  They offer evidence about health outcomes at a level of detail never before seen in the NHS, which fits well with the Transparency in Outcomes framework outlined in the recent White Paper.

As well as comparing how much hospitals improve health, what else is gained from measuring PROMs?

Putting PROMs and hospital cost data together gives another dimension of comparison.  By linking outcomes and costs, we can begin to look at how cost effective hospitals are in improving their patients’ health.  Using a simple model, we have estimated how much, on average, it costs hospitals to generate one quality adjusted life year (QALY) by carrying out hip operations.

Like the PROMs data, our results are also ‘experimental’: it’s possible to use more sophisticated methods for measuring hospital efficiency, and research is underway to apply those methods to PROMs data.  However, even a simple analysis is revealing.  Together with Prof David Parkin, Chief Economist, South East Coast SHA, we have analysed the hips PROMs data and it suggests that hip operations are very cost effective -- around £1,000 per QALY gained.  Compare that to NICE’s threshold range of £20,000 to £30,000.  But cost effectiveness seems to vary considerably between hospitals and the differences appear to be statistically significant.  And further, these seem to be driven as much by differences in costs as variations in outcomes.

All of this raises important questions for the NHS as it tackles its productivity challenge.  How can some hospitals achieve better outcomes for the same cost?  Could high cost hospitals reduce costs without affecting outcomes?  The initial PROMs data suggest that there is much to be learned from hospitals that achieve good outcomes in an efficient way.

Related Links: Getting the most out of PROMs

Prof John Appleby, Chief Economist, The King’s Fund

Prof Nancy Devlin, Director of Research, Office of Health Economics

Posted in EQ-5D and PROMs, Health Care Systems, Health Technology Assessment | Tagged News releases