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

• Dr Gavin Nimon • Season 5 • Episode 70

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The silent revolution happening in healthcare often goes unnoticed by patients, but medical registries have fundamentally transformed how medicine is practiced—particularly in orthopaedic surgery.Join Dr Gavin Nimon ( Host and Orthopaedic Surgeon ) as he interviews Professor Richard Page and they pull back the curtain on these powerful databases that track surgical outcomes across entire populations.

As the former Deputy Director of the Australian Orthopaedic Association National Joint Replacement Registry, Professor Page reveals how these systems have saved approximately $1.2 billion in healthcare costs while dramatically improving patient outcomes. The Australian registry, considered world-class, has tracked over 2.2 million joint replacements with extraordinary detail and accuracy exceeding 99%.

What began with passionate surgeons manually recording data has evolved into sophisticated systems that provide early warning signals when implants underperform. Professor Page shares the fascinating story of how shoulder replacements were integrated into the national registry—initially by surgeons who simply crossed out "knee" on data collection forms and wrote "shoulder" instead. This persistence paid off, with shoulder replacements growing from approximately 1,000 annually to nearly 12,000, making it the fastest-growing joint replacement procedure in Australia.

The registry has revealed crucial insights: total shoulder replacements outperform partial replacements for osteoarthritis, and reverse shoulder replacements have proven remarkably successful despite initial skepticism. These findings directly influence surgical decisions and have reduced revision rates by nearly 4%, sparing hundreds of patients from additional operations.

Looking forward, Professor Page describes an exciting future where registries integrate with AI, smartphone technology, and wearables to provide real-time monitoring of patient function. These powerful databases are evolving from quality assurance tools into platforms for innovative research, international collaboration, and personalized medicine.

Explore this fascinating conversation to understand how systematic data collection is quietly revolutionizing healthcare delivery and improving lives. What other medical advances might be hiding in plain sight within these vast repositories of patient data?

Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.


Aussie Med Ed is sponsored by Avant  Medical Indemnity: They state that 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.


Dr Gavin Nimon:

Medical registries are transforming health care, 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. Good day and welcome to Aussie MedEd. The Aussie style Medical podcast a 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 Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your 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 recognizing 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 renowned orthopaedic shoulder and upper limb surgeon based in Geelong, Victoria. He's the Foundation Chair of Orthopaedics at Deakin University, Director of Orthopaedic Research at Barwon Health, and has played a significant role in the AOA National Joint Replacement Registry. With over 150 publications, leadership roles in multiple orthopaedic research organizations 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's 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 Med Ed and talk about this really important topic.

Prof Richard Page:

Thanks, Gavin. It's a pleasure to be here and very generous introduction. Appreciate it.

Dr Gavin Nimon:

No worries. I would say that you do have a bit of interest in this, in that you are actually the past deputy director to the Australian Orthopedic Association National Joint Replacement Registry, and also on the committee for the Victorian Orthopedic 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

Prof Richard Page:

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 cost as well. But the principle 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 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 orthopedics, 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.

Dr Gavin Nimon:

Perhaps you could actually go through the type of registries that you are aware of,? Prof Richard Page: Yeah. Okay. Let's, maybe if I start with the ones that I'm involved in and I can talk,'cause 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 as orthopedic surgeons nationally in Australia and jewel in the crown as it's often referred to as 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 complimentary. They're not competing. They sit well together 'cause they have slightly different flavors 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 in my and your Gavin area of interest around the shoulder and upper limb. Looks at particular things like rotator cuff problems, shoulder instability, other painful shoulder conditions like frozen shoulder. No one registry can do everything. And different registries have a slightly different favor. 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, musculoskeletal, and they're really important, particularly when you're looking at rare and uncommon events where no one surgeon or no one center 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 have grown hugely. And this mirrors really what's happening globally so Australia's not the only country that's doing it. It's all around the world.

Prof Richard Page:

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 is it's, it's not can we afford to run a registry? But if you look at our national joint replacement registry and the significant savings over 20 years, the question is, can you afford not to? cause 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.

Dr Gavin Nimon:

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? Prof Richard Page: Obviously there, 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, but 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, 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 in New Zealand, New Zealand , we're early adopters of a national joint registry. So there's interpersonal collaboration, there's academic collaboration. And what that does is, and you've gotta remember that registries are not steady. 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 has improved how registries operate and also made them more efficient? And so they actually help contribute to improving patient outcome overall as well.

Prof Richard Page:

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 'cause 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 the part of the process of how it happens by the promoting the findings. And it, so that's, it's not just clearly, it's not just a collective data, that's not the end point. It's what you do with it. This what we think of as this audit cycle. You collect data, you measure, you then have to report and feedback, fi findings or changes and then try and improve. And it 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 reducing either unnecessary or revision surgery for patients and re reducing patient morbidity, improving the quality of care.

Dr Gavin Nimon:

How do you think they influence the practice? Apart from the the surgeons being aware of their actual outcomes what other ways can help influence practice?

Prof Richard Page:

Yeah. First of all, as we get information or huge amounts of information, in fact about both types of surgeries that, that and how they're performing for different diagnoses around, arthritic conditions and in 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 me measurement and then early assessment of the data, it could take five or 10 years , before you realize that a particular component or a 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, that might require close monitoring

Dr Gavin Nimon:

And I presume it's also helped by the fact that your pooling all the numbers together

Prof Richard Page:

absolutely it's a sheer weight of numbers. You or I can only do so much in a, 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, 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 close look at this next year when we've got more numbers. As you said, as the numbers game,

Dr Gavin Nimon:

So obviously you've mentioned the importance of having numbers. For what challenges are there in maintaining a registry and actually setting up a registry?

Prof Richard Page:

I mean, it's not for faint hearted to start up. You have to have funding. You have to be able to pay for the staff.'cause it is even with current digital data collection, there's still staff members, statisticians, data managers who need to make sure the data's accurate we still input some of our data, in fact, a lot of our data manually. Because it works.'cause 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 own IT infrastructure uses different software. So getting those to talk to each other is very difficult. Having said that, in Australia,'cause we're an island essentially particularly in orthopedics, 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 knee 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 are able to detect that. But going to the challenges, that requires a mechanism to tap in and detect that's happened.'cause , that clearly could happen across states and that's a bit like sometimes happening in a different neighboring 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 hello, they've. Gone to another state, two or three years later, they've had it operated on again. So you've gotta 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 de-identified, so 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 there what we call the confounders and 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're, but we can't, for example necessarily know if they've had certain, 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 industry, we know with a high level of accuracy'cause our data the 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 see. 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

Dr Gavin Nimon:

and this is all done on the background of de-identified data. So for the person listening. As a lay person, there's no way that we know who that person is or where they live or anything. We just know the sort of scores they've been given. We can make some assumptions about their health and their , body mass index and things like that.

Prof Richard Page:

And privacy protection, paramount importance. And it's to have the, so shall we say, the confidence in that data being accurate, but at the same time, no one individual can be identified., no one surgeon could be identified. And this is 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 enacted by Parliament and under the jurisdiction of the Federal Minister for Health. Those features are protected. And so, somebody could come in and say, I want that data, but they can't have it.

Dr Gavin Nimon:

Perhaps you can go through the history of the Australian Orthopedic National Joint Replacement Registry and the people that are involved in

Prof Richard Page:

yeah. Look, it's, it the great thing about the registry, the great strength, it was set up by surgeons, by the Australian Orthopedic Association and some very, shall I say the forefathers, but they're mostly still around, but with who had great insight and a great vision to what could happen. And this was whilst observing what had already been started in other countries, as I said, particularly Sweden, was that really the first one, the first registry really got known, the Swedish Hip 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 with David Davidson. And then it was led for a long time by Stephen Graves. And there were, other well-known surgeons, highly respected surgeon involved in it. Richard De Steiger was the next person in, and he'd been involved for a very long time from Melbourne. Won't list everybody, but there, there's an range of people and there's been a both a maturity in the registry. It's certainly bigger now. We've got about something in the order of 2.2 or it'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. I clearly, the management of that has got more complex. So the, that's the sort of history of how it's started and it, 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 as if 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 Steven. And at two or three meetings I kept on saying to him, we've gotta add, because it was, first of all, it was hip and knee. Gotta add shoulders to this, shoulders are a big joint, there's gonna be important, we should be. It's yeah, yeah, it's not very common. I dunno, there would be enough data, et cetera, et cetera. So it was a bit of resistance. And also there we 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 that out and writing shoulder and putting all the shoulder data on it, which they didn't know what to do.'cause 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 were doing the same. And we'd talk at meetings and sort the word spread. It was just like. Look just keep doing it. They'll have to, they'll get it, they'll get that. We're interested in this as shoulder surgeons. And anyway, it grew. Long story short, that was, 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.'cause there wasn't really much idea of how much shoulder replacements were 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 and 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 replacement surgery, nowhere near as much as hip and knee, but that grew. And in the first incomplete year was about a thousand. And then soon it was, clearly close to 2000. 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, that it was under serviced and this happened to knee replacements if you go back a couple of decades, there 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, 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 certainly with 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 the shoulder registry data, is not, 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.'cause I 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.

Dr Gavin Nimon:

And how has the data evolved over those years too? You

Prof Richard Page:

It is an interesting question when I first started as a young surgeon, I, had this idea that you have this, like for most research or studies you do, you have this really well defined set of data that you're gonna collect. And it's quite rigid and you can't change it because you don't want to muck it up. And you, needs to be able to compare what you're doing to later. So it's gotta 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.'cause you realize like some of the implants, for example, that we were using are no longer available, have been shown not to do so well or have been improved on. So they're different. They changed. So clearly that's data that you're not gonna collect anymore.'cause it's not happening, it's not being done Similarly you realize that there are additional data points, additional features around the, either the operation or the patient that have changed. And a good example is the advent or the introduction of some new technology. And, you don't want to miss that. You, we want to be able to evaluate and measure that. So you've gotta work out a way to effectively capture that. Activity, whether it's use of navigation, digital technology, robotic assisted surgery. We wanna be able to measure that so we can capture those patients and 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 head what volume it is, but it almost feels like a doubling. I would say that even in the shoulder domain and there are moves to add more data, to have more granular laser data, we're collecting information about the bony abnormalities of your boney wear. That, that's very different from the hip and knee. We are 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 registries, like in England. And Scandinavia is PROMS. So patient reported outcomes. So again, that adds , a significant level of complexity about both the collection and the storage of the data, but it 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 actual fact, you don't need it off everybody. You just need it off of a reliable reproducible sample that represents, it's got a 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 data is. You ask patients patient expectations before and after surgery, has that been met? But we also look at functional things, pain scores. That's in a national level 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.'cause 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 with this, that's a whole different podcast because you know that's where, that's the science, that's where the exciting bit is to work out. Are there things that we can modify that'll help the patients do better? But, that's a different topic and that we, I won't say we're yet there yet, but I think that's emerging is where we're going to Have great interest in the future.

Dr Gavin Nimon:

On that point, do you think AI will actually have some influence in helping you work

Prof Richard Page:

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 on, 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 gotta say how do we validate those findings in the real world and make sure it's not just a spurious statistical anomaly?, the limitation is you can only You can't, although it's tempting, you can't extrapolate that to things that you're not measuring. But there's some computational 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 of the patients. Often it, it will come up with a proposal, which is actually a hypothesis for which is another research project, if that makes sense. Think we've got huge potential. You could, for example, we know that BMI is an association with variability outcomes, it's not linear and it's not across all operations and 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, which we do, and looking at some of the other complications, which don't always result in a. A revision or even a re-operation is gonna be really important for us as well. And that'll involve linking to other data sets. But, I think using some of these technologies will help us refine down and look at things more specific for clinical trials. For example the unsolved question or the unsolved problem we still have is infection being able to look at attributes that can diagnose 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 gonna be crucial in help helping us answer these. For example, there, there's a whole classes of new drugs, as the GP colleagues would know, will be using almost daily practice. Ozempic, , is preconditioning patients who are at high risk with those to reduce their weight? Is that going to help outcomes? Is it gonna reduce risks, complications, or is it actually putting them at risk of something else? So the, these are questions that could have studies embedded in the registry or in registries to make them more easily to answer. And that's another new relatively new tool. It's been around for probably nearly 10 years now, but using registries for, to doing research 'cause they have all the linkages and the and the data structure to do research. And, one of the studies I'm doing, and there's some, 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.'cause 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 an a growing area of potential use.

Dr Gavin Nimon:

How is our registry perceived overseas then? What do people think of the Australian setup?

Prof Richard Page:

Yeah. World class. In fact, it's hard to, shall we say, measure competitively., but it's it's got a very. Strong reputation has being one world leading. And the other registries I've mentioned are also up there, but in terms of the structure, the design, particularly the data completeness, and that reflects like, again the intent, the people who set it up, and , how it's grown and the people who are now involved in it are doing, a great job. And they've got bringing new ideas like any. Organization or a, 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 the whole thing can evolve and have a fresh face and new ideas looking at new questions.

Dr Gavin Nimon:

Can the registries be joined together to con, to make a even larger data group for which you can do yeah.

, Prof Richard Page:

I've been lucky to be involved in a number of projects like that with cos pimento 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 is, sometimes it's greater than the sum of one plus one. There are some challenges.'cause sometimes we measure or define things slightly differently. So that requires some front end work. So it is not just as simple as getting two big spreadsheets and drawing 'em together and analyzing it. Because we are, we have different time points, for example. Or we might do different operations. And then certainly as you'll know, there may be different prosthesis available from one place to other, but that's also a strength so you can compare different things. So yes, and quite apart from the collaboration and having international connections and developing and growing a network of people who 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, but, 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 the problem and how they've dealt with it in terms of managing some data or a new device coming, how they've defined it, that can influence how you do it locally here. and there's some big projects. In fact, we've just had the, what's called the IAR meeting in New Zealand a few weeks ago, which is an annual, international meeting. So there's a great learning experience where, and unlike most of the professional meetings that we go to as surgeons or clinicians this is actually a meeting that with surgeons, but it's, there's statisticians, there's data managers, there's regulators, all these people in the same room. It's fascinating. One of the, one of the best meetings I go to and very little was 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 have come home with ideas about, they're doing this, maybe we should look at that or think about how that might work here.

Dr Gavin Nimon:

What about looking at other medical specialties and their registries? Does that have any influence our, on our arthroplasty

Prof Richard Page:

That's a good question. Certainly. I won't say specialties per se, but collaborating and working with the different people. And some of 'em are, 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 of interest. You see it for a different lens and that's hugely important to inform how you do something and also asking 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 dunno, 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, if you rub shoulders with you. Peers, but also people from that cross pollination from different specialties there's heaps of stuff that I use in my practice 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, there's a whole range of new I wouldn't be aware of if we weren't talking and interfacing to somebody else, 'cause we, all of us tend to. Narrow down our lane a bit and stick in our lane 'cause 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 that collaboration, communication, knowing what's going on around you, what new ways of doing things is crucial. Particularly with , some of the statistical analysis that are being done, which again, I'm not going to do, but to know what some of the new potentials are is I think really helpful.

Dr Gavin Nimon:

If we look national Joint replacement Registry, it's all online. It's per public knowledge. the data is there, and there's also a lay person's 30 page document too for people to look at which gives a few summaries but if we look at these 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

Prof Richard Page:

Yeah, great. And this is an area that I've got, a huge amount of personal s satisfaction and pride in having been involved in 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 information or things we've learned, right at the top that, total shoulder replacements in Australia function better for osteoarthritis than partial shoulder replacements. Okay. That, and that's been reflected in our practice. You can see that the revision rates are hugely low and partial shoulder replacements a seldom use. Now , you'd never say never.'cause there are some situations where through deformity or 'cause it's a revision or something, 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 'em 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's really helpful. It's demonstrated that in fact it actually performs really well. On the whole, there's a few exceptions and that's where you gotta get into the granular data. You can't just look at the high level. You say, yeah, okay, what 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. It 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'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 surface and showed if it's, modern treated highly crosslink, so more stable polyethylene that's stable against oxidation. That has a huge, downward push on revision rates compared to non crosslink. And in fact, this is where it's important for surgeons looking at the registry or anybody else of interest. GPs, you can't just look at the front page and see the first graph that shows, because it makes, in that one, it makes reverses look like it's much lower revision rate than anatomical, but that's because it's comparing all comers and all types and everything. But then if you go down and look at, okay, what about if we use best in class or the, best polyethylene stuff, then. It has a big difference in 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 in knee in some settings. We don't have that data yet in Shoulders, but we will in due course. It's a time and numbers game.

Dr Gavin Nimon:

Where do you think the actual registry data's gonna go down the track? How do you think it's gonna progress for the future?

Prof Richard Page:

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 is that our colleagues have taken the data on board, really proactively as collective group. And you could look at our revision rates of shoulder surgery have come down, like three point a half percent, nearly getting close to 4%, which doesn't sound huge, but that's hundreds and hundreds of patients who've avoided a 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 I the use of improved digital technology to make. More efficient data capture, more efficient dashboarding for you and I to look at what's happening in a closer to real time us compared to the rest of the population and more efficient capture of other attributes around the patients, their things like their activity level, linking it to their smart device like that, so this talks to, it talks to the registry and you have an app on there and it talks to the patient's profile. So we can really measure things that we can only dream of. Now the technology's actually there to do that, but to do it on a a large scale or a national scale that you can imagine the amount of computing and data capture power 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 perioperative. 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 give them better idea about the expectations. So , there is potential, some of this now. But aspirationally, to do that, take that from theory to practice is, I think that's the mid midterm. Um, 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 summarize what the registries is mainly used for, how it's done, and the main advantage that you see for it. So in a contemporary setting, all the registers 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 gonna happen for an individual patient, if you add thousands of patients, it can give a pretty good idea, a pretty good picture about how. 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 it may be a relative or , a grandchild. You know 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 benefit from all the data about medicines being collected that's improved in refined treatment to reduce complications, identify things that are risky or don't work, or have got complications. Eliminating those and focusing on the treatments, the operations, the procedures that, the implants that are doing well reliably and doing very well, in fact. So that's what a registry's all about. It's about, and that's what our national joint placement registry's all about. It's about providing, data to improve the quality of our 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.

Dr Gavin Nimon:

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.

Prof Richard Page:

Yeah. It's certainly sounds like it's the same for you, but certainly the thing that puts a bigger smile on my face is seeing, you know, your patients happy.

Dr Gavin Nimon:

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's out there for public access, for people. And I really appreciate your time this evening. Thank you.

Prof Richard Page:

Look. Thanks Gavin. It's been a pleasure and a, an honor to be able to join you on this. All the best Thank you.

Dr Gavin Nimon:

I'd like to remind you that all the information presented today is just one opinion, and that there are numerous ways of treating 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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