State of orthopaedic trauma registries in South Korea, Japan, and Australia

Abstract

Introduction:

The scope and complexity of orthopaedic trauma registries differ across the Asia-Pacific region. The purpose of this report was to review the existing registries in South Korea, Japan, and Australia focusing on their current utility, processes, and future directions.

Methods:

Representatives of the International Orthopaedic Trauma Associations and relevant national registry experts provided a comprehensive overview of their countries' orthopaedic trauma registries based on predetermined mandatory aspects of their systems consistent with the goals of the global review, which includes other regions in a review series.

Results:

Japan and Australia have dedicated orthopaedic trauma registries without comprehensive data collection from the entire countries. The Database of Orthopaedic Trauma Japan and the Victorian Orthopaedic Trauma Outcomes Registry in Australia collect data specific to the skeletal injury, treatment options utilized, and outcomes. South Korea mandates by legislation the collection of comprehensive data on trauma patients through the Korea Trauma Data Bank in conjunction with the National Emergency Department Information System and Health Insurance Review and Assessment Service. These registries are not specific to orthopaedic trauma, but some skeletal injury–specific outcomes are possible to extract from the large data sets.

Conclusion:

South Korea, Japan, and Australia collect and compile orthopaedic trauma data through different systems, but these reflect a similar dedication to the improvement of trauma care and outcomes. All 3 countries have the potential resources to develop comprehensive orthopaedic trauma registries to monitor epidemiology and outcomes of skeletal injuries in conjunction with their national major trauma registries.

1. Introduction

Registry usage among countries in the Asia-Pacific region differs in scope and complexity. Three countries in the region, South Korea, Japan, and Australia, have existing registries with contrasting orthopaedic registry systems. The purpose of this report was to review existing registries in these countries, with a focus on the aspects of the different systems, current usage and utility of the data, and future directions.

2. South Korea

2.1. Overview

The orthopaedic trauma registry system in South Korea is managed by a national health authority, including the Ministry of Health and Welfare (MOHW).¹ This system currently partners with various hospitals and institutions to improve the standard of trauma care. The central registries include the Korea Trauma Data Bank (KTDB), National Emergency Department Information System (NEDIS), and Health Insurance Review and Assessment Service (HIRA).^2,3 The KTDB aggregates data from regional trauma centers nationwide to create a comprehensive database of trauma patients while the NEDIS collects various emergency medical data including trauma incidents. The HIRA monitors and evaluates health care services to provide valuable data for orthopaedic trauma research. These registries are mandated by law to ensure that data are automatically generated whenever relevant patients are treated, requiring all related institutions nationwide to contribute data.^3,4

2.2. Existing Registries

The KTDB, a repository of over 250 variables ranging from patient demographics to injury mechanisms, clinical outcomes, and treatment information, offers a comprehensive data set that enables robust reporting and refinement of trauma care pathways.⁴ Similarly, the NEDIS, a database primarily responsible for emergency patient data, is a creation of the MOHW designed to augment the comprehensiveness of the national trauma database. The depth and breadth of data in these registries provide a solid foundation for research and policy development in orthopaedic trauma care, as evidenced by numerous studies that have harnessed HIRA data to gauge trends and outcomes in this field.⁵

2.3. Data Ownership

The data from these registries serve various purposes, including research, policy development, and clinical care.⁶ From a scientific perspective, the data are crucial for improving and creating trauma care protocols. Specific studies, such as those focusing on orthopaedic surgeries and outcome trends, contribute to evidence-based enhancements in clinical practice. At a policy level, these data are fundamental when government and health authorities formulate effective emergency medical policies and allocate resources. However, the most tangible benefit is for hospitals and providers who use these data for clinical purposes, improving patient care and facilitating personalized treatment plans. Data ownership is maintained by the collecting institutions and the MOHW, with stringent adherence to privacy laws.⁷ Because patient confidentiality is paramount, access to the data is restricted. These security standards feature data encryption, restricted access, and security controls, among other security measures, as well as routine security audits to ensure strict compliance and prevent breaches. Measures to secure patient-sensitive information management create trust between patients and health care providers.

2.4. Security

The management of trauma registries focuses on data security and patient confidentiality.¹ The KTDB uses several security measures to store patients' personal information safely. Legitimate parties in countries widely use the data, and these are always securely stored and handled according to strict protocols to prevent breaches and unauthorized use. The HIRA enacted strict data protection laws to ensure that patient information is securely managed and adequately protected. Regular audits and security practice updates ensure that the registry remains secure and compliant with national and international data protection standards.⁸

2.5. Future Directions

Continuous education and system improvements will improve the future data quality of the Korean trauma registry system.² Frequent medical staff education specific to data input and management helps guarantee the high-quality and uniform nature of the collected data. International cooperation must be improved, as the more the data are gathered and distributed globally, the better the perspective and development of best practices. Such cooperative endeavors with international trauma societies may result in standardized algorithms and enhanced trauma care worldwide.⁹ Furthermore, considerable emphasis is being placed on integrating modern technologies such as artificial intelligence (AI) and big data analytics to ensure the maximum utility of the collected data.¹⁰ These insights are a game changer in trauma care, as AI algorithms can identify patterns and predict outcomes. Big data analytics breaks down highly complex data to identify trends that conventional analyses might overlook. This breakthrough is expected to improve trauma care and patient outcomes in Korea.

3. Japan

3.1. Overview of Registries

Two registries for fractures currently exist in Japan. One is the Database of Orthopaedic Trauma Japan by the Japanese Society for Fracture Repair (DOTJ), which aims to improve outcomes for open fractures of the extremities. The other is the FFN-J Registry, a database of proximal femur fractures created by the Japanese Fragility Fracture Network (FFN-J) for interhospital, regional, and international comparisons of treatment characteristics and issues in Japan.

3.2. Database of Orthopaedic Trauma Japan by the Japanese Society for Fracture Repair

By analyzing the data in the DOTJ registry, various aspects of fractures, such as epidemiology, methods, complications, and factors affecting treatment outcomes, will be clarified and the standard of care at the national level will become apparent, allowing comparisons to be made between institutions, regions, and countries. Furthermore, comparisons can be made over time to verify the progress of medical care. One current problem is the large number of input items and the heavy burden placed on surgeons in charge, which leads to a bias that only facilities dedicated to trauma care will register.

The usage of registered data is based on the rules mentioned further. We are now in the final stage of documenting these rules: 1) each institute can use its data in need; 2) the data of another institute or overall data cannot be viewed or used without permission; and 3) interested parties must apply to the Japanese Society of Fracture Repair Registration Committee for utilization of the data, and data can only be used if accepted. Responsibility for data is on the surgeon who is in charge in each institute, and the registered data are kept by an outsourced data management company with strict security.

The open fracture registry as a subset of the DOTJ registry was running from February 2015 to June 2020, but this registry has been stopped.¹¹ However, by the end of 2024, we plan to set up a new orthopaedic trauma registry focused on acetabular and open fractures.

3.3. Japanese Fragility Fracture Network

Regarding the registry in FFN-J, proximal femur fractures require measures in Japan, where the population is aging, and on a global scale. The Fragility Fracture Network (FFN), an international organization, has created a common patient database and registry to track treatment progress and implement reforms to improve and advance the treatment. A current major challenge is minimizing missing data. Although more than 90% of the basic data during hospitalization have been secured, many follow-up data after discharge still need to be included.

The Fragility Fracture Network of Japan (FFNJ) began operating a registry in 2017 for patients aged 50 years or older with proximal femur fractures. The registry is mainly based on the Japanese translation of FFN global's minimum common data set with a few additional items, and input items were minimized as much as possible to reduce continuity and missing values. The number of registered facilities increased dramatically from 28 to more than 300 because of the new requirement to be registered in the FFNJ registry.¹² With the number of facilities increasing, the FFNJ shifted to web-based registration with a cloud database service called Kintone and over 50,000 cases were registered in 1 year. This cloud service is listed on the cloud service list of the Security Assessment System for Government Information Systems (ISMAP) (registration number: C21-0016-2) and has also obtained third-party certification for ISMS (Information Security: ISO/IEC 27001, certification registration number: IS 577142, Cloud Service Security: ISO/IEC 27017, certification registration number: CLOUD 715091).

Each facility can view and compare its data with the national average for each registry item. In addition to information on the acute stage, the registry includes 4-month and 1-year follow-up data, allowing the user to learn about walking ability and whether osteoporosis treatment is being used to prevent secondary fractures. This information is indispensable for promoting fracture liaison services, including motivation, understanding of the current situation, rationale for improvement, and effectiveness of interventions. Registration over time is expected to provide the basis for national trends and measures and help encourage policy changes.

4. Australia

4.1. Overview

Australia has a well developed public health care system to care for its population of approximatley 26 million people with a health expenditure ranking 11th among Organisation for Economic Co-operation and Development (OECD) countries.¹³ Part of this expenditure is spent on surveillance and quality improvement, of which registries and associated audit and research form an important aspect. In orthopaedic and trauma care, Australia has both national and binational registries, combined with New Zealand, for arthroplasty, the Australian Orthopaedic Association National Joint Replacement Registry,¹⁴ for hip fractures, the Australian & New Zealand Hip Fracture Registry,¹⁵ and for major trauma, the Australia New Zealand Trauma Registry.¹⁶ There is, however, no comprehensive national fracture or orthopaedic trauma registry.

4.2. Existing Registry

The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) is a region-based orthopaedic trauma registry.¹⁷ VOTOR is a comprehensive monitoring tool for orthopaedic trauma within the state of Victoria in Australia's south-east, capturing patients older than 16 years of age admitted for a minimum of 24 hours with a new bony injury from participating sites. Retrospective deidentified data are collected on patient demographics; comorbidities; mechanism of injury; and management including implant data, complications, length of stay, discharge destination, and short-term outcomes.

The registry began as a collaborative project in 2003 between the Alfred and Royal Melbourne Hospital (level 1 trauma center) and Monash University Department of Epidemiology and Preventative Medicine. This expanded to Geelong Hospital (major regional hospital) and the Northern Hospital in 2007 and Box Hill Hospital in 2021 (metropolitan hospitals).

VOTOR is led by 10 investigators along with a project manager and 2 research personnel. Their role includes registry governance, data administration and access approval, and research advice. Financial support is provided by Monash University and the Transport Accident Commission of Victoria. Data security and patient confidentiality are maintained with secure storage on the Monash University infrastructure. Infrastructure security is maintained to ISO 27001 global best practice guidelines to ensure that data are protected and meet privacy obligations.

VOTOR has published 10 annual reports from 2012 to 2022 providing an overview on the state of orthopaedic trauma in the region and how practice has changed over time. There have been over 116 research publications in peer-reviewed journals from the VOTOR registry.

4.3. Other Registry Uses

There have been other isolated regional registry projects around Australia including the Australian Capital Territory Orthopaedic Registry (ACTOR), which routinely collects data on the fractures within the ACT through the Trauma and Orthopaedic Research Unit at Australia National University and Canberra Hospital.¹⁸ Although still in the recruitment phase, the project has been able to develop a database, which is contributing to several current research projects.

4.4. Future Directions

The diverse nature and complexity of orthopaedic trauma injuries, coupled with the large volume, multiple treatment options, and patient characteristics, make registry surveillance resource intensive. Co-ordinating the collection of a large amount of data from heterogeneous medical systems and the management and appropriate infrastructure and systems for storage of these data seem to be the main rate-limiting step in setting up a broader orthopaedic trauma registry database across Australia. The future trajectory of orthopaedic trauma registries in Australia would involve expansion from regional registries to a state or national registry.

5. Conclusions

South Korea's, Japan's, and Australia's active work and interest in establishing and maintaining orthopaedic trauma registry systems reflect their dedication to enhancing trauma care and achieving good outcomes. There remains room for growth in developing centralized national orthopaedic trauma registries in each individual country, which will allow the possibility of regional and global partnerships to develop and assess the implementation of innovative and successful treatment standards.