The number of knee replacement surgeries has decreased in regions of England with restrictions on surgeries for overweight patients, with people in more needy areas being hardest hit, researchers have found.
Patients who need surgery but cannot lose weight are denied surgery that could relieve pain and increase mobility, said the team from the University of Bristol.
Health campaign participants expressed concern, arguing that politics was a “dumb tool” used to replace conversations between doctors and patients and risked exacerbating health inequalities.
Over the last decade, some clinical setting groups (CCGs) across England have introduced rules to restrict access to hip and knee replacement surgery for overweight or obese patients.
There are significant regional differences, with stricter CCGs telling patients that they must achieve a certain body mass index (BMI) before surgery can be performed or require waiting time. Others do not impose restrictions.
The study, funded by the National Institutes of Health and Care Research, suggests that regions that have made changes to their access policy to knee replacement surgery based on patient weight or BMI have seen a decline in surgery.
The researchers analyzed the rate of knee replacement surgery in 481,555 patients between January 2009 and December 2019 – before the Covid pandemic – using data from the National Joint Registry and compared regions with and without a BMI / weight policy.
The study found that more than two-thirds of CCGs in England have a BMI policy for knee replacement surgery, with 61% of those policies refusing access to surgery or requiring additional waiting time. It says surgery has been reduced by 14% overall compared to what would have been expected if policies restricting access had not been introduced.
Looking at patients’ zip codes, the researchers were able to see that people from less affluent areas seemed more likely to be denied surgery.
Lead author Joanna McLaughlin of Bristol School of Medicine said: “Our study raises concerns that these policies are linked to worsening health inequalities with fewer NHS operations for the poorest groups.
“We could see that the percentage of operations has decreased for those who are in the worst condition, but are increasing for those who are at their best, which correlates with more private operations that are carried out in these areas.
She said it was not useful to choose figures for specific CCGs, as local factors could distort the data. But it is clear that different approaches are being used in neighboring areas. South Lincolnshire, for example, has more liberal rules, while requirements are stricter next door to North Norfolk.
The report says that one in 10 people will probably need a knee replacement, many thousands of patients are affected.
Jacob Lant, Head of Policy, Partnership and Research at Healthwatch England, said: “The stupid use of BMI in this way is not helpful and should be treated as a guideline, not a hard and fast rule. What really needs to happen is a conversation between doctors and patients about the specific circumstances of the patient.
“Weight loss can be an incredible challenge, especially for those whose mobility is already affected by joint problems.”
The study, entitled What effect do NHS Commissioners’ policies on body mass index have on access to knee replacement surgery in England? – was published in the journal PLOS ONE.
Prof. John Skinner, a board member of the Royal College of Surgeons of England and a consultant orthopedic surgeon, said: “Hip and knee replacement surgery for osteoarthritis is dramatically improving the quality of life. The surgical decision must be made individually for each patient.
“Restrictive referral policies, such as BMI thresholds, penalize patients who become more immobile and are then likely to suffer from additional health problems. The good guidelines make it clear that restricting access to joint replacement based on BMI, smoking or other characteristics should not happen.
“This research paper confirms that restricting access to BMI-based surgery has a significant effect on access to care and exacerbates inequalities.
“It is prudent to promote weight loss when appropriate, and most hospitals use a system to promote weight loss in patients with a BMI of 40. However, this study shows that if commissioners restrict access for patients with a high BMI, then variability and much greater inequality arises for patients. “
A spokesman for the Ministry of Health and Welfare said: “We are helping local authorities to improve public health by increasing grants to just over £ 3.4 billion this year and investing another £ 39 billion in overall health and care in the coming years. three years “
An NHS spokesman said: “Patients and clinicians work together before surgery to optimize the chance of achieving the best results, and in some cases, weight loss before surgery reduces the risk to patients and improves the chances of success.
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