What effect have commissioners’ policies for body mass index had on hip replacement surgery?: An interrupted time series analysis from the National Joint Registry for England

Joanna C McLaughlin; Ruth R Kipping; Amanda L Owen-Smith; Hugh S T McLeod; Sam Hawley; Mark Wilkinson; Andrew Judge

doi:10.1186/s12916-023-02899-3

What effect have commissioners’ policies for body mass index had on hip replacement surgery? An interrupted time series analysis from the National Joint Registry for England

Joanna C McLaughlin, Ruth R Kipping, Amanda L Owen-Smith, Hugh S T McLeod, Sam Hawley, Mark Wilkinson, Andrew Judge

Research output: Contribution to journal › Article (Academic Journal) › peer-review

1 Citation (Scopus)

Abstract

Background: Despite widespread use, the impact of commissioners’ policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. The aim of this study was to assess the impact of policies for BMI on access to hip replacement surgery in England.

Methods: A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. Clinical commissioning group policies introduced before June 2018 to alter access to hip replacement for patients with overweight or obesity were considered the intervention. The main outcome measures were rate of surgery and patient demographics (BMI, Index of Multiple Deprivation, independently-funded surgery) over time.

Results: Commissioning localities which introduced a policy had higher surgery rates at baseline than those which did not. Rates of surgery fell after policy introduction, whereas rates rose in localities with no policy. ‘Strict’ policies mandating a BMI threshold for access to surgery were associated with the sharpest fall in rates (trend change of -1.39 operations per 100,000 population aged 40+ per quarter-year, 95% confidence interval -1.81 to -0.97, P
Conclusions: Commissioners and policymakers should be aware of the counterproductive effects of BMI policies on patient outcomes and inequalities. We recommend that BMI policies involving extra waiting time or mandatory BMI thresholds are no longer used to reduce access to hip replacement surgery.

Original language	English
Article number	202
Pages (from-to)	202
Journal	BMC Medicine
Volume	21
Issue number	1
DOIs	https://doi.org/10.1186/s12916-023-02899-3
Publication status	Published - 13 Jun 2023

Bibliographical note

Funding Information:
This study is funded by the National Institute for Health and Care Research (NIHR). JM holds an NIHR Doctoral Research Fellowship (NIHR 301469).

Funding Information:
We thank the patients and staff of all the hospitals in England, Wales and Northern Ireland who have contributed data to the National Joint Registry (NJR). We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Research Committee and the staff at the NJR Centre for facilitating this work. The authors have conformed to the NJR’s standard protocol for data access and publication. The views expressed represent those of the authors and do not necessarily reflect those of the National Joint Registry Steering Committee or HQIP who do not vouch for how the information is presented. HQIP and the NJR take no responsibility for the accuracy, currency, reliability and correctness of any data used or referred to in this report nor for the accuracy, currency, reliability and correctness of links or references to other information sources and disclaim all warranties in relation to such data, links and references to the maximum extent permitted by legislation. HQIP and NJR shall have no liability (including but not limited to liability by reason of negligence) for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on the data within this report and whether caused by reason of any error, omission or misrepresentation in the report or otherwise. This report is not to be taken as advice. Third parties using or relying on the data in this report do so at their own risk and will be responsible for making their own assessment and should verify all relevant representations, statements and information with their own professional advisers.

Funding Information:
AJ was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. HM was supported by the NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust.

Publisher Copyright:
© 2023, The Author(s).

Research Groups and Themes

HEHP@Bristol

Keywords

Humans
Body Mass Index
Interrupted Time Series Analysis
England
Obesity
Policy
Registries

Access to Document

10.1186/s12916-023-02899-3Licence: CC BY

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Persistent link

Mixed methods investigation of the public health impact of pre-surgical health optimisation interventions in elective arthroplasty
McLaughlin, J. C. (Author), Judge, A. (Supervisor), McLeod, H. (Supervisor), Owen-Smith, A. (Supervisor) & Kipping, R. (Supervisor), 19 Mar 2024
Student thesis: Doctoral Thesis › Doctor of Philosophy (PhD)

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Cite this

McLaughlin, J. C., Kipping, R. R., Owen-Smith, A. L., McLeod, H. S. T., Hawley, S., Wilkinson, M., & Judge, A. (2023). What effect have commissioners’ policies for body mass index had on hip replacement surgery? An interrupted time series analysis from the National Joint Registry for England. BMC Medicine, 21(1), 202. Article 202. https://doi.org/10.1186/s12916-023-02899-3

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abstract = "Background: Despite widespread use, the impact of commissioners{\textquoteright} policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. The aim of this study was to assess the impact of policies for BMI on access to hip replacement surgery in England.Methods: A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. Clinical commissioning group policies introduced before June 2018 to alter access to hip replacement for patients with overweight or obesity were considered the intervention. The main outcome measures were rate of surgery and patient demographics (BMI, Index of Multiple Deprivation, independently-funded surgery) over time.Results: Commissioning localities which introduced a policy had higher surgery rates at baseline than those which did not. Rates of surgery fell after policy introduction, whereas rates rose in localities with no policy. {\textquoteleft}Strict{\textquoteright} policies mandating a BMI threshold for access to surgery were associated with the sharpest fall in rates (trend change of -1.39 operations per 100,000 population aged 40+ per quarter-year, 95% confidence interval -1.81 to -0.97, PConclusions: Commissioners and policymakers should be aware of the counterproductive effects of BMI policies on patient outcomes and inequalities. We recommend that BMI policies involving extra waiting time or mandatory BMI thresholds are no longer used to reduce access to hip replacement surgery.",

keywords = "Humans, Body Mass Index, Interrupted Time Series Analysis, England, Obesity, Policy, Registries",

author = "McLaughlin, {Joanna C} and Kipping, {Ruth R} and Owen-Smith, {Amanda L} and McLeod, {Hugh S T} and Sam Hawley and Mark Wilkinson and Andrew Judge",

note = "Funding Information: This study is funded by the National Institute for Health and Care Research (NIHR). JM holds an NIHR Doctoral Research Fellowship (NIHR 301469). Funding Information: We thank the patients and staff of all the hospitals in England, Wales and Northern Ireland who have contributed data to the National Joint Registry (NJR). We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Research Committee and the staff at the NJR Centre for facilitating this work. The authors have conformed to the NJR{\textquoteright}s standard protocol for data access and publication. The views expressed represent those of the authors and do not necessarily reflect those of the National Joint Registry Steering Committee or HQIP who do not vouch for how the information is presented. HQIP and the NJR take no responsibility for the accuracy, currency, reliability and correctness of any data used or referred to in this report nor for the accuracy, currency, reliability and correctness of links or references to other information sources and disclaim all warranties in relation to such data, links and references to the maximum extent permitted by legislation. HQIP and NJR shall have no liability (including but not limited to liability by reason of negligence) for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on the data within this report and whether caused by reason of any error, omission or misrepresentation in the report or otherwise. This report is not to be taken as advice. Third parties using or relying on the data in this report do so at their own risk and will be responsible for making their own assessment and should verify all relevant representations, statements and information with their own professional advisers. Funding Information: AJ was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. HM was supported by the NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust. Publisher Copyright: {\textcopyright} 2023, The Author(s).",

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What effect have commissioners’ policies for body mass index had on hip replacement surgery? An interrupted time series analysis from the National Joint Registry for England. / McLaughlin, Joanna C ; Kipping, Ruth R ; Owen-Smith, Amanda L et al.
In: BMC Medicine, Vol. 21, No. 1, 202, 13.06.2023, p. 202.

Research output: Contribution to journal › Article (Academic Journal) › peer-review

TY - JOUR

T1 - What effect have commissioners’ policies for body mass index had on hip replacement surgery?

T2 - An interrupted time series analysis from the National Joint Registry for England

AU - McLaughlin, Joanna C

AU - Kipping, Ruth R

AU - Owen-Smith, Amanda L

AU - McLeod, Hugh S T

AU - Hawley, Sam

AU - Wilkinson, Mark

AU - Judge, Andrew

N1 - Funding Information: This study is funded by the National Institute for Health and Care Research (NIHR). JM holds an NIHR Doctoral Research Fellowship (NIHR 301469). Funding Information: We thank the patients and staff of all the hospitals in England, Wales and Northern Ireland who have contributed data to the National Joint Registry (NJR). We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Research Committee and the staff at the NJR Centre for facilitating this work. The authors have conformed to the NJR’s standard protocol for data access and publication. The views expressed represent those of the authors and do not necessarily reflect those of the National Joint Registry Steering Committee or HQIP who do not vouch for how the information is presented. HQIP and the NJR take no responsibility for the accuracy, currency, reliability and correctness of any data used or referred to in this report nor for the accuracy, currency, reliability and correctness of links or references to other information sources and disclaim all warranties in relation to such data, links and references to the maximum extent permitted by legislation. HQIP and NJR shall have no liability (including but not limited to liability by reason of negligence) for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on the data within this report and whether caused by reason of any error, omission or misrepresentation in the report or otherwise. This report is not to be taken as advice. Third parties using or relying on the data in this report do so at their own risk and will be responsible for making their own assessment and should verify all relevant representations, statements and information with their own professional advisers. Funding Information: AJ was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. HM was supported by the NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust. Publisher Copyright: © 2023, The Author(s).

PY - 2023/6/13

Y1 - 2023/6/13

N2 - Background: Despite widespread use, the impact of commissioners’ policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. The aim of this study was to assess the impact of policies for BMI on access to hip replacement surgery in England.Methods: A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. Clinical commissioning group policies introduced before June 2018 to alter access to hip replacement for patients with overweight or obesity were considered the intervention. The main outcome measures were rate of surgery and patient demographics (BMI, Index of Multiple Deprivation, independently-funded surgery) over time.Results: Commissioning localities which introduced a policy had higher surgery rates at baseline than those which did not. Rates of surgery fell after policy introduction, whereas rates rose in localities with no policy. ‘Strict’ policies mandating a BMI threshold for access to surgery were associated with the sharpest fall in rates (trend change of -1.39 operations per 100,000 population aged 40+ per quarter-year, 95% confidence interval -1.81 to -0.97, PConclusions: Commissioners and policymakers should be aware of the counterproductive effects of BMI policies on patient outcomes and inequalities. We recommend that BMI policies involving extra waiting time or mandatory BMI thresholds are no longer used to reduce access to hip replacement surgery.

AB - Background: Despite widespread use, the impact of commissioners’ policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. The aim of this study was to assess the impact of policies for BMI on access to hip replacement surgery in England.Methods: A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. Clinical commissioning group policies introduced before June 2018 to alter access to hip replacement for patients with overweight or obesity were considered the intervention. The main outcome measures were rate of surgery and patient demographics (BMI, Index of Multiple Deprivation, independently-funded surgery) over time.Results: Commissioning localities which introduced a policy had higher surgery rates at baseline than those which did not. Rates of surgery fell after policy introduction, whereas rates rose in localities with no policy. ‘Strict’ policies mandating a BMI threshold for access to surgery were associated with the sharpest fall in rates (trend change of -1.39 operations per 100,000 population aged 40+ per quarter-year, 95% confidence interval -1.81 to -0.97, PConclusions: Commissioners and policymakers should be aware of the counterproductive effects of BMI policies on patient outcomes and inequalities. We recommend that BMI policies involving extra waiting time or mandatory BMI thresholds are no longer used to reduce access to hip replacement surgery.

KW - Humans

KW - Body Mass Index

KW - Interrupted Time Series Analysis

KW - England

KW - Obesity

KW - Policy

KW - Registries

U2 - 10.1186/s12916-023-02899-3

DO - 10.1186/s12916-023-02899-3

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JO - BMC Medicine

JF - BMC Medicine

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