Researchers have called on the NHS to urgently reconsider policies that restrict access to joint replacement surgery for patients who are overweight or obese.
It follows research on hip replacements which shows falling rates of operations in areas in England with restrictive BMI-based policies in place.
An analysis of National Joint Registry Data for more than 480,000 patients between 2009 and 2019 also showed policies are driving inequalities in access to healthcare.
By 2021, 70% of clinical commissioning groups had restricted access policies in place varying from recommendations that patients are given advice to lose weight, or in some cases having to wait longer while they try to lose weight.
The most strict policies were those with mandatory body mass index (BMI) thresholds for referral to surgery, the researchers from Bristol University reported in BMC Medicine.
Where CCGs had enforced extra waiting time before surgery, there was an association with worsening symptom scores and rising obesity, they said.
Areas that introduced restrictions tended to have higher rates of surgery and more affluent populations at the start which may have been a driver for introducing the policy in the first place, the team explained.
But strict policies were linked to an increase in the proportion of independently funded surgery and the proportion of more affluent patients receiving surgery, raising concerns about widening inequalities.
A similar analysis last year by the NIHR-funded researchers into knee replacements last year found similar patterns of weight-related policies reducing the number of operations and contributing to inequities in care.
NICE guidance on osteoarthritis updated last year said BMI should not be used to deny patients access to hip replacement surgery, particularly as ‘osteoarthritis is more common in people in lower socio-economic groups’.
Now is the time to look again at restrictive policies that affect access to elective surgery with the formation of ICSs being an ‘opportunity for positive changes to policy position’.
There are encouraging signs that some areas are starting to do this, they added.
Lead author Dr Joanna McLaughlin, NIHR doctoral research fellow at Bristol Medical School, said: ‘NHS policy on whether people can immediately access referral for hip replacement surgery if they are overweight or obese varies depends on where you live in England.
‘NICE guidance on arthritis was updated in October 2022, and it clearly states that BMI should not be used to exclude people from referral to surgery, but restrictive policies are still in use in some regions.’
She added: ‘Both this current study, and our study on knee replacements published last June, show these policies have concerning associations with a sharp drop in the rate of joint replacements, worsening symptom scores, and worsening health inequalities.’
Overweight patients are progresively more likely to die of operative complications, and less likely to survive to walking as their BMI goes up.
Medicine is naturally discriminatory, weightist, racist (genes are inherited!), and sexist.
You cannot change natural prognosis simply by legislating against it – reminds me of a King who told the tide to stop, and he found out Nature is greater that Law.
@DC
I don’t think they are arguing about having a clinical risk assessment, but the specific fixed line drawing associated with BMI.
So a. 85 year old with a bmi of 34 (or 29) is clearly at higher risk than a 55 year old with a bmi of 36 (if both have no other medical problems). But in the areas with restrictions they will only fund the procedure for the higher risk, lower bmi patient.
The problem with common sense is that it is not common