Criteria for BMI and smoking governing access to hip or knee arthroplasty in end stage osteoarthritis affect many thousands of patients given that around 10% of adults will require a hip or knee arthroplasty in their lifetime, 64% of adults in England are obese or overweight and 14% are current smokers. In other cases, policies are used to restrict access to surgery without necessarily offering health improvement opportunities, heightening the risk of increasing health inequalities through rationing of surgery and raising ethical concerns. In some cases, ‘health optimisation’ is cited as the reason for policy introduction – whereby patients are offered extra support and/or an extra period of time before surgical referral to address weight management and smoking cessation in order to improve their overall health as well as their surgical outcome. CCGs set their own referral criteria for hip and knee arthroplasty leading to variation in policies across England, and these may include criteria for BMI (body mass index) and smoking thresholds. īetween 20, clinical commissioning groups (CCGs) were statutory NHS bodies with budgetary responsibility for the planning and commissioning of most health care services for their local population. In 2015, NICE’s osteoarthritis quality standard specified that commissioners “ensure that they commission services in which adults with osteoarthritis are not referred for consideration of joint surgery until they have been supported with non‑surgical core treatments for at least 3 months”. In England, National Institute for Health and Care Excellence (NICE) guidance (2008,20) for people with osteoarthritis promotes self-management to achieve positive behavioural changes including the offer of interventions to support weight loss for patients who are overweight or obese. If self-management and analgesia are not effective, the third line of treatment is referral to specialist care where patients may be considered for arthroplasty. The initial management pathway of osteoarthritis involves advice on therapeutic exercise and weight management, followed by topical, oral and transdermal analgesia. Hip and knee osteoarthritis is a leading contributor to the global burden of disease and hip and knee arthroplasty are two of the most common high-cost elective surgical procedures provided in the National Health Service (NHS). Further work should determine the impact of different types of policy on access to surgery and health inequalities. The high variation in policy stringency on BMI between regions is likely to cause inequality in access to arthroplasty and to specialist support for affected patients. ConclusionsĪccess policies to arthroplasty based on BMI and smoking status are widespread in England, have increased in prevalence since 2013, and persist within new ICSs.

It is estimated that 40% of ICSs may adopt a BMI policy restrictive to access to arthroplasty. In contrast, where smoking status policies were in place, most offered patients advice or optional smoking cessation support and only 15% (12/80) introduced extra waiting time or mandatory cessation before surgery. Where BMI policies were in place, 61.1% (44/72) introduced extra waiting time before surgery or restricted access to surgery based on BMI thresholds (modal threshold: BMI of 40 kg/m 2, range 30–45). For current CCGs, 67.9% (72/106) had a policy for body mass index (BMI) and 75.5% (80/106) had a policy for smoking status for hip or knee arthroplasty. Prevalence and severity of policies have increased over time.

With the addition of information from FOIs, complete policy information was available for 94.4% (235/249) of CCGs. Policy information was available online for 56.2% (140/249) CCGs. There were 106 current and 143 historic CCGs in England at the time of the search in June 2021. Estimates were made of the uptake of policies by ICSs based on the modal policy type of their constituent CCGs. Descriptive analyses of policy type, explicit threshold criteria and geography are reported. Policy data were obtained from an internet search for all current and historic clinical commissioning group (CCG) hip and knee arthroplasty policies and use of Freedom of Information (FOI) requests to each CCG.

Our objectives were to ascertain the prevalence, trend and nature of these policies, and consider the implications for new integrated care systems (ICSs). Commissioning policies are in place in England that alter access to hip and knee arthroplasty based on patients’ body mass index and smoking status.

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