SSM featuring 2022’s top scoring abstracts … Joanna McLaughlin

SSM featuring 2022’s top scoring abstracts … Dr Dr Joanna McLaughlin!

Joanna McLaughlin is a Doctoral Fellow and Specialty Registrar in Public Health, based at the University of Bristol. At 2022’s ASM in Exeter, her abstract What effect have clinical commissioning group policies for thresholds of weight loss and body mass index had on access to knee replacement surgery in England?: an analysis from the national joint registry for England was one of the top 10 highest scoring. Below, she shares a little about this study and subsequent research.

Joanna McLaughlin University of Bristol Doctoral Fellow & Specialty Registrar in Public Health

What effect have clinical commissioning group policies for thresholds of weight loss and body mass index had on access to knee replacement surgery in England?: An analysis from the National Joint Registry for England

“The introduction of ‘health optimisation’ interventions into the pathway to elective surgery, is becoming increasingly common in the NHS. These policies aim to reduce the number of surgical procedures, improve patient safety and outcomes, and encourage lifelong behavioural changes in patients. They are most commonly applied to joint replacement surgery. Despite NICE guidance, the policies sometimes include mandatory extra waiting periods or body mass index (BMI) thresholds for surgical referral. Such policies may exacerbate health inequalities and require further investigation.

As a first step we examined the policies put in place by clinical commissioning groups (CCGs) in England that use BMI or smoking status to restrict access to joint replacement surgery. Our study found that the prevalence and severity of these policies have increased over time. By 2021 two-thirds of CCGs had a policy for BMI and three-quarters had a policy for smoking status. The majority (61%) of the BMI policies introduced extra waiting time or restricted access to surgery for patients over certain BMI thresholds, while most smoking status policies offered patients advice or optional cessation support. Integrated care systems (ICSs) have now replaced CCGs in England, and the study estimates that 40% of these may have adopted restrictive BMI policies.

We then conducted a study to understand the impact of policy introduction on inequalities and patient access to elective knee replacement surgery in England. As different CCGs had introduced policies at different times, policy (intervention) and non-policy (control) regions can be compared over time in a natural experimental design. The study used data from the National Joint Registry and included 481,555 patients aged 40 years and above who had a primary knee replacement between January 2009 and December 2019.

Before BMI policy introduction, both intervention and control CCGs had an increasing trend in the rate of primary knee replacement surgery as would be expected with England’s ageing and increasingly obese population. However, after policy introduction, the trend in intervention CCGs reversed, while the control group continued upwards. Our results suggest that BMI policies were associated with reductions in the number of surgeries performed in the intervention CCGs.

We also noted differences in the patient characteristics; of particular concern was the increase in the proportion of affluent patients and in the proportion of privately funded surgery after policy introduction. The results suggest that BMI policies may contribute to health inequalities and limit access to knee replacement surgery for certain patient groups.

It is crucial to consider the wider public health opportunity offered by the ‘teachable moment’ of surgery to encourage lifestyle changes in patients. However, the results of our studies contribute to the ongoing debate whereby policymakers must carefully evaluate the impact of these policies on health inequalities and patient access to healthcare services.”

This is a special edition of our blog series that celebrates SSM members and their work. Over the next few months we will be featuring the authors of top-scoring abstracts from 2022’s ASM. To find out more visit socsocmed.org.uk/blog or email ecr.ssm@gmail.com.