An official website of the United States government
Here's how you know
Official websites use .gov
A
.gov website belongs to an official
government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you've safely
connected to the .gov website. Share sensitive
information only on official, secure websites.
As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with,
the contents by NLM or the National Institutes of Health.
Learn more:
PMC Disclaimer
|
PMC Copyright Notice
During the 1990s, some cardiac surgeons were pilloried for suggesting that coronary artery grafting should be withheld from patients who continued to smoke. This attitude was deemed unacceptable. Doctors should advise on risk factors and treat disease, but not withhold therapy on account of an individual patient's life-style.
Some Suffolk Primary Care Trusts (PCTs) have, apparently, restricted funding for arthroplasties to those with a body mass index (BMI) of less than 30 kg/m2. The paper from Davies and Porteous extrapolates local data concerning those in whom surgery is withheld to incorporate numbers that would be affected if this policy was instituted nation-wide.
Liz Symonds writes for the patient. For many, losing weight is not easy, especially for those living in poor circumstances where access is somewhat difficult to a personal trainer and a Mediterranean diet.
If health rationing based on the fortunes of PCTs is to occur, (which it undoubtedly will) should not PCTs engage the local population in the debate and give some lead time? If a PCT opines that treatment is to be denied to patients who do not address their own ‘poor’ life-styles (and perhaps that is the responsibility of these guardians of HM Treasury money), what other groups may be similarly affected – drug abusers, alcoholics, multipartner gays with HIV, smokers with COPD – all consume expensive and repeated visits for hospital treatment, so where does this stop?
Of 20th century surgical success stories, arthroplasty must count for one of the most frequently performed techniques which have resulted in improved quality of life for so many patients. Is there evidence that this surgery does not improve the quality of life of the obese?
Health rationing, not only by postcode, but also by life-style may be the future face of health commissioning: currently it is by stealth and not by public open debate.
In November 2005, three Primary Care Trusts (PCTs) in East Suffolk introduced a policy of refusing funding for total hip and knee replacement surgery in patients with a body mass index (BMI) of 30 kg/m2 or above. This was introduced due to the financial pressures faced by these trusts.1 This policy has subsequently been adopted across the county.
There have been no previous reports in the literature on the number of people such a policy would affect, nor if this could be justified on the basis of evidence currently available.
In this study we set out to:
Identify the number of patients who would be affected if this policy were also adopted in West Suffolk and estimate the effect nation-wide.
Examine the available literature to discover if there is any evidence that obesity affects outcome in hip and knee replacement surgery.
Patients and Methods
Since January 2000, the BMI of all patients undergoing total hip replacement at West Suffolk Hospital have been recorded prospectively and the same data have been collected on total knee replacement patients since February 2003. The BMI, age, sex and procedure performed have been retrieved from our database. Based on data from the National Joint Registry of England and Wales, an estimate was made of the numbers that would be affected were this policy to be implemented nationally, assuming the same obesity rates were to apply.
Using a Medline literature search, and cited references in any papers we could identify, we sought studies that examined the a link between BMI and both short- and longterm outcomes in hip and knee replacement surgery.
Results
Between January 2000 and December 2005, a total of 1366 hip replacements (569 males), and 585 knee replacements (271 males), were recorded on our database. The mean age of the patients was 71 years (range, 24–93 years).
A total of 553 (28.3%) of patients had a BMI of greater than 30 kg/m2 comprising 328 (24%) hip replacements and 225 (38.5%) knee replacements. A more detailed breakdown of these is given in Figures 1 and 2. The proportion of patients with a BMI of greater than 30 kg/m2 was significantly higher in patients undergoing total knee replacements compared with the total hip group (χ2P < 0.001; 95% CI 0.095–0.191).
Sex distribution and BMI of patients undergoing total knee replacement surgery.
There was no significant difference in BMI between the sexes in hip replacements, with 22% of men and 26% of women being obese. However, in the total knee group, 29% of men and 46% of women had a BMI of 30 kg/m2 or greater. This difference was statistically significant (χ2P < 0.001; 95% CI 0.096–0.25).
Using our obesity rate, (making the assumption that it is nationally representative) and data from the National Joint Register (35,217 hip replacements and 33,583 knee replacements in 2004), we calculate that if East Suffolk PCTs' policy were to be implemented nationally, an estimated 8452 patients would be denied a total hip replacement and 12,929 would be denied a total knee replacement every year.
Literature search
Total hip replacement
We identified nine papers in total that examined the impact of BMI on outcome following total hip replacement surgery. The largest study of almost a million patients (which included knee and shoulder arthroplasty) demonstrated that obese patients were 1.3 times more likely to develop a postoperative complication.2 However, the paper only examined the shortterm complications and failed to identify what these complications were.
Other studies examining the short-term outcome on total hip replacement surgery showed that obese patients had endured longer operations, lost more blood (both significant), needed more intra-operative blood transfusions and required more intravenous fluids (not significant). However, the rates of other complications were similar.3–5 Indeed one study3 demonstrated that obese patients had a lower incidence of minor and major complications.
In the medium term, Chan and Villar6 failed to demonstrate a difference in quality of life at 1 and 3 years' postoperatively between obese and non-obese patients (using the Harris Hip Score and Rosser Index Matrix). Moran et al.4 also showed that the Harris Hip Score increased dramatically in all patients, but obesity did predict a lower score at 6 and 18 months. Both studies concluded that patients should not be denied the benefits of total hip replacement on the basis of obesity alone.
There is a paucity of evidence in the literature regarding the long-term affects of obesity on the survival of total hip replacements. Only one paper reports results with more than 10-year follow-up.5 This reports no difference in outcome between normal, obese (BMI 30–39 kg/m2) and morbidly obese (BMI > 40 kg/m2) patients, though the overall survival of the hip was less than 40% at 18 years in both groups because of a high failure rate in the uncemented acetabular component.
Total knee replacement surgery
We identified 9 studies that looked at the impact that BMI has on operative morbidity, and outcome in total knee replacements.
Studies that have examined the short-term impact of performing a total knee replacement in an obese patient have shown that obesity was associated with an increased length of hospital stay, discharge to a rehabilitation facility (as opposed to home) and a higher complication rate. The changes become more significant as BMI increased, in particular the morbidly obese suffered from increased wound problems, infections and medial collateral ligament avulsion.7,8
Several studies examined quality-of-life scores following total knee replacements in obese versus non-obese patients. Foran et al.9 showed that non-obese patients were significantly more likely to have a higher knee society score than the obese patients. Other studies, however, have shown that the knee society score increases by a similar amount postoperatively, and that obese patients tended to have lower postoperative scores, suggesting the higher scores postoperatively in the non-obese group reflect the pre-operative difference.10
The long-term impact of BMI on survival rates has also been studied. Spicer et al.10 had similar 10-year survival rates (97.2% in the 326 obese patients being better than 95.5% in the non-obese matched control group). By contrast Vazquez et al.11 showed a 10-year survival rate of 92.7% in obese patients versus 98.5% in the non-obese patients. Despite this difference being significant, the authors concluded by suggesting that good results were still obtainable in the obese group.
Discussion
In our study, 24% of the population undergoing total hip replacement and 38.5% of patients undergoing total knee replacement were obese. We accept the proportion of patients who are clinically obese may differ between regions, but it seems unlikely that the situation in East Suffolk differs greatly from that in West Suffolk; therefore, on the face of it, denying joint replacement to patients with a BMI > 30 kg/m2 represents a significant cost saving to a purchasing authority. However, this is done at the expense of an increase in suffering in those patients denied surgery. It also takes no account of either the increased cost to social services for the care of patients, some of whom are likely to require a much higher level of care than they would have needed following successful surgery, nor the problems that will be created in terms of both volume and complexity of surgery if this policy is reversed in a year or two.
We could find no convincing evidence in the literature to support the policy of denying anyone a hip replacement on the grounds of obesity. There may be some justification for requiring the morbidly obese to loose weight before having a total knee replacement. This view is supported by Horan in a recent Editorial on the subject.12
Conclusions
In our view, the current policy discriminates not just against the overweight, but also has a greater impact on women than men. Were this policy to be adopted nation-wide, it would lead to unnecessary suffering in over 20,000 people every year.
References
1.Coombes R. Rationing of joint replacements raises fears of further cuts. BMJ. 2005;331:1290. doi: 10.1136/bmj.331.7528.1290. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Jain N, Guller U, Pietrobon, Bond T, Higgins L. Co-morbidities increase complication rates in patients having arthroplasty. Clin Orthop. 2005;435:232–8. doi: 10.1097/01.blo.0000156479.97488.a2. [DOI] [PubMed] [Google Scholar]
3.Jiganti J, Goldstein W, Williams C. A comparison of the perioperative morbidity in total joint arthroplasty in the obese and non-obese patients. Clin Orthop. 1993;289:175–9. [PubMed] [Google Scholar]
4.Moran M, Walmsly P, Brenkel I. Does BMI affect the outcome of primary cemented total hip replacement? J Bone Joint Surg Br. 2004;86(Suppl):81. [Google Scholar]
5.McLaughlin JR, Lee KR. The outcome of total hip replacement in obese and non obese patients at 10- to 18-years. J Bone Joint Surg Br. 2006;88:1286–92. doi: 10.1302/0301-620X.88B10.17660. [DOI] [PubMed] [Google Scholar]
6.Chan C, Villar R. Obesity and quality of life after primary hip arthroplasty. J Bone Joint Surg Br. 1996;78:78–81. [PubMed] [Google Scholar]
7.Miric A, Lim M, Kahn B, Rozenthal T. Perioperative morbidity following total knee arthroplasty among obese patients. J Knee Surg. 2002;15:77. [PubMed] [Google Scholar]
8.Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am. 1998;80:1770–4. doi: 10.2106/00004623-199812000-00006. [DOI] [PubMed] [Google Scholar]
9.Foran JRH, Mont MA, Etienne G, Jones LC, Hungerford DS. The outcome of total knee replacements in obese patients. J Bone Joint Surg Am. 2004;86:1609–16. doi: 10.2106/00004623-200408000-00002. [DOI] [PubMed] [Google Scholar]
10.Spicer D, Pomeroy D, Badenhausen W, Jr, Schaper L, Curry J, Suthers K, et al. Body mass index as a predicator of outcome in total knee replacement. Int Orthop. 2001;25:246–9. doi: 10.1007/s002640100255. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Vazquez-Vela Johnson G, Worland R, Keenan J, Norambuena N. Patient demographic as a predictor of ten year survival rate in primary total knee replacement. J Bone Joint Surg Br. 2003;85:52–7. doi: 10.1302/0301-620x.85b1.12992. [DOI] [PubMed] [Google Scholar]
12.Horan F. Obesity and joint replacement [Editorial] J Bone Joint Surg Br. 2006;88:1269–71. doi: 10.1302/0301-620X.88B10.18272. [DOI] [PubMed] [Google Scholar]
1Patient Liaison Group, The Royal College of Surgeons of England, London, UK
✉
Correspondence to Liz Symonds, c/o Communications Department, The Royal College of Surgeons of England, London, UK E: elizabeth.symonds1@btinternet.com
This policy is presented as something over which the patients have control – weight loss. But, without a reliable evidence base to support it, or consultation with patients, clinicians and the public, it appears to be arbitrary rationing that saves money easily by targeting two easily-defined and numerically large groups of patients.
There is apparent lack of consideration of what the costs of delaying surgery may be to both patients and services. It is not clear if there has been consideration of how easy or difficult it will be for these two groups of people to lose weight and what support will be available. Getting in the habit of exercising will be good for the success of a new joint, but that should be part of planned preparation for all patients, regardless of BMI, with exercises that take account of pain and tiredness. In addition, with resources available to help people stop smoking, it would be logical if they were available for obesity too. Not just for people awaiting joint replacements of course, but those people do have particular challenges. Change of diet, especially if the patient is also the cook, can be hard. Preparing and cooking fresh food requires legs that work well; without an adapted kitchen, not enough can be done sitting down. For some, snacks and pre-prepared food will be the only options. If evidence indicates that obese patients will not benefit so much from joint replacements as non-obese patients, then patients should be encouraged to lose weight, but the obese patients are still benefiting. If a change in policy is to be considered there needs to be more research, including quality of life and patient-reported outcomes research, first. A benefit can still be substantial from the patient's point of view even if it is not the maximum, and it will be easier to exercise and change diet when it has been received. And what consideration will be given to the evidence in this paper suggesting that postponing knee surgery will affect more women than men? The trouble with sudden introductions of policy, even if based on sound evidence, is that those affected have not been told they are in an at-risk group or a group that needs to be careful. In this case they are women, who often are carers of others, which will make postponement of surgery even more difficult.
In the NHS, there is a mixed message that quality of care, patient choice and patient experience should be the prime influences on services, while resources are the real influence. It is naïve to think they are not. But a national debate about rationing, or preferably how to avoid it, is not started. Who wants to start such a fraught process, even if there could be re-assurance it is a temporary situation while finances are particularly tight? So there is a bit of rationing here and there, affecting people who were not expecting it, are not prepared for it and may not have the energy to fight it. Perhaps Primary Care Trusts want to start a debate, in the interests of their patients. They should say so.
