UK: No joint replacements for obese patients?

December 22, 2005

Dec 22, 2005

London, UK - A storm of controversy has erupted in the UK, after one local health authority announced that it would be denying joint-replacement surgery to obese patients, in an attempt to save money for the National Health Service (NHS). Three primary-care trusts in east Suffolk announced that they would no longer consider patients for either hip- or knee-replacement surgery if they had a body-mass index (BMI) of more than 30.

If you are in severe pain, you are in severe pain. It's not humane to say we can't help you because you are not in the band of normal weight.

This condition was one of several "thresholds to treatment" drawn up by a group of consultants who carry out the procedures at Ipswich Hospital after discussions with local general practitioners, says a news report in the December 3, 2005 issue of BMJ [ 1 ]. Other "thresholds" were drawn up for the treatment of varicose veins and the use of grommets in children with glue ear. Dr Brian Keeble, director of public health for the Ipswich Primary Care Trust, said that serious financial pressures were behind the decision. "We cannot pretend that this work wasn't stimulated by the pressing financial problems of the NHS in East Suffolk," he is quoted as saying. This branch of the NHS currently has a deficit of ¿47.9 million ($83 million), which it is expected to eliminate before the end of the financial year.

The announcement has caused outrage. "If you are in severe pain, you are in severe pain. It's not humane to say we can't help you because you are not in the band of normal weight," says Dr David Dandy, vice president of the Royal College of Surgeons and a retired knee surgeon. He also points out that "by setting the [BMI] limit at 30, you are eliminating half the population."

"The decision on whether patients should receive treatment should always be based on clinical need and not solely financial reasons," adds Dr Jonathan Fielden, deputy chair of the British Medical Association consultants' committee, in the BMJ news report.

"Relief of pain is a universal human right, and if the trusts under discussion refuse to provide the most cost-effective treatment for severe [osteoarthritis] OA to these patients, one hopes they have the integrity and compassion to increase the resources available for the conservative management of these unfortunate patients," says musculoskeletal rehabilitation physician Dr Michael Vagg (McKellar Centre, Victoria, Australia), writing in an emailed rapid response to the BMJ [ 2 ]. "The rationale for introducing these changes is specious and ill considered. They will not save money overall, as the cost of managing these patients without a joint replacement will exceed the putative savings on prostheses.

The rationale for introducing these changes is specious and ill considered. They will not save money overall, as the cost of managing these patients without a joint replacement will exceed the putative savings on prostheses.

"This does not represent 'market forces' at work, this is arbitrary punishment of people who have often put on weight as their OA has increased their disability and restricted their ability to maintain appropriate activity levels," Vagg argues.

"The decision is perverse and appears to breach basic principles of healthcare," says obesity medicine consultant Nicholas Finer (Addenbrookes Hospital, Cambridge, UK). Patients shouldn't be judged for their illness, he says: logically extended, such a policy would deny treatment to, among others, smokers, most patients with HIV infection, and those who sustain sports injuries.

In a published letter to the BMJ [ 3 ], Finer questions the scientific evidence behind the decision, pointing out that the link between obesity and osteoarthritis?while fairly clear in the case of knee OA?is less clear when it comes to hips. He quotes from a recent UK Health Technology Assessment [ 4 ] of hip replacement, which concluded that "obese patients¿.¿.¿.¿could benefit from total primary hip arthroplasties without cement and that obesity did not markedly increase the operative risk." He also quotes another review [ 5 ], which concluded: "There was no statistically significant difference in the improvement in scores (of quality of life) between the nonobese and obese groups. It appears that relative body weight on its own does not influence the benefit derived from primary total hip arthroplasty."


Hip replacements more difficult in obese?

The decision is perverse and appears to breach basic principles of health care.

Among the reasoning behind the decision is the perception that hip replacements can be more difficult in obese patients. In the BMJ news report, Christopher Bulstrode, professor of trauma and orthopedics at Oxford University, says he tries to avoid carrying out hip replacements in patients with a BMI >35. "Obese patients are very difficult to operate on when doing a hip replacement because the weight tends to go on around the hips. This means that we have to make a longer incision to get down to the hip, so they lose more blood. There is also more dead space when we close, which could act as a locus for infection, so they tend to get infected more often. So my own personal experience is that the operation takes longer, the anesthetic takes longer, the bed stay is also longer, and the complication rates are higher."

However, others disagree. "I accept the complication rate is higher, but not excessively so. Putting the joints in fat patients means you just have to work a little harder: it is not dangerous I or impossible!" says consultant orthopedic surgeon Dr John Mackinnon (Cheltenham), writing in a rapid response to the BMJ [ 6 ]. "There is no convincing evidence of increased failure of the implants. There is no convincing difference in longevity or outcome in obese patients. The quality-of-life improvement is generally so good it is difficult to deny 'normal' people this surgery, and half the population in this age group will be obese."

 


Sources


  1. Coombes R. Rationing of joint replacement raises fears of further cuts. BMJ 2005; 331:1290. Abstract

  2. Vagg M. Re: Rationing joint replacements. BMJ 2005. Available at: http://bmj.bmjjournals.com/cgi/eletters/331/7528/1290#123161.

  3. Finer N. Rationing joint replacements: trust's decision seems to be based on prejudice or attributing blame. BMJ 2005; 331:1472. Abstract

  4. Faulkner A, Kennedy LG, Baxter K, et al. Effectiveness of hip prostheses in primary total hip replacement: a critical review of evidence and an economic model. Health Technol Assess 1998:2:1-133. Abstract

  5. Chan Cl, Villar RN. Obesity and quality of life after primary hip arthroplasty. J Bone Joint Surg Br 1996; 78: 78-81. Abstract

  6. Mackinnon J. Re: Rationing joint replacements. BMJ 2005. Available at: http://bmj.bmjjournals.com/cgi/eletters/331/7528/1290 .

 

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