HIO-Joint Study version1
Research type
Research Study
Full title
Investigating the effectiveness of pre-surgical ‘health optimisation’ public health interventions for obesity and smoking in elective hip and knee replacement surgery from health service and patient perspectives. Health improvement Opportunities for Joint arthritis patients (HIO-Joint study)
IRAS ID
294970
Contact name
Joanna McLaughlin
Contact email
Sponsor organisation
University of Bristol
Clinicaltrials.gov Identifier
NIHR301469, NIHR Doctoral Fellowship
Duration of Study in the UK
2 years, 1 months, 31 days
Research summary
Summary of Research
This research seeks to improve our understanding of National Health Service (NHS) interventions known as ‘health optimisation’ interventions. These interventions typically require patients to be offered support to lose weight or stop smoking ahead of surgery - most often for hip and knee replacement. Despite being commonly used, little evidence has been published to show whether they are beneficial and value for money, nor whether they have harmful effects, like making access to surgery difficult.The study is funded by the National Institute for Health Research, and will collect quantitative and qualitative data. Citizens and patients are key partners in this research and their involvement has shaped the study and will guide the interpretation and dissemination of the study’s findings.
A geographical area in South West England has introduced a health optimisation intervention which offers patients considering hip or knee surgery support to lose weight or stop smoking where needed. The study will gather data on patients referred to the intervention to understand how their care, outcomes and experience was different to patients in neighbouring regions that have no such existing intervention.
Participants will complete questionnaires at three points over 12 months on whether they were successful in losing weight or stopping smoking and how they went about their attempt. With their consent, routinely collected NHS data will be linked in to determine their demographics, clinical needs and outcomes – including whether they proceed to have surgery.
The study will use focus groups/interviews to investigate patient experiences of being offered the intervention. The study will also use interviews with key representatives from the organisations responsible for setting the interventions to understand what influences their decisions. The research evidence will equip these organisations to make evidence-based decisions on the use of health optimisation interventions, with an impact on many thousands of patients.
Summary of Results
This study had two parts - a questionnaire study for patients, and an interview study for healthcare and commissioning professionals.The questionnaire study was closed without reaching the point of data collection. This was due to the insufficient number of referrals of patients into the health optimisation service under study.
The interview study was completed as planned and is summarised below:
Introduction:
Interventions to help patients with obesity lose weight in the time before non-urgent surgery are encouraged in the UK NHS. There is regional variation in the introduction of these interventions. Despite National Institute for Health and Care Excellence (NICE) guidance to the contrary, ‘health optimisation’ policies with mandatory body mass index (BMI) thresholds are increasingly used to alter access to joint replacement surgery. This qualitative study investigated professionals' views on pre-surgical BMI-related policies.Methods:
Research interviews were conducted with twenty participants (commissioners, policy-makers, and clinical/public health professionals) involved in health optimisation policymaking and implementation. The interview topic guide covered: evidence, policy and practice, inequalities, and the future of health optimisation. Interview transcript data were analysed to identify key themes.Results:
Current practice
Participants accepted obesity reduction as a worthwhile pre-surgical goal, but expressed concern over the use of BMI as a threshold and the limited evidence for health optimisation's impact on long-term outcomes. Some participants supported a mandatory element of health optimisation, but more prominent were concerns about a risk of worsening health inequalities through limiting access to surgery. Participants highlighted obesity’s association with deprivation and under-provision of inclusive weight management support.Variation
Participants identified structural elements allowing variation: lack of national guidance, commissioning structures which permit localised decision-making, lack of challenge to NICE guidance non-compliance, and uncertain ownership of pre-surgical intervention planning/budgetary responsibility. Local factors driving restrictive policies included the strength of local leadership, appetite for reputational/legal risk, waiting list/financial pressures, ‘policy equalisation’ across neighbouring geographies, framing obesity as a personal responsibility, and ‘cherry-picking’ evidence.Future directions
Participants were consistent in identifying factors important in the expansion of good practice in prehabilitation: the need for adequate funding and leadership, digital and data linkage improvements, medical education and staff training, availability of accessible obesity services, and rigorous evaluation of existing approaches. There was variation in participants’ views on where health improvement is best placed within surgical pathways and in the role of national prehabilitation requirements.Conclusions:
Regional variation in pre-surgical obesity intervention reflects local drivers to introduce BMI policies that restrict access to surgery. Clinicians, commissioners and policy-makers seek to increase evidence-based prehabilitation which is sensitive to impacts on health inequalities.REC name
South West - Cornwall & Plymouth Research Ethics Committee
REC reference
21/SW/0106
Date of REC Opinion
24 Aug 2021
REC opinion
Favourable Opinion