February 10, 2017
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UK clinical group proposes rationing joint replacements to save money

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A proposal being considered by U.K. Clinical Commissioning Groups in the Worcestershire area seeks to ration total knee and hip replacement surgery based on various factors, including Oxford hip and knee scores, an outcome measure opponents of the proposal say was not designed to be used in this manner.

A spokesperson for the three Worcestershire Clinical Commissioning Groups (CCGs) said in a statement dated 27 January: “The Oxford scoring system is a guidance for clinicians who recognize that many patients will benefit from physiotherapy and weight loss before considering surgery.”

Ian B. Winson

Ray Fitzpatrick

Stephen Cannon

The statement noted that a reduction of the Oxford Hip score (OHS) and Oxford Knee score (OKS) from 30 points to 25 points would bring the Worcestershire CCGs into line with what other CCGs do and help reduce what the CCG spends on these two surgeries.

Articles in the U.K. press the week of 23 January first alerted the British Orthopaedic Association (BOA), the Royal College of Surgeons of England (RCS) and others to the proposal.

“We only got the heads up last week,” BOA president Ian B. Winson, MB, ChB, FRCS, told Orthopaedics Today Europe on 2 February.

Other CCGs have recently looked at adopting a similar approach, but have backed down on the idea, according to Winson.

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Measures as screening tools

Rationing hip and knee replacements in the United Kingdom as a cost-savings measure has been recommended in the past and this is not the first time the OHS and OKS have been proposed as a cut-off tool. But, it is inappropriate, as it is not designed for this purpose, Winson said.

“Essentially, they are trying to save money and think they found an easy way of doing this. [It] is a false way of looking at it to say that patients need a severe pain score before they deserve their operation,” Winson said.

Evidence shows that if patients wait for their surgery once their symptoms get to the point where they would contemplate surgery following advice, then their general health will deteriorate and the benefit of the surgery to their quality of life will be less significant, Winson noted. Timely surgery means patients with moderately bad symptoms will achieve a score close to normal when monitor. Patients who have prolonged symptoms and severe symptoms will never achieve anything close to a normal score, he said.

“It is a crazy situation. The whole principle is flawed because ultimately, if they are trying to save money by limiting appropriate people to surgery in a timely manner, it is costing the system as a whole money,” Winson, a foot and ankle surgeon who practices in Bristol, said.

Instead of rationing to reduce local health care costs, the BOA and other groups favor the implementation of a core plan that supports performing these procedures more efficiently. In that way, osteoarthritis would be managed by surgery at an early stage where it gets the best benefit for the patient.

Ray Fitzpatrick, BA, MSc, PhD, FMedSci, professor of public health and primary care in the Department of Public Health at Oxford University, who was a member of the team that developed the OHS and OKS, said he could find no strengths to the proposal.

He discussed research his group did in 2012 concerning rationing THR and TKR and said he thought the CCGs in Worcestershire were using the scores for needs assessment.

“The risk is that using these scores in sort of a mechanical way would ration access to treatment for people who will derive enormous benefit from it. The evidence that we have produced and that other people have produced of the cost-effectiveness of hip and knee replacement suggests they are cost-effective at moderate levels of pain and disability,” Fitzpatrick said.

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Creating a future problem

RCS Vice President Stephen Cannon, MCh, Orth, FRCS, MBE, who is an Orthopaedics Today Europe Editorial Board member, agreed with Winson and Fitzpatrick.

“I have not heard anyone say it is a good idea,” Cannon said, and noted that using the OHS and OKS to determine who needs an operation is a concern because patients with arthritis will eventually get down to a score that allows them to have the surgery.

“They are just stockpiling a problem to come.”

Cannon said, “These are clinical decisions that should remain in the clinician’s hands. They should not be allocated to what, in effect, is an accountancy principle.”

This CCG is trying to save £2 million by denying surgery to 350 people, “which is iniquitous,” Cannon said.

Cannon has been the face of the RCS in its wide-scale media exposure to put pressure on the government to consider better ways to fund its health service.

The Worcestershire CCG includes the Wyre Forest NHS CCG, the Redditch and Bromsgrove NHS CCG and the South Worcestershire NHS CCG. All the CCGs have approved the paper, including the Wyre Forest NHS CCG Governing Body, which approved it at its meeting on 7 February. The related time scales have yet to be determined, according a spokesperson for the CCGs in Worcestershire. – by Susan M. Rapp

References:

Dakin H, et al. BMJ Open. 2012;doi:10.1136/bmjopen-2011-000332.

www.boa.ac.uk/latest-news/letter-to-the-times-rationing-in-hip-and-knee-replacements/: Accessed Jan. 31, 2017.

www.rcseng.ac.uk/news-and-events/media-centre/press-releases/oxford-score-rationing/: Accessed Feb. 1, 2017.

Disclosures: Cannon, Fitzpatrick and Winson report no relevant financial disclosures.