{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T23:15:37Z","timestamp":1790291737370,"version":"4.1.0"},"reference-count":43,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2022,6,29]],"date-time":"2022-06-29T00:00:00Z","timestamp":1656460800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West"},{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"publisher","award":["NIHR 301469"],"award-info":[{"award-number":["NIHR 301469"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100015250","name":"NIHR Bristol Biomedical Research Centre","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100015250","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Objective<\/jats:title>\n<jats:p>To assess the impact of local commissioners\u2019 policies for body mass index on access to knee replacement surgery in England.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry for England data linked to the 2015 Index of Multiple Deprivation for 481,555 patients who had primary knee replacement surgery in England between January 2009 and December 2019. Clinical Commissioning Group policies introduced before June 2018 to alter access to knee replacement for patients who were overweight or obese were considered the intervention. The main outcome measures were rate per 100,000 of primary knee replacement surgery and patient demographics (body mass index, Index of Multiple Deprivation, independently-funded surgery) over time.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Rates of surgery had a sustained fall after the introduction of a policy (trend change of -0.98 operations per 100,000 population aged 40+, 95% confidence interval -1.22 to -0.74, P&lt;0.001), whereas rates increased in localities with no policy introduction. At three years after introduction, there were 10.5 per 100,000 population fewer operations per quarter aged 40+ compared to the counterfactual, representing a fall of 14.1% from the rate expected had there been no change in trend. There was no dose response effect with policy severity. Rates of surgery fell in all patient groups, including non-obese patients following policy introduction. The proportion of independently-funded operations increased after policy introduction, as did the measure of socioeconomic deprivation of patients.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Body mass index policy introduction was associated with decreases in the rates of knee replacement surgery across localities that introduced policies. This affected all patient groups, not just obese patients at whom the policies were targeted. Changes in patient demographics seen after policy introduction suggest these policies may increase health inequalities and further qualitative research is needed to understand their implementation and impact.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0270274","type":"journal-article","created":{"date-parts":[[2022,6,29]],"date-time":"2022-06-29T17:29:38Z","timestamp":1656523778000},"page":"e0270274","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":10,"title":["What effect have NHS commissioners\u2019 policies for body mass index had on access to knee replacement surgery in England?: An interrupted time series analysis from the National Joint Registry"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9921-4698","authenticated-orcid":true,"given":"Joanna","family":"McLaughlin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"Kipping","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Owen-Smith","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugh","family":"McLeod","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samuel","family":"Hawley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J Mark","family":"Wilkinson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Judge","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,6,29]]},"reference":[{"key":"pone.0270274.ref001","doi-asserted-by":"crossref","first-page":"1672","DOI":"10.1016\/S0140-6736(18)32344-4","article-title":"Knee replacement","volume":"3","author":"AJ Price","year":"2018","journal-title":"Lancet"},{"key":"pone.0270274.ref002","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1016\/S0140-6736(11)60752-6","article-title":"Knee replacement","volume":"379","author":"AJ Carr","year":"2012","journal-title":"Lancet"},{"key":"pone.0270274.ref003","first-page":"29","article-title":"Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies","author":"A Cui","year":"2020","journal-title":"EClinicalMedicine"},{"key":"pone.0270274.ref004","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1016\/j.joca.2012.02.636","article-title":"The lifetime risk of total hip and knee arthroplasty: Results from the UK general practice research database","volume":"20","author":"DJ Culliford","year":"2012","journal-title":"Osteoarthritis and Cartilage"},{"key":"pone.0270274.ref005","unstructured":"Brittain R, Howard P, Lawrence S, Stonadge J, Wilkinson M, Wilton T, et al. 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