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BACKGROUND: Despite their widespread use, the impact of commissioners' policies for body mass index (BMI) for access to elective surgery is not clear. Policy use varies by locality, and there are concerns that these policies may worsen health inequalities. The aim of this study was to assess the impact of policies for BMI on access to hip replacement surgery in England. METHODS: A natural experimental study using interrupted time series and difference-in-differences analysis. We used National Joint Registry data for 480,364 patients who had primary hip replacement surgery in England between January 2009 and December 2019. Clinical commissioning group policies introduced before June 2018 to alter access to hip replacement for patients with overweight or obesity were considered the intervention. The main outcome measures were rate of surgery and patient demographics (BMI, index of multiple deprivation, independently funded surgery) over time. RESULTS: Commissioning localities which introduced a policy had higher surgery rates at baseline than those which did not. Rates of surgery fell after policy introduction, whereas rates rose in localities with no policy. 'Strict' policies mandating a BMI threshold for access to surgery were associated with the sharpest fall in rates (trend change of - 1.39 operations per 100,000 population aged 40 + per quarter-year, 95% confidence interval - 1.81 to - 0.97, P 

Original publication




Journal article


Bmc med

Publication Date





Commissioning, Epidemiology, Health policy, Hip replacement, Obesity, Osteoarthritis, Humans, Body Mass Index, Interrupted Time Series Analysis, England, Obesity, Policy, Registries