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
Funder: Department of Health and Social Care

Abstract: Research question What impact do pre-surgical health optimisation interventions (for obesity and smoking) in hip and knee replacement patients have on patient outcomes, are they cost effective and do they risk causing health inequalities? Background Clinical Commissioning Groups (CCGs) have introduced 'health optimisation' interventions (HOIs) that require or support National Health Service (NHS) patients to lose weight and/or stop smoking ahead of surgical referral. The interventions are intended to: Improve clinical outcomes from surgery Reduce the need for surgery Trigger long-term lifestyle changes in patients at a key moment in their lives when they are motivated to improve their healthThere is significant geographical variation in intervention content, reflecting the current inadequate evidence-base for their effects on patients, public health and cost-effectiveness. They also have potential unintended consequences of increasing health inequalities through differential impact on vulnerable sociodemographic groups' access to surgery. Evaluations of existing interventions have not been published. Aims and objectives Investigate the effectiveness, cost-effectiveness and impact on health inequalities of HOIs for body mass index (BMI) and smoking in elective hip and knee replacement surgery from NHS and patient perspectives, using a mixed methodology approach. Methods Complete four Work Packages and a training and development programme through collaboration with clinical, commissioning and research settings and with integral patient and public involvement (PPI): Natural experimental study using existing data centred on the National Joint Registry for England to determine the impact of HOIs on surgery rates, patient clinical and public health outcomes and association with sociodemographic inequality. Data will be analysed using interrupted time series and difference-in-differences analyses to assess the effect of HOI introduction on trends in outcomes before and after the date a HOI was introduced in each CCG area. Extended natural experimental study with an embedded case study of a CCG's new HOI in one of its sub-regions. This will address deficits in existing datasets and evaluations by measuring patient engagement and changes in BMI and smoking status, and the associated costs, alongside the outcomes addressed above. Health economic modelling with use of data from Work Packages 1 and 2 and published literature to estimate the long-term cost-effectiveness of HOIs relating to hip and knee replacement surgery. Qualitative study using interviews with 30 key stakeholders and six citizen focus groups in two contrasting English regions to investigate their views on HOIs and the motivations and barriers to their introduction.Timelines Three-year full-time doctoral fellowship where the Work Packages are completed in parallel including time for reporting and dissemination. Anticipated impact and dissemination I will work with PPI groups and collaborators to use the findings to form and disseminate meaningful recommendations to policy decision-makers and wider stakeholders to enable their evidence-based decisions on the ongoing use or expansion of HOIs. This will have an immediate impact on many thousands of patients. There may be the result of a recommendation of a standard HOI for all CCGs where this would improve outcomes, public health and use of health and care resources.

Lay abstract: This research seeks to improve our understanding of the effects 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. These interventions are rising within the NHS and differ by geographical area; sometimes with strict requirements for patients to reach a target weight or quit smoking before surgery. Some patients receive professional support, whereas others may have to make lifestyle changes on their own. The intended effect of health optimisation interventions is to: Improve patient health before surgery, for safer surgery and better patient outcomes Reduce the number of patients who need surgery Trigger long-term lifestyle changes in patients at a key moment in their lives when they are motivated to improve their health.Though some areas of England have had interventions in place for many years and intervention use is increasing, their effects have not been evaluated adequately. This means there is little evidence to show that they meet any of their intended purposes and whether they are beneficial to patients and good value for money. There is also concern that they might have harmful effects, like making access to surgery more difficult for certain groups in society e.g. minority ethnic groups with higher levels of obesity, or carers who struggle to find time to take up support to stop smoking. For the first time, this research will examine the national picture on the use of health optimisation interventions and study in detail the effects of individual interventions. The research will investigate the interventions in three different ways: Using a register of all hip and knee replacement surgery completed in England since 2010, I will investigate whether patients under these interventions had different amounts of surgery and different outcomes, compared to patients in areas with less strict or no such interventions. This will help us understand whether these interventions affect access to surgery, whether they are good value for money and whether they are causing unfair differences in some groups in society. In a geographical area introducing a new health optimisation intervention, I will follow patients for 18 months to understand how their care, outcomes and experience was different to patients in the area before the intervention started, or to patients in neighbouring regions that have no such existing intervention. For example, did the patients successfully lose weight and did they still need surgery? This would help us understand where interventions could be improved. Use interviews and focus groups to talk to the people responsible for setting the interventions (commissioners), GPs, surgeons and citizens to understand their views on these interventions and what influences their decisions on whether to use them in the future.Citizens and patients are key partners in this research and their involvement has been planned at all stages. This will ensure that I use the most suitable research methods, address the real impacts on patients and their families, and that I do an effective job of communicating my findings for the benefit of others. To do this I will make the results publicly available on websites and in print. I will have a communication and engagement plan to actively share the recommendations from this work with those who have most influence on how the interventions are used. This will ensure the best versions of the interventions are used by the NHS in the future to help more patients improve their health before surgery and reduce unnecessary operations without causing unfair disadvantages between social groups.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE