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Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement

Giori, Nicholas J., MD, PhD1,2,a; Amanatullah, Derek F., MD, PhD2; Gupta, Shalini, MS1; Bowe, Thomas, PhD1; Harris, Alex H.S., PhD1,2

doi: 10.2106/JBJS.17.00120
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Background: Morbidly obese patients with severe osteoarthritis benefit from successful total joint arthroplasty. However, morbid obesity increases the risk of complications. Because of this, some surgeons enforce a body mass index (BMI) eligibility criterion above which total joint arthroplasty is denied. In this study, we investigate the trade-off between avoiding complications and restricting access to care when enforcing BMI-based eligibility criteria for total joint arthroplasty.

Methods: In this retrospective cohort study, the Veterans Health Administration (VHA) Corporate Data Warehouse (CDW) and Veterans Affairs Surgical Quality Improvement Program (VASQIP) databases were reviewed for patients undergoing total joint arthroplasty from October 2011 through September 2014. We determined, if various BMI eligibility criteria had been enforced over that period of time, how many short-term complications would have been avoided, how many complication-free surgical procedures would have been denied, and the positive predictive value of BMI eligibility criteria as tests for major complications. To provide a frame of reference, we also determined what would have happened if eligibility for total joint arthroplasty were arbitrarily determined by flipping a coin.

Results: In this study, 27,671 total joint arthroplasties were reviewed. With a BMI criterion of ≥40 kg/m2, 1,148 patients would have been denied a surgical procedure free of major complications, and 83 patients would have avoided a major complication. The positive predictive value of a complication using a BMI of ≥40 kg/m2 as a test for major complications was 6.74% (95% confidence interval [CI], 5.44% to 8.33%). The positive predictive value of a complication using a BMI criterion of 30 kg/m2 was 5.33% (95% CI, 4.99% to 5.71%). Flipping a coin had a positive predictive value of 5.05%.

Conclusions: A 30 kg/m2 criterion for total joint arthroplasty eligibility is marginally better than flipping a coin and should not determine surgical eligibility. With a BMI criterion of ≥40 kg/m2, the number of patients denied a complication-free surgical procedure is about 14 times larger than those spared a complication. Although the acceptable balance between avoiding complications and providing access to care can be debated, such a quantitative assessment helps to inform decisions regarding the advisability of enforcing a BMI criterion for total joint arthroplasty.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

1VA Palo Alto Health Care System, Palo Alto, California

2Stanford University, Stanford, California

aE-mail address for N.J. Giori: ngiori@stanford.edu

Written work prepared by employees of the Federal Government as part of their official duties is, under the United States Copyright Act, a ‘work of the United States Government’ for which copyright protection under that Act is not available. As such, copyright protection does not extend to the contributions of employees of the Federal Government prepared as part of their employment.
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