Lack of public bariatric surgery potentially “substandard care”

You’re not offering international level standard of care if you don’t have access to bariatric surgery. It’s about knowing that this is actually an integral part of the treatment of so many other diseases, that if patients are not able to access bariatric surgery in public hospitals when needed, we are offering care that fails to meet current standards. It’s as simple as that

DESPITE the well documented benefits of bariatric surgery beyond simple weight loss, fewer than ten public hospitals in Australia have bariatric services doing the surgery in any volume, a situation described by experts as “staggering”.

“About 30% of people who are wait-listed for a knee replacement can avoid it if they have bariatric surgery to lose weight,” said Associate Professor Ahmad Aly, Head of Upper Gastrointestinal Surgery at Austin Hospital in Melbourne.

“This is staggering. And yet we are not prioritising [bariatric surgery in the public health system].”

A/Professor Aly is the co-author of a Perspective, published by the MJA, detailing the benefits of bariatric surgery and the barriers to its routine occurrence in public hospitals in Australia.

Obesity is now the second largest risk for non-fatal disease in this country over the past 15 years, with direct costs estimated at $5.4 billion and indirect costs at $6.4 billion per year.

Associate Professor Michael Talbot, co-author of the MJA Perspective, and an upper gastrointestinal surgeon at St George Hospital in Sydney, told InSight+ that obesity was “more common than smoking”.

“Within a decade it will be our number one preventable cause of disease and death,” he said. “What we’re going to have is a whole lot of people turning up requiring care for their obesity-related conditions. So the current stress – medical and financial – with obesity is only going to get worse.”

Ninety per cent of bariatric is currently done in the private health system, a situation that penalises the patients who need it most, those in lower socio-economic populations.

“That’s the crux of the problem,” said A/Professor Talbot.

A/Professor Aly described the situation as “really concerning”.

“By 2025, the prediction is that about 80% of Australian adults aged 20 and over will be overweight or obese, with obesity probably sitting at around 40%. And about a third of children over five will be obese.”

Why is it so hard to have bariatric surgery performed in the public heath system?

Some of it is stigma, some of it is lack of understanding, and some of it is misconceptions, say A/Professors Aly and Talbot.

“The majority of hospitals are still vested with this idea that obesity is a lifestyle issue, that bariatric surgery is not necessary treatment,” said A/Professor Aly.

“It reflects an underlying lack of understanding of the biology, and reflects a lack of understanding of obesity as a disease. And it reflects a level of obesity stigma that persists.”

While all bariatric surgeons and services follow national and international guidelines for who should be considered for surgery, those guidelines date back to 1992.

The Australian and New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) formed a national taskforce to develop a standardised set of criteria for who should be eligible for bariatric surgery.

“If you just tried to operate on everybody, you’d be operating all day, every day, and you wouldn’t get through it because the burden is incredibly high,” said A/Professor Aly.

“Arguably, you will also be operating on people that don’t necessarily need surgery.

“If we model obesity as a chronic disease, you’re looking at an incurable progressive disease that presents for care at different stages. And like any disease of that nature, there are appropriate interventions for the stage of disease and for that individual.

“We should be couching our treatment, including surgery, in the framework of that multimodal chronic disease model, which means patients that need help don’t always need surgery. There are many other treatments that we can offer that might be appropriate for that individual at that time.

“So, our bariatric services need to be cognizant of that and work in that multimodal framework.”

As an example of the criteria for public bariatric surgery, the Alfred Hospital in Melbourne requires candidates to:

• have either a body mass index (BMI) greater than 40, or less than 35 with two or more morbid obesity-related comorbidities;
• be aged between 18 and 65 years;
• have tried but failed to achieve or maintain clinically beneficial weight loss using non-surgical measures.

A/Professor Aly told InSight+ that the BMI-centric approach could be replaced by a framework that prioritised mortality risk over BMI, using the Edmonton Obesity Staging System.

“It’s a hard endpoint, but it’s a measurable one,” he said.

“There are two ends: there’s the extreme end, where pretty much no matter what you do, they’re on a path to mortality. In which case, it’s probably not sensible to be offering bariatric surgery to that patient, certainly in the public system, with the constrained resources.

“At the other end, you have people that have a very low risk of mortality. I’m not saying they wouldn’t necessarily benefit in some way from surgery, but their mortality risk is very low, at least at that stage, when they’re presenting.

“But the group in the middle are more likely to derive that mortality benefit.

“We know that bariatric surgery saves lives, it’s been clearly documented that it reduced cardiovascular and cancer risk by 30% or so.

“We reasoned that this was a validated score that could be used to select patients where we believe we’re getting the most value.

“In the delivery of a public surgery service, we need to be cognizant of resource constraints and the volume of disease and build that into our selection criteria so that we can get the maximum benefit.”

In their MJA Perspective, A/Professor Aly and Talbot, and co-author Professor Wendy Brown, Chair of Surgery at Monash University and the Alfred Hospital, wrote that public hospitals’ reluctance to set up bariatric surgery services was not about lack of surgeons, nor about lack of proven efficacy, nor a question of safety or intensive inpatient resource use.

“Obesity stigma based on misperception of obesity as a self-inflicted lifestyle choice, a lack of understanding of the powerful physiology that drives weight regain, and a misplaced belief that conservative treatment suffices persist among the general community, medical practitioners and health policymakers, leading to easy sidelining of service establishment at the local level,” they wrote.

At the heart of the problem lies the need for funding reform.

“We allow people with severe obesity to cycle in and out of health services without actually treating the underlying condition,” said A/Professor Talbot.

“You save money by treating people effectively, right? But you need the investment in the service to start providing effective treatment.”

A/Professor Aly said that willingness to invest was hard to find in hospital administrations.

“There is no funding for the establishment of a multidisciplinary clinic, which is absolutely crucial for helping to treat a person with obesity, otherwise, there’s no point doing the operation,” he said.

“Somehow the hospital has to take the money, they will pay for that activity, and make it sufficient to cover the activity as well as this multidisciplinary clinic.

“We need to change that funding model somewhat. It can’t be just activity-based, we need to be providing some level of resource for the multidisciplinary care.

“We’re already spending that money, as Michael said, in our patients, treating them over and over and over again. We need to change our funding model to be able to redirect that in the appropriate way.

“Even within my own hospital, I said, if you want me to do an extra 50 operations, you can fund me for those 50 operations by giving me another half a million dollars. Or you can give me one dietician session a week and a nurse session a week, and I’ll give you those 50 operations.

“What I actually need is this ancillary support to get it done.”

The bottom line is something has to change. Forcing people into the private system and its out-of-pocket costs, or forcing them to continue untreated, is an indication of poor levels of care, said A/Professor Aly.

“If you run a diabetes treatment service, and you don’t offer bariatric surgery, or have access to bariatric surgery, you can argue that you’re running the risk of providing substandard care,” he said.

“You’re not offering international level standard of care if you don’t have access to bariatric surgery.

“So it isn’t just about establishing a bariatric surgical service for the sake of it. It’s about knowing now that this is actually an integral part of the treatment of so many other diseases, that if patients are not able to access bariatric surgery in public hospitals when needed, we are offering care that fails to meet current standards.

“It’s as simple as that.”

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