You are not providing internationally standard care if you do not have access to bariatric surgery. It’s about knowing that this is actually an integral part of treating so many other diseases, that if patients can’t access bariatric surgery in public hospitals when needed, we’re providing care that doesn’t 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 that perform the surgery in any volume, a situation described by experts as “shocking”.
“About 30% of people on the waiting list for a knee replacement can avoid it if they have bariatric surgery to lose weight,” said Associate Professor Ahmad Aly, head of gastrointestinal surgery senior at Melbourne’s Austin Hospital.
“That’s amazing. And yet we’re not prioritizing [bariatric surgery in the public health system]”.
A/Professor Aly co-authored a perspective, published by the MJA, detailing the benefits of bariatric surgery and barriers to its routine occurrence in Australian public hospitals.
Obesity is now the second largest non-fatal disease risk in this country over the past 15 years, with direct costs estimated at $5.4 billion and indirect costs at $6.4 billion annually.
Associate Professor Michael Talbot, co-author of the MJA Perspective and senior gastrointestinal surgeon at St George’s Hospital in Sydney, told InSight+ that obesity was “more common than smoking”.
“In a decade it will be our number one preventable cause of disease and death,” he said. “What we’re going to have is a lot of people showing up who require care for their obesity-related conditions. So the current stress, medically and financially, with obesity is only going to get worse.”
Ninety percent of bariatric surgery is currently done in the private healthcare system, a situation that penalizes patients who need it most, those from lower socioeconomic populations.
“That’s the crux of the problem,” Professor Talbot said.
Teacher A/Aly described the situation as “really worrying”.
“By 2025, the prediction is that around 80% of Australian adults aged 20 and over will be overweight or obese, with obesity likely to be around 40%. And around a third of children aged five and over will be obese”.
Why is it so difficult to get bariatric surgery in the public health system?
Part of it is stigma, part of it is lack of understanding and part of it is misconceptions, say Professors A/Aly and Talbot.
“Most hospitals still have this idea that obesity is a lifestyle problem, that bariatric surgery is not a necessary treatment,” Professor Aly said.
“It reflects an underlying lack of understanding of biology and it reflects a lack of understanding of obesity as a disease. And it reflects a level of obesity stigma that persists.”
Although all bariatric surgeons and services follow national and international guidelines on who should be considered for surgery, these guidelines date back to 1992.
The Australian and New Zealand Obesity and Metabolic Surgery Society (ANZMOSS) formed a national working group to develop a standardized set of criteria for who should be eligible for bariatric surgery.
“If you just tried to operate on everyone, you’d be operating all day, every day, and you wouldn’t make it because the burden is incredibly high,” Professor Aly said.
“You may also be operating on people who don’t necessarily need surgery.
“If we model obesity as a chronic disease, you’re looking at a progressive, incurable disease that presents itself for treatment at different stages. And like any disease of this nature, there are appropriate interventions for the stage of the disease and for this individual.
“We should adapt our treatment, including surgery, within this multimodal chronic disease model, which means that patients who need help don’t always need surgery. There are many other treatments we can offer that can be appropriate for that person at that time.
“So our bariatric services need to be aware of this and work within this multimodal framework.”
As an example of the criteria for public bariatric surgery, The Alfred Hospital in Melbourne requires candidates to:
- have a body mass index (BMI) greater than 40 or less than 35 with two or more comorbidities related to morbid obesity;
- be between 18 and 65 years old;
- have attempted but failed to achieve or maintain clinically beneficial weight loss through nonsurgical measures.
Professor A/Aly told InSight+ that the BMI-focused approach could be replaced by a framework that prioritizes mortality risk over BMI, using the Edmonton Obesity Staging System .
“It’s a tough endpoint, but it’s measurable,” he said.
“There are two extremes: there’s the extreme, where it almost doesn’t matter what you do, they’re on the path to mortality. In that case, it’s probably not reasonable to offer bariatric surgery to that patient, certainly in the public system, with limited resources.
“At the other extreme, there are people who have a very low risk of mortality. I’m not saying that they don’t necessarily benefit in some way from surgery, but their risk of mortality is very low, at least at this stage, when they present themselves
“But the middle group is more likely to get that mortality benefit.
“We know that bariatric surgery saves lives, it has 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 felt we were getting the most value.
“In providing a public surgery service, we need to be aware of resource constraints and the volume of disease and incorporate this into our selection criteria so that we can get maximum benefit.”
In their MJA perspective, Professor Aly and Talbot and co-author Professor Wendy Brown, chair of surgery at Monash University and The Alfred Hospital, wrote that the reluctance of public hospitals to establish bariatric surgery services was not because of the lack of surgeons, or about the lack of proven effectiveness, or a question of safety or intensive use of hospital resources.
“Obesity stigma based on the misperception of obesity as a self-inflicted lifestyle choice, a lack of understanding of the powerful physiology that drives weight regain, and a mistaken belief that conservative treatment is “Sufficient knowledge persists among the general community, clinicians and health officials to facilitate the elimination of service establishment at the local level,” they wrote.
At the heart of the problem is the need for funding reform.
“We allow people with severe obesity to come in and out of health services without actually treating the underlying condition,” Professor Talbot said.
“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 the 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 to help treat an obese person, otherwise there is no point in doing the operation,” he said.
“Somehow the hospital has to take the money, they will pay for this activity, and they will make it enough to cover the activity and this multidisciplinary clinic.
“We need to change this funding model a bit. It can’t just be based on activity, we need to provide some level of resources for multidisciplinary care.
“We’re already spending that money, as Michael said, on our patients, treating them over and over and over again. We need to change our funding model so we can redirect it in the right way.
“Even within my own hospital, I said, if you want me to do 50 extra operations, you can finance those 50 operations by giving me another half a million dollars. Or you can give me one dietitian session a week and one nurse session a week, and I’ll do these 50 operations for you.
“What I really need is this auxiliary support to do it.”
The bottom line is that something has to change. Forcing people into the private system and their out-of-pocket costs, or forcing them to continue without treatment, is indicative of poor levels of care, Professor Aly said.
“If you have a diabetes care service and you don’t offer bariatric surgery or you have access to bariatric surgery, you can argue that you are at risk of providing poor care,” he said.
“You’re not providing an international standard of care if you don’t have access to bariatric surgery.
“So it’s not just about establishing a bariatric surgery service for the sake of it. It’s about knowing now that this is actually an integral part of treating so many other diseases, that if patients can’t access bariatric surgery in public hospitals when needed, we’re providing care that doesn’t meet today’s standards.
“It’s as simple as that.”
Subscribe to the free weekly InSight+ newsletter here. It is available to all readers, not just registered doctors.