Ethnic disparities in rates of publicly funded bariatric surgery in New Zealand (2009-2014)

Empowering Pacific Patients on the Weight Loss Surgery Pathway: A Co-designed Evaluation Study

PURPOSE

Despite having the highest medical needs by population for weight loss treatment, Pacific patients in Aotearoa New Zealand face substantial levels of attrition in publicly funded weight loss surgery programs. In collaboration with the Auckland City Hospital bariatric surgery team, a Pacific-led preoperative weight loss surgery program was co-designed, delivered, and evaluated between 2020 and 2023.

MATERIALS AND METHODS

This was a single-arm, prospective co-designed evaluation study that took place at Auckland City Hospital in Aotearoa New Zealand. Participants were Pacific patients (n = 14) referred to the weight loss surgery program. Survey and video diaries were analyzed to determine if the program had the potential to increase Pacific patient retention through the preoperative stage of weight loss surgery, increase surgery completion rates, and improve the quality of treatment experiences.

RESULTS

Nine out of 14 participants attended all preoperative sessions. Six participants subsequently underwent weight loss surgery. Program components that had positive impacts on patient success and satisfaction were accessibility, information quality, having Pacific role models, cultural safety, and the group support system. The patients found the program to be culturally anchored and there was support for the implementation of the program going forward.

CONCLUSION

This study demonstrated how a culturally anchored intervention can increase patient retention for those patients who may not respond to mainstream treatment. Adjusting existing preoperative weight loss surgery programs to integrate Pacific-led models of healthcare has the potential to increase Pacific patient resiliency to follow through with surgery.

Does the National Bariatric Prioritization Tool predict health outcomes?

BACKGROUND

The National Bariatric Prioritization Tool (NBPT), developed in Aotearoa New Zealand (AoNZ), has not been validated using real patient data. The aim was to determine the predictive validity of the NBPT on health outcomes.

METHODS

An observational study was undertaken of consecutive patients undergoing elective bariatric surgery at Middlemore Hospital using the NBPT from December 2014 to December 2016. The primary outcome was the correlation between prioritization score and percentage total weight loss (%TWL) at 18 months follow-up, with secondary outcomes being correlation with change in HbA1c, lipids, resolution of OSA, resolution of hypertension, and reduction in arthritis medications. Equity of access was measured by the relationship to age group, gender and ethnicity.

RESULTS

There were 294 patients included. There was no correlation between %TWL and prioritization score (correlation -0.09, P = 0.14). The benefit score correlated with %TWL (correlation 0.25, P < 0.0001). There were correlations between prioritization score and HbA1c reduction (correlation 0.28, P < 0.0001), resolution of OSA (correlation 0.20, P < 0.001) and resolution of hypertension (correlation 0.20, P < 0.001). There was a significant difference in prioritization score based on ethnicity, with Māori and Pasifika scoring higher than New Zealand European (P = 0.0023).

CONCLUSIONS

While the NBPT does not correlate with %TWL, it may have predictive validity through correlations with improvement of comorbidities such as diabetes, OSA and hypertension. Given higher rates of obesity and comorbidities in Māori and Pasifika, the higher scores may suggest the tool may be used to achieve equity of access. Further modifications should be considered to optimize outcomes.

Bariatric Surgery and Psychological Health: A Randomised Clinical Trial in Patients with Obesity and Type 2 Diabetes

PURPOSE

This study investigated the impact of either Roux-en-Y gastric bypass with silastic ring (SR-RYGB) or sleeve gastrectomy (SG) types of bariatric surgery on psychological health and explored the role of pre-existing depressive symptoms on weight loss.

MATERIALS AND METHODS

A total of 114 participants with obesity and type 2 diabetes were randomized to receive SR-RYGB or SG at a single centre. Data from the Hospital Anxiety and Depression Scale (HADS), RAND 36-item Health Survey and body weight were collected before surgery and annually for 5 years.

RESULTS

Sixteen patients were lost to follow-up at 5 years. Of the 98 patients who completed 5-year psychological follow-up assessments, 13 had mild to severe depressive symptoms (SR-RYGB n = 6, SG n = 7). SR-RYGB and SG resulted in similar psychological health improvement but percent weight loss at 5 years was greater for SR-RYGB by 10.6% (95% CI: 7.2 to 14.0, P < 0.0001). Scores for depressive symptoms and most RAND-36 domains improved significantly from baseline to 5 years in both groups. Patients with pre-existing depressive symptoms had similar percent weight loss at 5 years compared to patients without depressive symptoms, irrespective of procedural type.

CONCLUSION

Patients receiving either SR-RYGB or SG had comparable psychosocial functioning, which was maintained to 5 years post-surgery. Pre-existing depressive symptoms did not affect weight loss achieved at 5 years. These findings confirm previous longitudinal studies demonstrating that bariatric surgery is generally associated with improved psychosocial functioning.

Proof of Concept for a Mindfulness-Informed Intervention for Eating Disorder Symptoms, Self-Efficacy, and Emotion Regulation among Bariatric Surgery Candidates

Up to 64% of patients seeking bariatric (weight-loss) surgery report eating disorder (ED) symptoms (addictive-like eating, binge eating, emotional eating, grazing) that can interfere with post-surgical weight loss. This prospective proof-of-concept study aimed to evaluate the impact of a pre-surgical mindfulness-informed intervention (MII) on ED symptoms and potential mechanisms-of-action to inform optimization of the intervention. Surgery-seeking adults attended four, 2-hour, MII sessions held weekly. Participants completed validated questionnaires assessing ED symptoms, eating self-efficacy, emotion regulation, and mindful eating pre-MII, post-MII, and at a 12-week follow-up. The MII consisted of mindfulness training, with cognitive, behavioral, and psychoeducational components. Fifty-six patients (M = 47.41 years old, 89.3% female) participated. Improvements in addictive-like eating, binge eating, emotional eating, and grazing were observed from pre- to post-MII. ED symptom treatment gains were either maintained or improved further at 12-week follow-up. Eating self-efficacy and emotion regulation improved from pre-MII to follow-up. Scores on the mindful eating questionnaire deteriorated from pre-MII to follow-up. In mediation analyses, there was a combined indirect effect of emotion regulation, eating self-efficacy, and mindful eating on grazing and binge eating, and an indirect effect of emotion regulation on emotional eating and addictive-like eating. Participation in the MII was associated with improvements in ED symptoms and some mechanisms-of-action, establishing proof-of-concept for the intervention. Future work to establish the MII's efficacy in a randomized controlled trial is warranted.

Variation in publicly funded bariatric surgery in New Zealand by ethnicity: cohort study of 328,739 patients

BACKGROUND

New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities.

OBJECTIVES

To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities.

SETTING

New Zealand primary care.

METHODS

A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities.

RESULTS

A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality.

CONCLUSIONS

Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care.

Ethnic Variations in the Quality Use of Medicines in Older Adults: Māori and Non-Māori in Aotearoa New Zealand

In Aotearoa New Zealand (NZ), ethnic inequities in health outcomes exist. Non-Māori experience better access to healthcare than Māori, including access to the quality use of medicines. Quality medicines use requires that medicines provide maximal therapeutic benefit with minimal harm. As older adults are more at risk of harm from medicines, and, because inequities are compounded with age, Māori older adults may be at more risk of medicines-related harm than younger and non-Māori populations. This narrative review examined ethnic variation in the quality use of medicines, including medicines utilisation and associated clinical outcomes, between Māori and non-Māori older adult populations in NZ. The review was structured around prevalence of medicine utilisation by medicine class and in particular disease states; high-risk medicines; polypharmacy; prevalence of potentially inappropriate prescribing (PIP); and association between PIP and clinical outcomes. 22 studies were included in the review. There is ethnic variation in the access to medicines in NZ, with Māori older adults often having reduced access to particular medicine types, or in particular disease states, compared with non-Māori older adults. Māori older adults are less likely than non-Māori to be prescribed medicines inappropriately, as defined by standardised tools; however, PIP is more strongly associated with adverse outcomes for Māori than non-Māori. This review identifies that inequities in quality medicines use exist and provides a starting point to develop pro-equity solutions. The aetiology of inequities in the quality use of medicines is multifactorial and our approaches to addressing the inequitable ethnic variation also need to be.

Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation.

Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population.

Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m², 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year (“improved”) compared with surgery at 3.5 years (“standard”). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics.

Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68–1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0- and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery.

Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.

A pharmacist-led medicines review intervention in community-dwelling Māori older adults- a feasibility study protocol

BACKGROUND

Pharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults.

METHOD

This is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12619001070123.

Enhancing responsiveness to Māori in a publicly funded bariatric service in Aotearoa New Zealand

BACKGROUND

Health equity is a fundamental right afforded to all regardless of ethnicity. However, in New Zealand (NZ), health inequities are most compelling for Indigenous Māori who experience inadequate access to services, poorer quality of care and poor health outcomes as a result. Bariatric surgery is the most effective intervention for weight loss and remission of obesity-related disease where all other interventions have been exhausted. This Kaupapa Māori qualitative study presents Māori perspectives of bariatric surgery from the largest public bariatric centre in NZ and offers solutions for enhancing bariatric service responsiveness to Māori.

METHODS

This qualitative study was informed by Kaupapa Māori methodology and involved a general inductive thematic analysis of 31 semi-structured interviews with Māori patients who had bariatric surgery at Counties Manukau Health in South Auckland, NZ.

RESULTS

Four key themes were identified following analysis: (i) Kaupapa Māori standards of health; (ii) bariatric mentors; (iii) bariatric psychologists; and (iv) community-integrated support. These themes offer four tangible solutions for optimizing bariatric pathways for Māori from the perspectives of Māori bariatric patients.

CONCLUSION

Kaupapa Māori, community-centred and greater non-surgeon aspects of bariatric supportive mechanisms comprise key areas of opportunity for public bariatric pathways in NZ. Surgical leadership is required to advance health equity and service responsiveness to Māori.

Preoperative bariatric surgery programme barriers facing Pacific patients in Auckland, New Zealand as perceived by health sector professionals: a qualitative study

Minority ethnic patient groups typically have the highest bariatric surgery preoperative attrition rates and lowest surgery utilisation worldwide. Eligible patients of Pacific Island ethnicity (Pacific patients) in New Zealand (NZ) follow this wider trend.

OBJECTIVES

The present study explored structural barriers contributing to Pacific patients' disproportionately high preoperative attrition rates from publicly-funded bariatric surgery in Auckland, NZ.

SETTING

Publicly-funded bariatric surgery programmes based in the wider Auckland area, NZ.

DESIGN

Semi-structured interviews with health sector professionals (n=21) were conducted.Data were analysed using an inductive thematic approach.

RESULTS

Two primary themes were identified: (1) Confidence negotiating the medical system, which included Emotional safety in clinical settings and Relating to non-Pacific health professionals and (2) Appropriate support to achieve preoperative goals, which included Cultural considerations, Practical support and Relating health information. Clinical environments and an under-representation of Pacific staff were considered to be barriers to developing emotional safety, trust and acceptance of the surgery process with patients and their families. Additionally, economic deprivation and lower health literacy impacted preoperative goals.

CONCLUSIONS

Health professionals' accounts indicated that Pacific patients face substantial levels of disconnection in bariatric surgery programmes. Increasing representation of Pacific ethnicity by employing more Pacific health professionals in bariatric teams and finding novel solutions to implement preoperative programme components have the potential to reduce this disconnect. Addressing cultural competency of staff, increasing consultancy times and working in community settings may enable staff to better support Pacific patients and their families. Programme structures could be more accommodating to practical barriers of attending appointments, managing patients' preoperative health goals and improving patients' health literacy. Given that Pacific populations, and other patients from minority ethnic backgrounds living globally, also face high rates of obesity and barriers accessing bariatric surgery, our findings are likely to have broader applicability.

Exploring motivation for bariatric surgery among Indigenous Māori women

INTRODUCTION

Bariatric surgery is the most effective intervention for alleviating obesity and its complications. Indigenous people worldwide experience higher rates of obesity and obesity disease burden. However, few studies exploring bariatric surgery among Indigenous peoples are published. In this study we aimed to explore the motivation of Māori women in coming forward for bariatric surgery.

METHODS

Māori women who had bariatric surgery prior to December 31, 2014, were invited to participate in semi-structured interpersonal interviews. Kaupapa Māori research, an Indigenous Māori research methodology, informed this study. Interviews were recorded, transcribed and subject to inductive thematic analysis.

RESULTS

Twenty-nine Māori women participated in semi-structured interpersonal interviews. The majority of women reported that the presence of obesity-related disease alongside the desire for a better quality of life served as the greatest sources of motivation for having bariatric surgery. Whānau (family) were key for participants achieving the preoperative milestones needed to be accepted for bariatric surgery. Interpersonal experiences of fat-shaming and yo-yo dieting also impacted their choice to have surgery.

CONCLUSION

This study is one of the first to describe the motivations of Indigenous Māori women to have bariatric surgery. Our study conveys the importance of health, a desire to have a better quality of life and whānau in motivating Māori women to come forward for bariatric surgery.

Attrition after Acceptance onto a Publicly Funded Bariatric Surgery Program

BACKGROUND

Factors such as ethnicity, gender, and socioeconomic status may play a role in both access to and attrition from bariatric programs before surgery is undertaken. New Zealand (NZ) has high rates of obesity in its Pacific population and the indigenous Māori. These groups also experience poorer health outcomes and therefore have the greatest need for surgery.

METHODOLOGY

A retrospective cross-sectional study of 704 people referred for and accepted onto a publicly funded bariatric surgery from 2007 to 2016. The demographic and clinical features of two groups were compared: those that completed surgery successfully (n = 326) and those that dropped out of the program before surgery (n = 378). We also attempted to identify factors associated with attrition.

RESULTS

The attrition rate was high (54%), with a significant difference according to gender (men 66% vs 45% women, p < 0.001) and ethnicity (39% in NZ Europeans, 50% in Māori, and 73% in Pacific patients, p < 0.001). Two out of three European women proceeded to surgery, but fewer than one in seven Pacific men. Attrition was associated with having a higher mean BMI and being a smoker. Logistic regression modeling showed that while employment seemed to be protective against attrition for NZ Europeans (p < 0.004), it was not for Pacific patients.

CONCLUSIONS

While there was no obvious bias in rates of referral, there is clearly a need for better ways to support Māori and Pacific people, and men in particular, to complete bariatric surgery. Further research is needed to clarify the socio-economic and cultural barriers that underlie this phenomenon.

Pre-operative Bariatric Clinic Attendance Is a Predictor of Post-operative Clinic Attendance and Weight Loss Outcomes

AIM

Our primary aim was to determine whether non-attendance at pre-operative clinics were associated with non-attendance at post-operative clinics and its influence on weight loss. We also sought to examine the relationship between gender, ethnicity and post-operative clinic attendance with respect to weight loss post-bariatric surgery.

METHODS

A retrospective audit was performed for patients undertaking the bariatric surgery program at the Auckland City Hospital between 2013 and 2016.

RESULTS

One hundred and eighty-four patients completed our program, with a mean age of 46.1 years. Mean weight at commencement was 133.3 kg, with a BMI of 47.4. At 2 years follow-up (n = 143), excess weight loss was 70.8% following RYGB and 68.0% following LSG (p = 0.5743). More patients attended all pre-operative than post-operative clinics (67.4% vs 37.5% p = < 0.001). One pre-operative clinic non-attendance was associated with less weight loss at 2 years and it increases the risk of missing at least 50% of post-operative clinics with a risk ratio of 2.73, p = 0.005. Non-attendance of at least 50% of post-operative clinics was also associated with less weight loss at 2 years (33.4 kg vs 44.3 kg, p = 0.040). Although Maori and Pacific Islanders more frequently missed > 50% of post-operative clinics, weight loss was similar between European, Maori and Pacific Islander populations (2-year weight loss 44.2 kg vs 40.74 kg vs 44.1 kg, respectively, p = 0.8192).

CONCLUSION

Pre-operative clinic non-attendance helps predict post-operative clinic non-attendance. Missing any pre-operative clinics and at least 50% of scheduled post-operative clinics is associated with poorer weight loss outcomes.

A systematic review of pharmacist-led medicines review services in New Zealand - is there equity for Māori older adults?

BACKGROUND

Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults.

OBJECTIVE

This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported.

RESULTS

The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori.

CONCLUSION

Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.

A narrative review of bariatric surgery in Indigenous peoples

INTRODUCTION

Indigenous peoples suffer high rates of obesity and obesity-related disease worldwide. Currently, bariatric surgery is the most effective intervention for severe obesity and obesity-related disease. The role bariatric surgery plays in alleviating the obesity burden amongst Indigenous peoples is unknown. We aimed to collate studies investigating bariatric surgery in Indigenous peoples and to provide a simple framework to use in future research surrounding this important issue.

MATERIALS AND METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that investigated outcomes for Indigenous peoples at any point along the bariatric surgery journey were included.

RESULTS

Six articles were included in this review. Three studies investigated access to bariatric surgery and the remaining three studies investigated short to long-term outcomes following bariatric surgery. A narrative review was performed given study heterogeneity and quality of included studies. Indigenous peoples had lower access to bariatric surgery and in one study had greater weight loss in comparison to non-Indigenous peoples.

CONCLUSION

Despite a paucity of studies, it appears that there is emerging interest in investigating bariatric surgery among Indigenous peoples. We encourage those who seek to investigate this important issue at any point along the bariatric surgery journey, to do so using an equity-based approach.