The support needs of patients waiting for publicly funded bariatric surgery - implications for health service planners

Priority Index for Bariatric Surgery Based on a New Classification of Severity in Obesity

This study aimed to propose and evaluate a severity rating in obesity (SERO) based on a new priority index for bariatric surgery (PIBS). We compared the waiting time for surgery (WTS) in a simulated list of 200 patients diagnosed, classified, and hypothetically submitted to bariatric surgery using two prioritization criteria: date of inclusion in the list and PIBS. Our simulations show that patients spent an average of 350.44 days waiting for surgery while in the first case, when PIBS was adopted as the prioritization criterion, the WTS varied according to the severity of each patient's condition so more severe cases waited an average of 82.56 days, i.e., up to 75.55% less time considering statistical significance in the differences (p < 0.05). Therefore, the proposed prioritization model proved effective, fair, and reproducible and can be used to manage waiting lists for bariatric surgery.

Social History of Bariatric Surgery: Relationship to Patient and Associations with Postoperative Outcomes

PURPOSE

There is limited research about the prevalence of patients initiating metabolic and bariatric surgery (MBS) who also know someone who had MBS, referred to as having a social history of MBS. Evidence about the specific relationship of these individuals to the patient, how having a social history of MBS is associated with patients' choice of surgical procedure, and how having a social history of MBS is associated with patients' postoperative outcomes can be used to inform future preoperative assessments. The objective was to (a) define the number of people patients knew who had MBS and relationship to patient, (b) assess congruence between those who had MBS with patients' procedure selection, and (c) explore associations between social history of MBS and postoperative outcomes.

MATERIALS AND METHODS

The sample included 123 patients who had MBS in 2021 (83.7% female; 44.7% Sleeve Gastrectomy, 55.3% Gastric Bypass). For up to 5 people, patients provided their relationship and surgical procedure, and completed the Family Assessment Device (FAD). Bivariate analyses assessed congruence in type of procedure, and social history of MBS with complications, readmissions, and %TWL. Three mixed multilevel models were conducted with (1) close friend, (2) coworker, and (3) close family history of MBS including the FAD on change in %TWL over 12 months with surgical procedure as a covariate.

RESULTS

Ninety-one percent of patients knew someone who had MBS, average 2.66±1.45. Patients reported a close friend (56.1%), close family member (43.9%), and coworker (19.5%) who had MBS. Patients with a close family member who had MBS and reported healthy vs impaired family functioning had greater %TWL over 12 months (p=0.016). Patients with a close friend who had MBS had less %TWL (p=0.015), and patients with a coworker who had MBS had greater %TWL (p=0.012), which did not change over time.

CONCLUSION

Patients with coworkers or close family members with healthy family functioning with a history of MBS had more weight loss, whereas those with close friends with a history of MBS had less weight loss.

Quality of Life After Bariatric and Body Contouring Surgery in the Australian Public Health System

INTRODUCTION

The goals of bariatric surgery are weight loss, improved management of obesity-related diseases, and enhanced health-related quality of life (HRQoL). The aim of this study is to determine HRQoL among postoperative bariatric surgery patients. The aim of this study was to evaluate the utility of bariatric surgery and the role of body contouring surgery (BCS) when considering quality of life in low-volume centres in the Australian public health system.

METHODS

This cohort study compared patients who underwent bariatric surgery between 2008 and 2018, to those awaiting surgery. An additional analysis was completed for patients who also underwent BCS. Patients completed the Short Form-36 quality of life (SF-36) survey. Linear regression was used to assess the differences in mean scores between cohorts for each of the SF-36 domains.

RESULTS

A total of 131 postoperative patients were identified, with a follow up rate of 68%. The mean follow up was 5.4 y. The mean scores for all domains of the SF-36 in the postoperative group were higher than the preoperative group (P ≤ 0.0001). A significant difference in scores persisted after controlling for patients' current BMI. When considering patients who underwent BCS (n = 24), there was a further global improvement in HRQoL in physical function (P = 0.0065), role limitation to physical health (P = 0.0026), pain (P = 0.0004), energy (P = 0.0023) and general health perceptions (P = 0.0023).

CONCLUSIONS

Bariatric surgery followed by BCS may improve HRQoL for the patient when compared to bariatric surgery alone. We advocate for the use of bariatric surgery followed by BCS in low-volume centres in the Australian public health system.

Self-withdrawal from scheduled bariatric surgery: Qualitative study exploring patient and healthcare provider perspectives

The objective of the study was to explore the experience of patients who self-withdrew from their scheduled bariatric surgery (BS) after completing the lengthy multidisciplinary assessment and optimization process, and to examine how these withdrawals affect healthcare providers (HCPs) in a Bariatric Centre of Excellence (BCoE). Interviews were conducted with patients who self-withdrew, within 1 month, from scheduled BS. Additionally, a focus group with HCPs from the same BCoE was completed. The data were analysed using an inductive, emergent thematic approach with open coding in NVivo 12, with comparative analysis to identify common themes between groups. Eleven patients and 14 HCPs participated. HCPs identified several behavioural and logistical red flags among patients who self-withdrew from scheduled BS. Patients and HCPs felt the decision was appropriate, owing to a patient's lack of mental preparedness for change, social supports, or fears of postoperative complications. HCPs reported frustration and described negative impacts on clinic efficiency. Additional mental health resources for patients contemplating self-withdrawal, such as peer support, were suggested. In conclusion, a patient's decision to self-withdraw from a scheduled BS is often sudden, definite, and associated with anxiety, fear of surgical risks and post-operative complications. Additional mental health resources at a BCoE may be beneficial to support patients at risk of self-withdrawal from scheduled BS.

Social Support for People with Morbid Obesity in a Bariatric Surgery Programme: A Qualitative Descriptive Study

Background-Morbid obesity (MO) is a chronic metabolic disease affecting physical, psychological and social wellbeing. Bariatric surgery is a reliable method for losing weight in the long term, improving the quality of life, body image and social life of people with MO. Current literature recognises the importance of social support in controlling weight and coping with MO. The objective of this study was to describe and understand experiences related to social support for patients with MO included in a bariatric surgery programme. Methods-A qualitative descriptive study, where data collection included thirty-one interviews with people diagnosed with MO involved in a bariatric surgery programme. Results-Three main themes emerged from the analysis: (1) accepting the problem in order to ask for help, (2) the need for close support and (3) professional support: opposing feelings. Conclusions-A partner, family and friends are the key pillars of social support for those with MO included in a bariatric surgery programme. Healthcare professionals gave formal support; the bariatric surgery team provided information, trust and assurance. Nurses provided healthcare 24 h a day, making them the main formal support for people in the bariatric surgery programme.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Path taken by morbidly obese people in search of bariatric surgery in the public health system

Objective:

to understand the path taken in the public health system by people with morbid obesity in the search for bariatric surgery.

Method:

qualitative research based on the social phenomenology of Alfred Schütz, with 17 hospitalized morbidly obese people, with a scheduled date for bariatric surgery. The phenomenological interview with open questions was used and the statements were analyzed in the light of the theoretical-methodological framework and literature related to the theme.

Results:

the participants were able to schedule bariatric surgery by referring friends, family and public people. The waiting list for the procedure generated anguish and anxiety due to fear of surgery, weight gain, risk of worsening health and physical limitations, but it helped prepare for its performance. The experience lived in the search for bariatric surgery led these people to want continuity of care in the Basic Health Unit, after the surgery, by professionals trained to meet their needs.

Conclusion:

the aspects inscribed in the path of people in search of bariatric surgery signal the need to strengthen the assistance-related flows of the public health system and to invest in professional training to reduce the social inequalities in access to bariatric surgery and increased quality of services.

Prospective Analysis Regarding Health-Related Quality of Life (HR-QOL) between Morbid Obese Patients Following Bariatric Surgery Versus on a Waiting List

BACKGROUND

Major impairment of health-related quality of life (HRQoL) is one of the main reasons why obese patients request surgical treatment.

OBJECTIVE

To prospectively analyze the impact of HRQoL between obese patients who underwent surgery and those who were wait-listed.

METHODS

Between April 2017 and March 2018, 70 surgical and 69 wait-listed patients were interviewed twice, at baseline and at the 12-month follow-up. Quality of life was measured by the SF-12v2 and the Impact of Weight on Quality of Life-Lite (IWQoL-Lite) questionnaires. Sociodemographic-, clinical-, and surgical-related variables were collected.

RESULTS

One hundred thirty-nine patients were analyzed, showing similar baseline characteristics but differences in HRQoL. Performing more qualified work improved scores on some aspects of the SF-12 survey. In contrast, women scored worse on the self-esteem domain, and men scored worse on the mental health domain. By group, at the 12-month follow-up, statistically significant differences were found among all aspects of the questionnaires between both groups (P < 0.001) and between baseline and postoperative 12-month follow-up in the surgical group (P < 0.001). Furthermore, scores were lower in all domains in the evolution of wait-listed patients, with statistically significant differences among the Bodily Pain, Emotional Role, Mental Health, and Mental Component Summary Domains (P < 0.05).

CONCLUSION

HRQoL is a multimodal concept that allows the identification of factors impacting obese patients' quality of life. It promotes the benefit of surgery against waiting list delays, which can take up to 4 years in our hospital. Therefore, HRQoL is an important pillar to justify more resources for reducing unacceptable surgical delays.

Weight and Waiting for Adolescent's Bariatric Surgery: Changes in Weight During Waiting Periods for Bariatric Surgery in Adolescents

BACKGROUND

Bariatric surgery is an emerging effective treatment option for adolescents suffering from morbid obesity. However, the surgery is often in high demand with long waiting periods. No prior research regarding the significance of waiting periods for bariatric surgery in adolescents was found. Our study aimed to evaluate changes in weight trends in adolescent candidates for bariatric surgery during the waiting period between acceptance and admission to the bariatric process (pre-surgical preparation, surgery, and follow-up).

METHODS

Fifty-one adolescent bariatric surgery candidates were accepted and subsequently admitted to the bariatric process. BMI data was retrieved from medical files and direct measurements, and BMI-change trends during the waiting period were compared with naturalistic trends (i.e., prior to the first evaluation for bariatric surgery).

RESULTS

Naturalistic BMI-trends showed an average gain of 0.3 BMI points per-month. After acceptance to the bariatric process and during the waiting period, this figure dropped, and candidates for surgery lost an average of 0.06 BMI points per-month. Waiting periods lasted an average of 5.2 months. Shorter waiting periods were associated with better weight reduction and maintenance.

CONCLUSIONS

A significant reduction in weight-gaining trends occurred during the waiting period for bariatric surgery in adolescents, which may reflect motivational and lifestyle changes due to expectancy for surgery. Decision makers may aim for short waiting periods in order to capitalize on this effect. Further research needs to be conducted in order to clarify the effects of waiting periods for bariatric surgery in adolescents.

Comparison of Comorbidity Treatment and Costs Associated With Bariatric Surgery Among Adults With Obesity in Canada

IMPORTANCE

Information on the associations between barriers to delivery of bariatric surgery and poor weight trajectory afterward is lacking. Estimates are needed to inform decisions by administrators and clinicians to improve care.

OBJECTIVE

To estimate the difference in patient-years of treatment for diabetes, hypertension, and dyslipidemia and public-payer cost between the Canadian standard and an improved bariatric surgery care pathway.

DESIGN, SETTING, AND PARTICIPANTS

Economic evaluation of a decision analytic model comparing the outcomes of the standard care in Canada with an improved bariatric care pathway with earlier sleeve gastrectomy delivery and better postsurgical weight trajectory. The model was informed by published clinical data (101 studies) and meta-analyses (11 studies) between January and May 2019. Participants were a hypothetical 100-patient cohort with demographic characteristics derived from a Canadian study.

INTERVENTIONS

Reduction of Canadian mean bariatric surgery wait time by 2.5 years following referral and improvement of patient postsurgery weight trajectory to levels observed in other countries.

MAIN OUTCOMES AND MEASURES

Modeling weight trajectory after sleeve gastrectomy and resolution rates for comorbidities in Canada in comparison with an improved care pathway to estimate differences in patient-years of comorbidity treatment over 10 years following referral and the associated costs.

RESULTS

For the 100-patient cohort (mean [SD] 88.2% [1.4%] female; mean [SD] age, 43.6 [9.2] years; mean [SD] body mass index, 49.4 [8.2]; and mean [SD] comorbidity prevalence of 50.0% [4.1%], 66.0% [3.9%], and 59.3% [4.0%] for diabetes, hypertension, and dyslipidemia, respectively) over 10 years following referral, the improved vs standard care pathway was associated with median reduction in patient-years of treatment of 324 (95% credibility interval [CrI], 249-396) for diabetes, 245 (95% CrI, 163-356) for hypertension, and 255 (95% CrI, 169-352) for dyslipidemia, corresponding to total savings of $900 000 (95% CrI, $630 000 to $1.2 million) for public payers in the base case. Relative to standard of care, the associated reduction in costs was approximately 29% (95% CrI, 20%-42%) in the improved pathway. Sensitivity analyses demonstrated independent associations of earlier surgical delivery and various levels of postsurgical weight trajectory improvements with overall savings.

CONCLUSIONS AND RELEVANCE

This study suggests that health care burden may be decreased through improvements to delivery and management of patients undergoing sleeve gastrectomy. More data are needed on long-term patient experience with bariatric surgery in Canada to inform better estimates.

Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus

We aimed to describe the current state of specialist obesity services for adults with clinically severe obesity in public hospitals in Australia, and to analyse the gap in resources based on expert consensus. We conducted two surveys to collect information about current and required specialist obesity services and resources using open-ended questionnaires. Organizational level data were sought from clinician expert representatives of specialist obesity services across Australia in 2017. Fifteen of 16 representatives of current services in New South Wales (n = 8), Queensland (n = 1), Victoria (n = 2), South Australia (n = 3), and the Australian Capital Territory (n = 1) provided data. The composition of services varied substantially between hospitals, and patient access to services and effective treatments were limited by strict entry criteria (e.g. body mass index 40 kg/m² or higher with specific complication/s), prolonged wait times, geographical location (major cities only) and out-of-pocket costs. Of these services, 47% had a multidisciplinary team (MDT), 53% had an exercise physiologist/physiotherapist, 53% had a bariatric surgeon and 33% had pharmacotherapy resources. Key gaps included staffing components of the MDT (psychologist, exercise physiologist/physiotherapist) and access to publicly funded weight loss pharmacotherapy and bariatric surgery. There was consensus on the need for significant improvements in staff, physical infrastructure, access to services, education/training in obesity medicine and targeted research funding. Based on the small number of existing, often under-resourced specialist obesity services that are located only in a few major cities, the vast majority of Australians with clinically severe obesity cannot access the specialist evidence based treatments needed.

An Exploratory Study of Long-Term Publicly Waitlisted Bariatric Surgery Patients' Quality of Life Before and 1 Year After Bariatric Surgery, and Considerations for Healthcare Planners

BACKGROUND

Long-term publicly waitlisted bariatric surgery patients typically experience debilitating physical/psychosocial obesity-related comorbidities that profoundly affect their quality of life.

OBJECTIVES

We sought to measure quality-of-life impacts in a study population of severely obese patients who had multiyear waitlist times and then underwent bariatric surgery.

METHODS

Participants were recruited opportunistically following a government-funded initiative to provide bariatric surgery to morbidly obese long-term waitlisted patients. Participants self-completed the EQ-5D-5L and AQoL-8D questionnaires pre- and postoperatively. Utility valuations (utilities) and individual/super dimension scores (AQoL-8D only) were generated.

RESULTS

Participants' (n = 23) waitlisted time was mean [standard deviation (SD)] 6.5 (2) years, body mass index reduced from 49.3 (9.35) kg/m² preoperatively to 40.8 (7.01) 1 year postoperatively (p = 0.02). One year utilities revealed clinical improvements (both instruments). AQoL-8D improved significantly from baseline to 1 year, with the change twice that of the EQ-5D-5L [EQ-5D-5L: mean (SD) 0.70 (0.25) to 0.78 (0.25); AQoL-8D: 0.51 (0.24) to 0.67 (0.23), p = 0.04], despite the AQoL-8D's narrower algorithmic range. EQ-5D-5L utility plateaued from 3 months to 1 year. AQoL-8D 1-year utility improvements were driven by Happiness/Coping/Self-worth (p < 0.05), and the Psychosocial super dimension score almost doubled at 1 year (p < 0.05). AQoL-8D revealed a wider dispersion of individual utilities.

CONCLUSIONS

Ongoing improvements in psychosocial parameters from 3 months to 1 year post-surgery accounted for improvements in overall utilities measured by the AQoL-8D that were not detected by EQ-5D-5L. Selection of a sensitive instrument is important to adequately assess changes in quality of life and to accurately reflect changes in quality-adjusted life-years for cost-utility analyses and resource allocation in a public healthcare resource-constrained environment.

Population estimates and characteristics of Australians potentially eligible for bariatric surgery: findings from the 2011–13 Australian Health Survey

Objective The aim of the present study was to determine the potential demand for publicly and privately funded bariatric surgery in Australia. Methods Nationally representative data from the 2011–13 Australian Health Survey were used to estimate the numbers and characteristics of Australians meeting specific eligibility criteria as recommended in National Health and Medical Research Council guidelines for the management of overweight and obesity. Results Of the 3 352 037 adult Australians (aged 18–65 years) estimated to be obese in 2011–13, 882 441 (26.3%; 95% confidence interval (CI) 23.0–29.6) were potentially eligible for bariatric surgery (accounting for 6.2% (95% CI 5.4–7.1) of the adult population aged 18–65 years (n = 14 122 020)). Of these, 396 856 (45.0%; 95% CI 40.4–49.5) had Class 3 obesity (body mass index (BMI) ≥40 kg m–2), 470945 (53.4%; 95% CI 49.0–57.7) had Class 2 obesity (BMI 35–39.9 kg m–2) with obesity-related comorbidities or risk factors and 14 640 (1.7%; 95% CI 0.6–2.7) had Class 1 obesity (BMI 30–34.9 kg m–2) with poorly controlled type 2 diabetes and increased cardiovascular risk; 458 869 (52.0%; 95% CI 46.4–57.6) were female, 404 594 (45.8%; 95% CI 37.3–54.4) had no private health insurance and 309 983 (35.1%; 95% CI 28.8–41.4) resided outside a major city. Conclusion Even if only 5% of Australian adults estimated to be eligible for bariatric surgery sought this intervention, the demand, particularly in the public health system and outside major cities, would far outstrip current capacity. Better guidance on patient prioritisation and greater resourcing of public surgery are needed. What is known about this topic? In the period 2011–13, 4 million Australian adults were estimated to be obese, with obesity disproportionately more prevalent in areas of socioeconomic disadvantage. Bariatric surgery is considered to be cost-effective and the most effective treatment for adults with obesity, but is mainly privately funded in Australia (>90%), with 16 650 primary privately funded procedures performed in 2015. The extent to which the supply of bariatric surgery is falling short of demand in Australia is unknown. What does this paper add? The present study provides important information for health service planners. For the first time, population estimates and characteristics of those potentially eligible for bariatric surgery in Australia have been described based on the best available evidence, using categories that best approximate the national recommended eligibility criteria. What are the implications for practitioners? Even if only 5% of those estimated to be potentially eligible for bariatric surgery in Australia sought a surgical pathway (44 122 of 882 441), the potential demand, particularly in the public health system and outside major cities, would still far outstrip current capacity, underscoring the immediate need for better guidance on patient prioritisation. The findings of the present study provide a strong signal that more funding of public surgery and other effective interventions to assist this population group are necessary.

A Landscape of Bariatric Surgery in Canada: For the Treatment of Obesity, Type 2 Diabetes and Other Comorbidities in Adults

Obesity has escalated worldwide and in Canada. Many chronic conditions, including type 2 diabetes, are directly correlated with obesity, and although the benefits and effectiveness of bariatric surgery have been proven in terms of sustained weight loss and improving comorbidities, the procedure is underaccessed and underutilized in Canada. We explored the complex landscape of bariatric surgery in Canada, reviewing the current state and focusing on the volume of procedures nationwide and at the provincial level, the type of surgical procedures performed, their outcomes and their associated complications. Barriers and challenges curbing access to bariatric surgery are also explored. Approximately 8,583 publicly funded bariatric surgeries were performed in 9 of 10 provinces in 2015/2016; Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric banding and biliopancreatic diversion with or without duodenal switch are the most common procedures performed, and coverage varies among provinces and territories. Dedicated bariatric programs have been created and, in some instances, provincial networks have also emerged. Weight loss, resolution of comorbidities and rates of complications in Canada are similar to those found in the literature. The increase in the number of bariatric procedures performed over time has still not met the current demand. The rise in obesity rates, the speed and regional variations in the development and standardization of processes, adequate patient selection, funding and prioritization and gaps in knowledge and attitudes about the merits of bariatric surgery of patients, health providers and policy makers create considerable waiting times and are some of the barriers to better access to bariatric surgery.

What is the impact on the healthcare system if access to bariatric surgery is delayed?

BACKGROUND

Bariatric surgery has been available as part of the Brazilian Public Health System for patients with body mass index>40 kg/m² (or>35 kg/m² with co-morbidities) since 1999. However, access to surgery is challenging, with eligible patients waiting up to 7 years before surgery.

OBJECTIVE

Our objective was to compare costs and effectiveness of different waiting times before surgery versus prompt surgery.

SETTINGS

Public practice.

METHODS

A Markov microsimulation model compared 5 different strategies: no surgery, prompt surgery, and delaying surgery for 1, 2, 4, and 7 years. Markov tracker variables and states reflected changes in body mass index, type 2 diabetes status (including remission and relapse), and cardiovascular events. Time horizon was 20 years; discount rate, 5%; and the perspective of the Brazilian Public Health System. Effectiveness was calculated as quality adjusted life years.

RESULTS

Prompt surgery was the least costly and most effective strategy compared with any delay. Costs increased and effectiveness diminished progressively with the length of delays. Waiting 7 years for surgery was the most expensive and least effective strategy. Prompt surgery maintained dominance in 99.9%, 90.7%, 96.1%, and 94.2% of simulations in probabilistic sensitivity analyses versus 1-, 2-, 4-, and 7-year delays, respectively. Immediate surgery was very cost effective compared with no surgery in the case base. In the scenario with all patients having type 2 diabetes, immediate surgery was dominant to any strategy, including the no surgery group.

CONCLUSIONS

Delaying bariatric operations is more expensive and less effective compared with prompt surgery and very cost effective compared with no surgery. Public health systems should pursue strategies to accelerate access to surgery to decrease obesity related complications and mortality of patients, but also to improve cost effectiveness.