The frequency of obesity has skyrocketed across Canada, and its treatment is a major challenge to the health care system.
Bariatric surgery is an effective treatment for obesity that appears to be good value for money.
Although Ontario is expanding bariatric surgery capacity, some are concerned that capacity remains below current needs.
What is bariatric surgery?
Bariatric surgery is a term used to refer to a number of different surgical weight loss procedures. Evidence shows that gastric bypass surgery, which reduces the size of the stomach, is the most effective surgical treatment for weight loss. Bariatric surgery is relatively safe – the risk of dying within 30 days of the surgery is 0.1-0.3 percent, which is about the risk of dying after having one’s gallbladder removed. The surgery works by reducing the intake and absorption of food.
After surgery, a substantial number of obese individuals with diabetes are able to stop taking the medications they needed to control their blood sugar before surgery. Bariatric surgery is currently paid for by the Ontario government for individuals with severe obesity.
Bariatric surgery in Ontario
The Ontario Ministry of Health and Long-Term Care conducted a detailed review of the evidence that bariatric surgery reduces obesity in the mid-2000s, and determined that it is an effective treatment for people with morbid obesity. The review noted that “surgery for morbid obesity is considered an intervention of last resort for patients who previously attempted first line forms of medical management”, including diet, physical activity, behavioural modification and drugs.
Until 2009, access to bariatric surgery was limited in Ontario, with only a few hundred surgeries performed in the province annually. Because of the limited capacity in the province, doctors were able to directly refer eligible patients to American surgical centers, and the costs of the operation for these patients were covered by the Ontario Health Insurance Plan. In 2008/2009, the Ontario government stated that it would fund 1660 bariatric procedures in the United States.
In May 2009, however, the Ontario Ministry of Health and Long-Term Care announced that it was spending $75 million to increase bariatric surgical capacity in the province by 500% over a 3 year period, from 244 procedures per year, to 2,085 procedures per year at four centres.
The Ontario Bariatric Services Strategy is part of the province’s larger diabetes strategy to prevent, control, and manage diabetes. Through increasing provincial capacity for bariatric surgery, the government wanted to reduce reliance on American providers, improve access in Ontario and save “$10,000 for every case done in Ontario.” Following the introduction of the strategy, the Ontario government no longer pays for bariatric surgery performed in the United States.
The new strategy includes a centralized referral process and standardized referral criteria, including body mass index measurements and other medical eligibility criteria for Ontario patients. Once an application is received, patients are sent to the closest bariatric assessment centre where patients undergo an assessment which could include medical tests and a psychological assessment, all of which help determine whether the patient is a good candidate for the surgery. Following surgery, there is close post-operative follow up care.
There are currently four provincial bariatric centres of excellence, which provide assessment, surgery and follow up to patients. These centres are based at hospitals in Ottawa, Guelph, Hamilton and Toronto. Wait times for the surgery vary across the province according to region, but the Ministry of Health and Long-Term Care reports that average wait times from the decision to operate, to the surgery itself, are around 6 months for 90% of all bariatric surgery patients.
Two years into the strategy, are the goals of increasing capacity being met? Is there sufficient capacity to meet the need for bariatric surgery?
Demand & Capacity for Bariatric Surgery
Yoni Freedhoff, a family doctor who specializes in obesity says that there is a growing need in Ontario for this surgery, and that current capacity is not sufficient. Freedhoff says that “statistically speaking, 3% of Ontarian’s meet the criteria for bariatric surgery” and notes that “even if only 5% of them want the surgery, that’s still 18,000 cases per year”. The Bariatric Services Strategy was given $75 million, and committed to performing 2,085 surgeries per year in Ontario by 2011.
Mehran Anvari, a surgeon and chair of the Ontario Bariatric Network says that the strategy has “steadily been building capacity in Ontario” and anticipates that by the end of 2011, nearly 2800 surgeries will have been performed in Ontario, which exceeds Ministry-established targets.
A recent report suggested that obesity costs Ontario approximately $1.6 billion annually, with $647 million in direct costs and $905 million in indirect costs. Given the significant costs associated with obesity, Freedhoff suggests that funding for bariatric surgery is limited in part due to stigma surrounding obesity because many members of the public “believe that obese people should push away from table.” However Freedhoff says that while taxpayers may not see the value of bariatric surgery, “it’s in the best interest of public funding of health care to do this surgery expeditiously and quickly.”
However, while many Ontarians may be eligible for the surgery, this does not mean that it is the right intervention for all of them. Teodor Grantcharov, a surgeon at St Michaels Hospital who performs bariatric surgery says that “obesity is a complex issue and patient selection is crucial.” Grantcharov notes that “surgery itself is just a small part of this process” and that rigorous assessment before the surgery and “close follow up after surgery, which includes compliance with an exercise, diet and supplement regime” is critical to sustained weight loss and improved health. Bariatric surgery is not a one size fits all solution to obesity and Anvari notes that “success of the procedure depends on how well the patient is worked up, and the selection of patients.”
The important question now is whether those targets are the right ones – is Freedhoff correct that many more surgeries are needed, and do the current four bariatric centres adequately meet the needs of patients across the province? Another important question is the amount of resources that should be spent to prevent obesity in the first place, compared to treating obesity once it is established.