Bariatric surgery : pathways, perspectives and policy options

Background Bariatric surgery is the most effective treatment for obesity in adults, but providing equitable access to this service is a challenge in resource constrained public health systems (>90% of bariatric surgery is privately-funded in Australia, with 18,890 primary bariatric surgeries conducted through the private system in 2016). In the presence of many evidence gaps, health service planners face difficult decisions in determining how many primary bariatric surgery procedures should be funded, who should be prioritised and which models of care are needed. The Tasmanian department of Health and Human Services sought assistance from the University of Tasmania, to fill knowledge gaps needed to inform evidence based policy and service delivery of bariatric surgery. Aims The three principal aims of this PhD project were to: 1. Estimate the number and characteristics of adult Australians in each state and territorypotentially eligible for bariatric surgery and the potential demand for this service throughthe public and private health systems. 2. Compare jurisdictional and national level guidance on bariatric surgery and providerecommendations for future policy development. 3. Provide advice on service delivery models based on knowledge of why people seeksurgery, patient perspectives on the impact of prolonged waits for surgery and the supportneeds of bariatric surgery recipients. Methods Aim 1: 2011-13 Australian Health Survey data was extracted to estimate the number and characteristics of those potentially eligible for bariatric surgery. Aim 2: National (Australia, UK and US) and Australian state and territory guidelines on bariatric surgery were reviewed and compared. Aim 3: The pre- and post-bariatric surgery patient experience was thematically analysed following ten semi-structured focus groups and 19 individual interviews, involving recipients of bariatric surgery and patients waiting for surgery. Results Of the 3,352,037 adult Australians (18-65 years) estimated to be living with obesity in 2011-13, 882,441 (26.3%) were potentially eligible for bariatric surgery (6.2%; CI 5.4, 7.1 of the adult population aged 18-65 (n=14,122,020)), of which 45.8% were without private health insurance (Aim 1). National and jurisdictional guidelines were not uniform (e.g. access criteria were inconsistent) and there was limited or no guidance on prioritisation of eligible patients and follow-up surgical services (e.g. reoperations and removal of excess skin) (Aim 2). Patients waiting for surgery and those who had undergone surgery (n=68), identified many support gaps (e.g. deficits in psychological, peer and dietetic support and follow up surgical services), that may influence their outcomes (Aim 3). Conclusions The potential demand for bariatric surgery in Australia far outstrips the current supply of this service especially through the public health system, indicating a need for more resourcing of this service and other effective interventions. Determining who should have priority for the limited resource of bariatric surgery in the public health system is challenging and is made more difficult because guidelines on this intervention are inconsistent and are generally silent on some key policy issues (e.g. patient prioritisation), highlighting a need for policy renewal. Models of care for bariatric surgery should reflect pre- and post-surgical support needs of patients (e.g. dietetic, psychological, peer support and follow-up surgical services), because the support experience may influence outcomes. The challenge lies in determining how a public health system can provide better support with limited resources. Future research designed to assist patient prioritisation decisions and to determine the most efficacious and cost-effective models of care is needed, ideally leading to better service delivery of bariatric surgery and improved patient outcomes.