Tuesday, November 30, 2010

Ontario's bariatric surgery strategy reflects monetary realities.

This will be the first of a few posts this week on bariatric surgery including a post detailing one patient's experience in successfully overturning Ontario's Ministry of Health's cancellation of her pre-approved out-of-country gastric bypass.

Today's post though will cover a topic that I've blogged about before - why the changes?

The Ministry of Health, through their press releases and official spokespeople, has stated that the point of shutting the doors to out-of-country surgical access and spending $75 million on increasing access to in-province surgical care was to improve timely access to surgery and to improve the quality of patient care.

Unfortunately to date all they've succeeded in doing is markedly increase wait times and put people at increased risk of surgical mortality. What do I mean? Well prior to shutting the doors to patients accessing the 18 American bariatric surgical centres of excellence (a moniker they earned rather than one they simply awarded themselves) the MOH covered , patients could go from referral to surgery within 4 months of application and surgical mortality was in the order of 1 in 1,000 or better. Since the American corridor has been shut wait times have easily reached 1-2 years with Ontario striving towards the procedure's reported all comers "average" death rate of 1/200, a rate that still isn't the one I'd be striving to hit for as noted, the American centres of excellence, where their high volume gives them a tremendous amount of experience, have death rates markedly better than the 1/200 average and tend to range between 0.5 and 1 in a thousand.

Sure doesn't sound like improved access to better care to me.

So why have they made these changes?

My belief has always been that the primary driver for changes was, is, and always will be, money. And frankly that's a very fair consideration in our single-payer health care system. Problem is, without identifying that as the driver for change, we're obscuring the real problem - the system's failing, and pretending that this is all about delivery of care means that we'll be far less likely to try to fix it.

Well, my belief was confirmed on Saturday when I was sharing a podium with Dr. Mehran Anvari, one of the principle investigators of the new bariatric registry program in Ontario. Between his talk and the answers he was able to provide to my questions, he clarified a few things.

Firstly he commented on how one of the main problems with the out-of-country surgeries wasn't the surgery itself, but rather after-care. A very valid point and one that makes me wish at least some of the $75 million dollars Ontario recently allocated to bariatric surgery was spent on the creation and propagation of educational tools and resources for family physicians and general surgeons that would help instruct them on the needs and common complications of the post-operative patient.

He also said this,

"We simply as a province, we cannot afford to send every patient who requires bariatric surgery to the US"
I believe it. At the end of the day despite having patients "requiring" surgery, the monetary truth is we simply can't offer to pay for everyone, and as I'll be discussing later this week, I don't think we have or will have the funding to do them in Ontario either.

Once again I must point out that money is a fair consideration here in Canada, and perhaps if more people were as up front about it as Dr. Anvari we'd be busier trying to find innovative and creative solutions rather than trying to protect an already broken system from valid criticism.

Of course fair or not I imagine the Ministry of Health will soon find itself in quite a pickle because as far as I'm aware, money may enter the equation of whether or not a procedure should be funded, but I'm not aware of it being a defensible rationale for an approved procedure having an inordinately long wait list. But more on that over the course of the next few days.

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  1. Anonymous9:48 am

    Your comments about "money" is spot on. Another part of this is the insane amount of "consultation" that's required before surgery. WHY, WHY, WHY is a consult with a flippin' social worker required?

  2. Anonymous9:50 am

    I am of the opinion that bariatric surgery should not be done until the candidate has demonstrated changes in lifestyle ie quitting smoking, pop, starting mild exercise, seeking counseling for emotional problems.
    Right now there is almost a rubber stamp approach to the pre-op assessment. Rarely are patients asked to go back for more nutritional counseling - recently someone who was eating Lucky Charms and told the dietician this was only asked to do another few weeks of diet journaling. Her response was not one of 'oh, I shouldn't have eaten that" no, it was "I wanted them, and at least I was honest in telling them."
    No wonder there is such a high rate of people re-gaining weight.
    HMO's in the US ask for 6-12 months of pre-op teaching, participation in exercise and nutritional counseling. Not sure if there is evidence to support this- but rushing to surgery is not the answer. People don't become morbidly obese overnight.
    I waited 18 months for my surgery - the system did not give me much to help me make changes pre-op, I did that myself. Others are not as well equipped to do this and it is sad to know that many will fail because for some strange reason, the goal is the surgery, not changing how people eat and live. The surgery is a tool, you need to learn to use it before getting it.

  3. Anonymous9:58 am

    Just as an alcoholic isn't a candidate for a liver transplant, a person who can't demonstrate some semblance of lifestyle modification/control with regards to food shouldn't be a candidate for this type of surgery.

  4. Anonymous10:16 am

    I have now been through information sessions with my wife at two U.S. bariatric centers, and Windsor following OHIP's slamming of the door. The U.S. centers proudly presented their mortality stats at 0.25 percent or better, and even covered what went wrong in the couple of fatalities.

    By contrast, Windsor tossed out a 1-2 percent mortality rate. Is my daughter really 4-8 times more likely to grow up without a mother if my wife has here surgery here? Or did they simply quote the same number I came across in some several-year old information on the RNY procedure? Or both?

    OHIP is doing a disservice not only to patients, but to the health care workers in the system. Based on our Windsor experiences, they are trying to make a first class system, but OHIP's mass diversion of patients into the Ontario system is like tossing an anchor to a beginning swimmer.

    But, hey, OHIP says everything is fine. "Pay no attention to that man behind the curtain. The great and powerful [OHIP] has spoken!"

  5. Anonymous10:52 am

    Yes of course a lifestyle assessment must be considered when determining weight loss surgery of any kind. Weight loss surgery is a tool that must be used in correlation with change of lifestyle. To say that anyone believes that this surgery should not be covered would be like saying that any “self inflicted” health concern should also not be covered – like for instance sport injuries (running, football, hockey, baseball, swimming, diving), that perhaps hunters should not receive care if hurt while on the hunt for food, sport or recreation, sports car drivers and the technicians that work with them should also not receive treatment because they choose to work in unsafe circumstances…. Loggers….. Bloggers (stress)…. Etc… the question is where does it stop?

    Overweight Ontarians are going to be a burden on the healthcare system in one way or the other. Either you provide them with a proven tool to aid in weight loss or you pay to treat their comorbidities such as Arthritis, Heart Disease, Diabetes, Gallstones, Hypertension and Stroke. Once you accept that the surgery is necessary, life saving and ultimately cost saving the question is: how to we make it available in a timely manner?

    The current Ontario system is not working, we do not have Centres of Excellence, we have Centres of Learning and they cannot meet present-day needs. How many Ontarians need to die on waiting lists to get this point across?

  6. Anonymous8:44 pm

    Rubber stamp? Like hell. People are waiting upwards and past 2 years to get surgery. And trust me, if losing weight was as easy as just doing exercise and swearing off the donuts, there would be no need for diet centres or surgery.

    "Fat" people are such easy targets for sanctimonious twits who know little or nothing about the digestive system, genetics and the like. Subsequently these centres of excellence hold the same bias. They make people jump through hoops that no other type of surgery requires. You can get a sex change faster for god sakes.

    As for money, if this was REALLY about health, and NOT money why did the govt just dlist Vitamin D testing? Why did they dlist duo-denal switch surgery which has the highest success rate among the weight loss surgeries? Oh, wait...I know... not enough govt flunkies get paid for their "consultations" with that surgery.