Wednesday, December 01, 2010

Ontario's bariatric surgical wait times set to skyrocket.

One of the things that is quite true about Ontario's efforts in increasing in-province access to bariatric surgery is that Ontario is light years ahead of virtually all of Canada's other provinces.

That said, the likelihood Ontario will ever be able to meet bariatric surgical demand is virtually nil.

Why do I say that?

Well in his lecture this past Saturday, Dr. Mehran Anvari, project lead of Ontario's bariatric registry, talked about numbers. And the numbers just don't add up.

Currently he reports that this year Ontario will perform 1,700 surgeries. Next year 2,200, and the year after that 2,800. He also reports,

"Our goal is eventually to reach close to three and a half thousand to four thousand which we believe is what is necessary in Ontario"
In terms of demand, we know that between 2006 and 2009 demand for out-of-country bariatric surgery for Ontarians tripled to near 1,600.

That sure sounds like a rapid rise in demand, and perhaps if demand were to triple again by 2012 and if somehow Ontario was on track to do even 5,000 bariatric surgeries a year that'd be enough to keep up. Assuming of course demand didn't continue to rise.

But here's the rub.

Dr. Anvari reports that Ontario's current monthly average of referrals through the bariatric registry is 800-900/month. That means that even without an increase in demand (a strange assumption given the apparently exponential rise in same), 2011 alone will see roughly 10,000 referrals. And yet Dr. Anvari is talking about a 2011 goal of performing 2,200 surgeries, a 2012 goal of 2800 surgeries and an "eventual" goal of 4,000 surgeries. That means that by the end of 2011, even if only 70% of those referred were appropriate and actually went on to seek surgery, there'll be a 3.1 year wait list for surgery (not even counting those already waiting). By the end of 2012, it'll be 4.2 years. And even if we even somehow manage to reach what Dr. Anvari called an "eventual" goal of 4,000 surgeries a year, and still assuming no increase in demand and only 70% of folks referred going on to have surgery, we'd see the wait list grow by another 8 months each and every year.

Now while I'm scared to tempt Dan Gardner's scorn, I'd guess that given the meteoric rise Ontario has experienced in bariatric surgical demand, combined with the ongoing rise in obesity rates, increasing public and physician understanding of bariatric surgery, and more and more success stories to spread the word themselves, demand will continue to rise and there's a great deal of room for movement. Remember, in terms of eligibility, there are likely on the order of 360,000 Ontarians that would meet bariatric surgical criteria and that's a number that to some extent is self-replenishing. That means the 10,000 projected referrals for this year represents less than 3% of eligible patients.

Remember too, these aren't benign waitlists. Unlike wait times for things like joint replacements, suffering will increase and some people will likely die as a consequence of not having access to this procedure sooner.

Ultimately our system is broken. The sooner the public and politicians understand that, the sooner we're likely to see innovation.

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  1. Hmm. Count me in the (small?) group who thinks there may be a silver lining to this news. I know it's anecdotal, but the people around me who have had WLS are gaining the weight back after a year or two or three, as they figure out how to work problem foods back into their diets.

    In fact, recently saw this this woman on Rachael Ray, and of course, there's also Carnie Wilson. And if this is true, then nearly a third of women replace compulsive eating with compulsive drinking!

    I do have an anti-surgery bias (my sister is one of those who has regained the weight), so I offer that in full disclosure. But it seems to me the best that can be said for some (or many?) WLS patients is that WLS just is really kicking the can down the road a bit further than with other obesity treatments. It may not be a lifelong solution.

    Me, I'm hoping that in the years that these candidates are awaiting WLS, we learn enough about the causes of obesity to identify even better (and less invasive) treatments. I can wish, can't I?

  2. Anonymous1:06 pm

    Dr. Anvari's eventual capacity goal of 3500-4000 surgeries per year is in keeping with the OHTAC (Ontario Health Technology Advisory Committee) Recommendation from 2005 for Bariatric Surgery available from the MOHLTC site. They say "Extrapolating from 2003 U.S. experience, Ontario would require 3,500 bariatric surgeries per year...".

    As you point out, however, obesity rates are growing. The recommendation should have included an estimated growth rate based on the increasing obesity. The 3500 number was made five years ago and is now based on seven year old data.

    As you also point out, only a small fraction of those medically eligible for the surgery are having it done. Tip that fraction through awareness and success stories, and the 3500 figure becomes completely obsolete.

    As high as the numbers (and costs) are associated with bariatric surgery, the frightening reality is that it is more expensive to not properly fund it.

    Supportive Spouse

  3. is it the system that is broken? or is it the overload of broken people? I mean, there should never be a system that can handle the current demand, or rise to meet the demand of the future. That would somehow be saying, it's ok, or that we've at least found a way to deal with it (much like the anxiety and depression problems).

    I mean... I love blaming the system for all sorts of things, but when it comes down to it, if we dont stop shoveling obscene amounts of crud in our bodies, it's just a loser.

    Honestly, how many people NEED gastric bipass surgery? I'm not a Dr. so really, I dont know. But are there that many that absolutely need it to the point diet and exercise wouldnt help?

    Love your blog! Keep it up Freedhoff!

  4. Anonymous1:26 pm

    Sorry Beachbody, but the system is broken.

    Mother: 3 months to see an oncologist. She died in the mean time.

    Father, 5 months to see a kidney specialist after surgery for another matter.

    Bar client of mine - 2.3 years for hip replacement. Not an overweight man what so ever.

    My own experience - 3 and a half months to get test and results of a mammogram for suspicious lump. I suggest YOU go 3 months not knowing if you have cancer or not and see how you like it.

    Bariatric surgery waiting times are in line with a health system who prides it self more on administration than it does outcome and patient care.

    I rather resent your uninformed opinion as well that it's about "shoving crud" in our bodies. Frankly dude, you have NO idea. No idea what so ever. I bet you think that exercise alone with make skin shrink back too eh?

  5. Anonymous7:26 am

    Beth, the various surgeries all have a failure factor. Lapband, VSG, RNY etc all have failure rates over 20%, some higher than that. Lap band I believe hits the 40% mark. Duodenal Switch has a lower rate of approximately 10% failure rate according the the studies posted on some of the WLS sites.

    While yeah, if you consume tacos and gallons of root beer 6 times a week, chances are you aren't going to be thin, not for long at any rate. That said, understanding carbs and proteins and how a body deals with them is still being researched. Theories range (in layman terms ) from "carb trapper" follicles in the intestine/digestive track being over active to actually multiplying in times of reduced intake (explaining for example the yoyo diet + extra weight gain each time someone actually loses a significant amount of weight)

    So, lets just say for example that that is the case for people who regain the weight. Is the fact that their body adapts by creating yet MORE weight gaining follicles THEIR fault? Of course not.

    Lets not forget for one second that the diet industry brings in BILLIONS of dollars per annum. It's unregulated in Ontario (among other places) and there's a lot of money that stands to be lost if it is in fact proven that it's not about consumption so much as it is about what your body does with ANY consumption, healthy or otherwise.

  6. @anonymous

    I must admit, I am not familiar with the Canadian health care system Anonymous. I think you misunderstood what I was saying.

    I was merely trying to point out that as patients we have a responsibility to ourselves. What we eat, what we choose to do with our bodies.

    It would be like me running my car without ever changing the oil, then getting mad at the mechanic for not being able to get me an appointment in a timely manner, when the mechanic is highly overloaded because no one is changing the oil in their cars.

    I dont believe I ever said that exercise would make skin shrink.

    I DO believe that we can PREVENT a lot of disease and health care problems through diet and exercise though, yes.

    I dont think that any "system" is perfect, and I know the U.S. is in total disaray right now, but I also look at it and see a portion of it being personal responsibility. Certainly we should be able to make some dietary changes and lifestyle changes that will impact our lives, and in addition everything else.

    Just look at the trending. In a little over 20 years the amount of overweight/obese in the U.S. has increased over 200%. We can not continue the trend. And increased surgery just isnt a viable option. I dont think medication is either.

    How will we go down in the history books? The people that ate itself to death? The people that modified their food to the point it killed them? The people that were so addicted to their food and lifestyle that they refused to make changes that would save their lives?

    I mean, that's what I get from this blog. Maybe its not the case, but I see all the foods that the Doc posts and yea, it's laughable, why do we make the crap, let alone eat it? I think it's a great blog. But maybe its bad for bariatric business. Maybe the blog should be saying eat McDonalds 4 times a day.

    I'm not saying the "system" shouldnt be fixed, but if trending continues, the system will continually have to be fixed to meet growing demand, it must be a dynamic solution including patient responsibility.