Tuesday, December 08, 2009

Ontario residents to wait even longer for bariatric surgery?

Sure looks that way for as of November 1st there are new hoops to jump through for physicians trying to access a bariatric surgical consult for their patients.

On the surface, surgical criteria couldn't be more straightforward:

A. BMI >35 and <40>
  1. Coronary heart disease.
  2. Diabetes
  3. Obstructive sleep apnea
  4. Medical refractory hypertension despite optimal medical management

B. BMI >40 for greater than 2 years
Meet those criteria and theoretically you should be cleared for surgery. Problem is in Ontario we have far more demand than we have supply. Consequently last year Ontario funded 1,660 out of province bariatric surgeries, triple the number from 2006. The rapid increase is likely due to the fact that more and more physicians (and patients) are recognizing the utility of bariatric surgery; spreading word of mouth from those who've had success; and the publication of long term results that undeniably demonstrate increased longevity and decreased morbidity post-operatively. In other words, physicians and patients are recognizing bariatric surgery for what for many it is - a quantity of life prolonging and quality of life improving procedure. Consequently demand will only be going up.

So how many Ontarians qualify for bariatric surgery?

Estimates put roughly 3% of Ontario's population as being appropriate bariatric surgical candidates - that'd be 345,000 people.

So what's our government doing about it?

On February 7th, 2007 the McGuinty liberals announced that they'd be increasing funding for Ontario based bariatric surgery and providing sufficient funding to support 225 additional annual bariatric surgeries at the Humber River Regional Hospital. That press release flaunted this statement,
"Today’s initiative is part of the McGuinty government’s plan for innovation in public health care, building a system that delivers on three priorities - keeping Ontarians healthy, reducing wait times and providing better access to doctors and nurses."
On February 23rd, 2009 this initiative was expanded upon and it was announced that Ontario would be spending an additional $75 million dollars so that by 2011/2012 Ontario's bariatric surgical capacity will be 2,085 cases per year.

Why spend the money?

Firstly there's the estimate that for every procedure done in Ontario rather than out-of-country the Province will save $10,000. Secondly there's this statement from the backgrounder put out along with the announcement,
"Bariatric surgery can help resolve several health conditions, such as diabetes, hypertension and dyslipidemias. Dyslipidemias is a condition that can lead to atherosclerosis, the hardening of the artery walls, which can restrict blood flow to the heart. Bariatric surgery can also reduce other obesity-related conditions, such as hypertension (high blood pressure), osteoarthritis (a painful joint disease), ischemic heart disease, stroke and some cancers."
Translation - it's a remarkably effective surgery that increases longevity and decreases co-morbidity (in fact eliminating most weight related co-morbidity).

So let's look at the initiative.

So far the Ministry has established a total of five regional assessment centres - locations where physicians are supposed to refer their patients if they're interested in bariatric surgery. The five are Humber River Regional Hospital in Scarborough, St. Joseph's Healthcare in Hamilton, Guelph's General Hospital, the Ottawa Hospital, and Windsor Regional Hospital. Once referred it's up to those centres to determine need. According to Ministry sources I spoke with, more are planned.

But wait a second, do we really need to have our patients seen by another physician to determine eligibility and won't that also markedly hamstring folks who don't happen to live in one of the cities with designated centres? Aren't the surgical criteria extremely straightforward? Shouldn't a minimum of 6 years of medical education equip physicians with the ability to determine suitability?

Personally I think so, and certainly doctors as a general rule are great at following flowcharts but given the added costs here, I readily agree that there should be a step to ensure that indeed the patients are suitable. Before the establishment of these centres there was a committee that reviewed applications and turnaround was in the neighbourhood of 4 weeks to approval. If the patient didn't meet criteria then the committee either rejected the application or requested further information from the referring physician.

Speaking to folks working with the committee they were getting swamped (not just with requests for bariatric surgery but also other out-of-country needs) and clearly something needed to change.

But is there really a need for a committee? Couldn't the Ministry with some of that $75 million create an online application, accessible by physicians, that in turn screens itself and would automatically eliminate those folks who weren't clear cut surgical candidates based off pre-determined and pre-programmed criteria, and in those cases where outright rejected or where other factors may necessitate further assessment - age, psychiatric history, etc., perhaps those could be the folks who should be assessed at a regional assessment centre?

Alright, so how are these centres working at reducing wait times like the press release suggested? Well, just 1 month ago when we didn't have these centres the wait would have been a maximum of 4 weeks to approval for a surgical consultation, what about now?

Our front-desk administrator Wendy called the assessment centres and here's what she found out:

Ottawa: They outright refused to provide us with any information. They refused to tell us the length of the waiting list or how many people were on it. Wendy was polite. She explained she was calling from a physician's office and she was told that their policy, regardless of who was calling, is not to divulge any information. They also told Wendy that if she were a patient on that list that it would be their policy not to tell her when they thought we might be seen.

Windsor: They didn't really know. They told Wendy that it would be a minimum of 1-3 months but when pressed they admitted that they really had no idea and that they had well over 100 consults that hadn't even been contacted for appointments yet.

Guelph: They were extremely helpful and pleasant. Wendy was told that if we had a patient to refer that the next available date would be May 10th (a 6 month wait).

St. Joseph's Health Centre
: Over the course of the past week Wendy called 4 times and left 2 messages. No one ever called us back and we were never able to reach a human being.

Humber River Regional: Wendy left 2 messages and I also had one of their staff surgeons email them a request on our behalf and so far, no one has gotten back to us. UPDATE: They finally got back to us (almost 2 weeks later) and the wait is between 12 and 14 months.

Not exactly promising stuff.

So is there any way to get a patient to an out-of-country surgeon without the regional assessment unit? Yes. There's a criteria that the patient needs to be assessed by the unit OR needs to have failed a 3 month inter-disciplinary management of their obesity that specifically includes physicians and dietitians in patient care. That said, there are very few inter-disciplinary weight management programs in Ontario (mine being one of them, and off the top of my head I can only think of 4).

Now despite the fact that my patients will in fact still have timely access to out-of-country surgeries I am slightly uneasy with that requirement. Why? Well even though I'm incredibly proud of the services we provide in my offices, to date there has yet to be a medically managed program reproducible enough to serve as a "gold standard". What I mean is that medical weight management is a service that depends highly on the staff providing it and while good behavioural programs can indeed yield great outcomes, I feel that requiring a 3 month trial of such a program in the absence of a reproducible gold standard may be an unreasonable requirement which in some cases will just end up costing patients 3 months of time and some amount of money given that OHIP doesn't cover ancillary health care services like dietitians.

Given that the number of out-of-country bariatric surgery cases tripled since 2006 to 1,660 and with no reason to believe that the rise in demand won't continue to be extremely rapid, and given that the Ontario surgical centres established aren't yet at their 2011/2012 capacity I have no doubt that demand will continue to dramatically outstrip supply and consequently wait times will likely be far greater with this new system than when we physicians could access out-of-country bariatric surgery for our patients directly (rather than through the additional step of a regional assessment centre).

Having spoken to one person intricately involved in the establishment of these new rules I was given the impression that they viewed this surgery as comparable to a hip replacement, and just like hips, waits of 1-2 years to have the surgery are less than ideal but still completely acceptable. I disagreed. While living with a painful hip certainly impacts on quality of life, it doesn't impact on quantity. Living with severe obesity and its many co-morbidities certainly risks dying from weight-related complications prior to your surgical date and risks permanent damage as a consequence of disease processes and the physical effects of the weight itself.

At the end of the day I think this is all about money. At some point there was a high level discussion where somebody took a look at the ever increasing amount of money flowing South of the border and somebody said we've got to figure out a way to stop this flow. Given that we live in a nation of socialized medicine money's a very fair concern and even if each and every one of these surgeries in the long run saves the Province money by reducing long term health care costs for these patients and increasing their productivity and ability to work, if you don't have the money up front you can't make the investment.

I just wish the Ministry would have come out and said that it was wholly about money rather than suggest it was about wait lists and access to care since the waits are now much, much longer, and only likely to grow, and with the rare exceptions of folks like me with an inter-disciplinary program backing them up, access to care has become more difficult to obtain. Really, by not actually coming right out and saying it's about money the Province is far less likely to address money as a problem. and consequently it's less likely that people will be actively looking and advocating for novel solutions to increase Ontario based surgical availabilities such as the establishment of public-private partnerships (so called P3 hospitals) to build privately built and publicly funded baratric surgical hospitals and the public also won't see a great example of a massive crack in our publicly funded healthcare system and if you don't see cracks you tend not to look for ways to repair them.

I'm hoping this is just an example of growing pains and that my worries won't pan out but so far this new system, in its current state, effectively puts a cork in what was already a bottleneck.