DDHHS’ Response to the Obesity Epidemic

Publicly Funded Bariatric Surgery

Dr. Peter Gillies Acting Health Service Chief Executive

SOURCE: Sturm, R., J. Ringel, and T. Andreyeva, "Increasing Obesity Rates and Disability Trends," Health Affairs, Vol. 23, No. 2, March/April 2004, pp. 1–7.

People with a BMI >35 have twice the risk of death at any age when compared to people who have a BMI within the normal range.

“Obesity is now overtaking tobacco as the largest preventable cause of

disease in Australia”. (Australian Chronic Disease Prevention Alliance, 2010)

Adams, K. F., Schatzkin, A., Harris, T. B., Kipnis, V., Mouw, T., Ballard-Barbash, R., ... & Leitzmann, M. F. (2006). Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. New England Journal of Medicine, 355(8), 763-778.

May 2015 - http://thenewdaily.com.au/news/2015/05/04/australias-fattest-fittest-suburbs/

http://www.heartfoundation.org.au/SiteCollectionDocuments/HF%20Obesity%20and%20Physical%20Inactivity%20Report%20overview.pdf

Five out of 10 of

Australia’s

unhealthiest

regions are in

Queensland.

In 2015, the National Heart Foundation

rated Darling Downs – Maranoa as the

most obese and inactive place in

Australia.

Toowoomba was 10th worst in

Australia

Fattest towns

237 patients older than 50, on the

waiting list for possible TJR of the hip or knee.

63% had a BMI greater than 30

16% had a BMI greater than 40

Patients with a BMI greater than 40 are generally not considered suitable for joint replacement surgery at Toowoomba Hospital. At any one time there are up to 40 patients on the waiting list whose weight alone precludes them from joint replacement surgery. It also does not include those patients who have already been seen in an Orthopaedic clinic & who have been advised they are not suitable for joint replacement surgery because of their weight.

Mrs S 56 Y.O. Female patient: Date Intervention Outcome

18/04/2008 First Orthopaedic appointment. 48 y.o.

Warrants TKR but too young for surgery. Review in 12 months

20/03/09 Orthopaedic review. BMI recorded as 35 – weight would be 80.85 kg

Continue conservative treatment and review 6 months

25/09/09 Has gained 10 kg Review 12 months

27/10/10 No change in symptoms Review 12 months

26/08/2011 Orthopaedic review Weight recorded as 107 kg

Continue conservative treatment, review 12 months

28/11/12 Orthopaedic review. No change noted

Continue conservative treatment, review 12 months

26/02/14 Further GP referral – severe knee osteoarthritis

Review appointment arranged

7/05/14 Morbid obesity noted Advised needs to lose weight, review in 12 months

6/05/15 Orthopaedic review. Weight 137.4, BMI 59

Would require significant weight loss before TKR could be considered.

It has been identified that a number of obese patients are returning to Orthopaedic OPD for regular review with a diagnosis of hip or knee osteoarthritis where joint replacement would be appropriate. Each visit, they are advised that surgery is not feasible because of their obesity and they are given advice to continue conservative management, try and lose weight and surgery may be offered when they achieve a certain weight. Unfortunately most of these patients have actually gained more weight when they return for review so they are given the same advice and a further review appointment made. The clinicians are frustrated at not being able to offer these patients a more useful service, and the patients are frustrated feeling the hospital is not addressing their needs.

“For patients with BMI 30-35 who do not achieve substantial and durable weight and co-

morbidity improvement with non-surgical methods, bariatric surgery should be an

available option for suitable individuals”. (American

Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, 2013)

“Bariatric surgery, when indicated, should be included as part of an overall clinical pathway for adult weight management that is delivered by a multidisciplinary

team (including surgeons, dietitians, nurses, psychologists and physicians) and includes planning for continuing follow-up”. (NHMRC (2013) Clinical Practice Guidelines for the

Management of Overweight and Obesity in Adults, Adolescents and Children)

Mingrone G, Panunzi S, De Gaetano A, et al. (2012) Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012;366(17):1577-1585

A Cochrane review published in 2003 and updated in 2005 and again in 2009 concluded that bariatric surgery resulted in greater weight loss and improved quality of life compared with people who did not have surgery. (Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for Weight loss in adults Cochrane Database of Systemic Review 2014, Issue 8. Art. No.:

CD003641. DOI: 10.1002/14651858.CD003641.pub.4.)

Mingrone G, Panunzi S, De Gaetano A, et al. (2012) Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012;366(17):1577-1585

“The co-morbidities of severe obesity affect all the major organ systems of the body. Surgically induced weight loss will substantially improve or reverse the vast majority of these adverse effects from severe obesity.” American Association of Clinical Endocrinologists

(AACE) July 2011: AACE Task Force on Obesity

One trial showed Type 2 diabetes remission rates of 75-95% within 2 years following surgery (Mingrone et al, 2012)

Australian guidelines quote weight loss figures of between 16-43% (varying between 22 and 63 kilograms) for morbidly obese adults following bariatric surgery, claiming that these are “reasonably well maintained over three to eight years” (Australian

Government, 2003, p. 168) .

Conceptual summary of clinical outcomes of treatment alternatives for morbidly obese patients

Holtorf, A. P., Brixner, D., Rupprecht, F., Rinde, H., & Alder, H. (2012). The Economic Impact of Bariatric Surgery. INTECH Open Access Publisher.

“There is evidence to suggest that no other currently available therapies are as effective as surgical management in achieving weight loss

and improving obesity-related diseases in morbidly obese individuals…Surgical interventions for morbid obesity carry some risk, but these are significantly less than the health risks associated with morbid

obesity” (State Government of Victoria, 2009)

A study comparing the Australian lifetime costs and quality-adjusted life-years found that the mean number of years in diabetes remission over a lifetime was 11.4 for surgical therapy patients and 2.1 for conventional therapy patients. Relative to conventional therapy, surgically induced weight loss was associated with a mean health care saving of AUD$ 2,400 and 1.2 additional QALYs per patient (Keating et al, 2009).

Annual number of bariatric procedures performed in Australia 1998 – 2008 (public & private hospitals)

SOURCE: State of Victoria (2009, p. 7)

In 2007–08, over 90% of separations for weight loss surgery in Australia were in private hospitals, with private health insurance funding 82% of separations (Royal Australasian College of Surgeons, 2015a).

Currently the only public bariatric surgery service in Queensland is at the

Royal Brisbane and Women’s Hospital.

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5

10

15

20

25

30

35

40

45

50

Bariatric Surgery Rates in Relation to Education

Korda, R. J., Jorm, L. R., Butler, J. R., & Banks, E. (2012). Inequalities in bariatric surgery in Australia: findings from 49,364 obese participants in a prospective cohort study.

Available at: https://digitalcollections.anu.edu.au/bitstream/1885/9791/1/Korda_InequalitiesBariatric2012.pdf

“RACS recommends equity of access to weight loss surgery by publicly funding bariatric surgery, including support from a team of expert clinicians for patients that

meet appropriate clinical guidelines”. (Royal Australasian College of Surgeons Recommendations , 2015)

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15

20

25

30

35

40

45

50

<20k $20k - $30k $30k - $40k $40k - 50k $50k-70K >70k

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Household Income

Bariatric Surgery Rates in Relation to Household Income

“Our findings parallel similar studies suggesting that there is equal benefit in publicly funded and privately performed procedures. This study highlights that

obese patients reliant on public health care maintain sufficient intrinsic motivation in the absence of payment and supposed value-driven incentive. Improved access to bariatric surgery in the public sector can justifiably reduce the health inequities

for those most in need”.

Publicly funded patients pilot: Patient weight change over time after bariatric surgery

SOURCE: Lukas et al (2014, p.221)

Toowoomba Hospital is planning to undertake a small prospective trial where obese osteoarthritic patients

on the waiting list for a joint replacement are randomised into a conservative management group or

a bariatric surgery group.

*Pre and Post Surgery Support team through private Allied Health

providers

• Psychologist • Exercise Physiologist • Dietitian • DDHHS Endocrinologist • Home monitoring

support available • Face-to-face, group and

phone support available

1. Identify patients

2. Pre-Surgical Support Team*

3. Bariatric Surgery

4.Post-surgery Support Team*

5.Discharged back to GP

- Identify suitable patients for surgery

- Refer to Pre-Surgical Support team

Yes

Screening and short term intervention

No

Short term intervention focussed on

self-management

support

- Surgeon screens for suitability for surgery

- -Surgical Support Team may undertake preparatory work with the individual prior to surgery

“Overweight" is defined as a Body mass Index (BMI) equal to or more than 25, and a BMI of 30kg/m² or above denotes “obesity”. (WHO , 2000)

Implementation of bariatric surgery and Allied Health support for patients who would benefit from surgical intervention

A bariatric surgery service could be offered in a limited number of Centres of Excellence

It could be a limited access service. I.e. requiring referral by a specialist of a patient already on an

existing waiting list

Dr Peter Gillies Acting Health Service Chief Executive Darling Downs Hospital and Health Service Peter.gillies@health.qld.gov.au P: 07 46165889

“Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek”.

Barack Obama