The frequency of obesity has skyrocketed across Canada, and its treatment is a major challenge to the health care system.
Bariatric surgery is an effective treatment for obesity that appears to be good value for money.
Although Ontario is expanding bariatric surgery capacity, some are concerned that capacity remains below current needs.
What is bariatric surgery?
Bariatric surgery is a term used to refer to a number of different surgical weight loss procedures. Evidence shows that gastric bypass surgery, which reduces the size of the stomach, is the most effective surgical treatment for weight loss. Bariatric surgery is relatively safe – the risk of dying within 30 days of the surgery is 0.1-0.3 percent, which is about the risk of dying after having one’s gallbladder removed. The surgery works by reducing the intake and absorption of food.
After surgery, a substantial number of obese individuals with diabetes are able to stop taking the medications they needed to control their blood sugar before surgery. Bariatric surgery is currently paid for by the Ontario government for individuals with severe obesity.
Bariatric surgery in Ontario
The Ontario Ministry of Health and Long-Term Care conducted a detailed review of the evidence that bariatric surgery reduces obesity in the mid-2000s, and determined that it is an effective treatment for people with morbid obesity. The review noted that “surgery for morbid obesity is considered an intervention of last resort for patients who previously attempted first line forms of medical management”, including diet, physical activity, behavioural modification and drugs.
Until 2009, access to bariatric surgery was limited in Ontario, with only a few hundred surgeries performed in the province annually. Because of the limited capacity in the province, doctors were able to directly refer eligible patients to American surgical centers, and the costs of the operation for these patients were covered by the Ontario Health Insurance Plan. In 2008/2009, the Ontario government stated that it would fund 1660 bariatric procedures in the United States.
In May 2009, however, the Ontario Ministry of Health and Long-Term Care announced that it was spending $75 million to increase bariatric surgical capacity in the province by 500% over a 3 year period, from 244 procedures per year, to 2,085 procedures per year at four centres.
The Ontario Bariatric Services Strategy is part of the province’s larger diabetes strategy to prevent, control, and manage diabetes. Through increasing provincial capacity for bariatric surgery, the government wanted to reduce reliance on American providers, improve access in Ontario and save “$10,000 for every case done in Ontario.” Following the introduction of the strategy, the Ontario government no longer pays for bariatric surgery performed in the United States.
The new strategy includes a centralized referral process and standardized referral criteria, including body mass index measurements and other medical eligibility criteria for Ontario patients. Once an application is received, patients are sent to the closest bariatric assessment centre where patients undergo an assessment which could include medical tests and a psychological assessment, all of which help determine whether the patient is a good candidate for the surgery. Following surgery, there is close post-operative follow up care.
There are currently four provincial bariatric centres of excellence, which provide assessment, surgery and follow up to patients. These centres are based at hospitals in Ottawa, Guelph, Hamilton and Toronto. Wait times for the surgery vary across the province according to region, but the Ministry of Health and Long-Term Care reports that average wait times from the decision to operate, to the surgery itself, are around 6 months for 90% of all bariatric surgery patients.
Two years into the strategy, are the goals of increasing capacity being met? Is there sufficient capacity to meet the need for bariatric surgery?
Demand & Capacity for Bariatric Surgery
Yoni Freedhoff, a family doctor who specializes in obesity says that there is a growing need in Ontario for this surgery, and that current capacity is not sufficient. Freedhoff says that “statistically speaking, 3% of Ontarian’s meet the criteria for bariatric surgery” and notes that “even if only 5% of them want the surgery, that’s still 18,000 cases per year”. The Bariatric Services Strategy was given $75 million, and committed to performing 2,085 surgeries per year in Ontario by 2011.
Mehran Anvari, a surgeon and chair of the Ontario Bariatric Network says that the strategy has “steadily been building capacity in Ontario” and anticipates that by the end of 2011, nearly 2800 surgeries will have been performed in Ontario, which exceeds Ministry-established targets.
A recent report suggested that obesity costs Ontario approximately $1.6 billion annually, with $647 million in direct costs and $905 million in indirect costs. Given the significant costs associated with obesity, Freedhoff suggests that funding for bariatric surgery is limited in part due to stigma surrounding obesity because many members of the public “believe that obese people should push away from table.” However Freedhoff says that while taxpayers may not see the value of bariatric surgery, “it’s in the best interest of public funding of health care to do this surgery expeditiously and quickly.”
However, while many Ontarians may be eligible for the surgery, this does not mean that it is the right intervention for all of them. Teodor Grantcharov, a surgeon at St Michaels Hospital who performs bariatric surgery says that “obesity is a complex issue and patient selection is crucial.” Grantcharov notes that “surgery itself is just a small part of this process” and that rigorous assessment before the surgery and “close follow up after surgery, which includes compliance with an exercise, diet and supplement regime” is critical to sustained weight loss and improved health. Bariatric surgery is not a one size fits all solution to obesity and Anvari notes that “success of the procedure depends on how well the patient is worked up, and the selection of patients.”
The important question now is whether those targets are the right ones – is Freedhoff correct that many more surgeries are needed, and do the current four bariatric centres adequately meet the needs of patients across the province? Another important question is the amount of resources that should be spent to prevent obesity in the first place, compared to treating obesity once it is established.
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I started the process in Ontario 3 yrs. ago when my Dr. faxed the referral to Toronto centre. They lost my file. My Dr. faxed another referral to the Hamilton centre. They verbally acknowledged receipt of the referral but told me it would be approx. 6 mos. to get a call for my first appointments. Shortly before the end of the 6 mos. waiting time, someone decided to set up a central registry office. My referral got lost after it was sent to the central registry. My Dr. had to fax a third referral to the registry. The Windsor office was in the planning stages but I still had to wait for it to be set up and then wait in line for a first appointment. I’ve had to go through two yrs. of the Windsor staff’s mistakes. I was sent for two and three of each test but drew the line when they tried to send me for a third scope. Some of their staff need to go for “sensitivity training” and some need to learn how to read a file before sending patients for more tests. My family Dr. and general surgeon had sent me for all the tests prior to my first appointment at the Windsor clinic.
I finally got to meet a surgeon in Hamilton on Sept. 1st but it’s now Sept. 13th and they haven’t called with a surgery date yet. They also tried to force me to buy a milk based meal replacement when I told them that I’m allergic to milk. They finally gave me a diet to follow for a few weeks before surgery, whenever that might be.
This entire process has been very frustrating, to put it mildly.
I am almost six years post-op from roux-en-y surgery with dr O’Malley in Rochester NY that OHIP paid for.
I am considered “successful” but I have regained approx 30 lbs & never really reached my “goal”.
I started looking for help before I had my surgery because I knew they weren’t operating on my head so to speak and I knew my problem with weight was definatly tied to emotions.
Finally after six years I have been referred to the bariatric department at the General Hospital in Hamilton where they seem to run a very well rounded program with many facets – I think I have finally landed in a place where they understand and can help me.I think this is a fabulous thing for the people who are just getting their surgery now to have this program in place right from the beginning!!!
I also think that there really needs to be ONE POST OP PROGRAM that is uniform across the board when it comes to supplements and vitamins and protein amounts needed. I did most of my research on line & have been told by some Drs that my B-12 is too high = but from the horror stories I’ve read about people not being told to take B-12 & vitamins & the neurological damage they suffered I don’t take any chances. Our B-12 being high will not hurt us only protect us.
Having been educated in the last 9 months about the process of getting Bariatric Surgery I feel that this should be much more available because it can be so vert successful now. Having received my surgery 30 years ago almost prehistoric times in terms of what is now known compared to today. I strongly feel that more after care should be made available to those like my self who received virtually no pre or post-op care and who desire to get back on track. Or, may need revisions to upgrade their procedures. There seems to be no avenue for gaining this care at this time.
I’m almost 2.5 yrs post op and maintaining my lowest post-op weight successfully. It’s work because what many pre-ops and newly post-ops don’t realize is that while we are drastically re-engineered internally, the desire to eat as we did in the past doesn’t entirely go away. It’s a life-long issue folks like me have to deal with. It’s not always a battle, but it is ever-present.
I can tell you that I have been “educated” and “reminded” about healthy eating/lifestyle choices since I childhood when I first became obese. I learned about portion control at the age of 10 when I first joined Weight Watchers with my Dad at my side. I learned about calorie counting at the age of 12 when I starting seeing a local diet “coach” with my Mom at my side. I learnt about the value of exercise when went back to Weight Watchers and started their “points” program which credits a person for exercise by giving them more points to be used on food choices in addition to daily allowances. I learnt about the psychology of eating when I was referred to counselling for my eating at the age of 18.
For those of us who find ourselves even considering bariatric surgery or have been referred for bariatric surgery, I have no hesitation in saying that we have been educated and reminded to the point of insult regarding healthy eating/lifestyle choices. Everyone from well meaning family, to physicians, to friends, to co-workers often feel the need to educate obese people they come into contact with. Believe me when I say as post-op person, the decision to have bariatric surgery is a serious one and a last resort when the other reality is death.
This is a mental health issue – surgery should be a last resort and should be paid for by the patient not the Ontario tax payers. There should be more emphasis on mental therapy and education for people on why they are eating themselves to death and also to inform and educate on nutrition and the importance of exercise.
I know an example of a husband and wife who qualified for the surgery but was not mentally ready – right up to the time of surgery their viewpoint was to eat as much as possible until they have to go in for the surgery. Two years later, the wife is obese again…
While it is great that the Ontario Government is stepping up the number of surgeries being done, they are forgetting one important thing. Not all of Ontarians live in Southern Ontario. It may not seem like a big deal to Southern Ontarian but when you have to make at least 4 trip of 8 hours there and back, it becomes a hardship. Who pays for these trips and why are Northern Ontarian be treated as second class. When you ask your MP why you should have to go so far way when a previously approved facility is located just 3 hours away. Even Thunder Bay, which is a major city does have facitilities. Why ??? Patients in Northern Ontario need this surgery just as much and should have facilities closer to their homes than an 8 to 10 hour drive one way.
Take advantage of the US Dollar being close to the CDN and let people go to these US cities like we were able to before.
We are now in the situation whereby there are many obese people. This is not going away any time soon. We only need to look at the next generation who are exposed to inactivity due to video games and the abundance of fast foods. We do need to fund more bariatric surgery which hopefully will help reduce medical costs for both drugs and follow-up visits. By reducing the doctor’s billings for follow-ups on blood pressure, cholesterol and diabetes every 3 months, this will provide additional savings for OHIP. Doctors are very busy and would probably appreciate not having to do the continuous follow-ups for blood pressure, etc.
On the other hand, we also really need to intelligently educate the public regarding healthy livingstyle programs to reduce future needs for bariatric surgery. I remember the Participaction program from years ago. It didn’t really do much. I saw a recent ad wrt to the new awareness program whereby a mother says her child plays soccer twice a week believing that was sufficient. The ad quantifies that it should be 30 minutes of exercise every day. I think this type of quantificaion helps people to put into perspective exactly how much exercise is required.
With respect to food, telling me how many calories each food contains is not as memorable as Oprah showing how many blocks of butter that these calories are equivalent to. These are things poeple can really understand.
Hopefully, if the new programs work, we will have less need for bariatric surgery down the line and at that point redirect funds towards other programs.
There is no doubt that as of August, 2011 the best treatment for morbidly obese individuals is surgery. However, from a public health perspective, more surgery cannot be considered the answer to the problem of obesity in our society. The answer to the problem of lung cancer was not primarily to provide for more surgery, but eliminating the cause, cigarettes. While medical care for the victims of cigarettes was and continues to be very important, the public health solution was not medical, but social. If every qualified general surgeon in Ontario did nothing but bariatric surgery five days a week, we probably could not keep up with the demand.
In my view our primary emphasis should be to identify strategies to prevent obesity.
Yes, this is lifesaving surgery. In my area, though, people must qualify for it. That means, for example, being smoke free for a minimum of six months. I think that’s great. Why should we spend thousands of dollars on a surgical procedure for people who continue to ruin their health? I know of one instance where a prospective patient admitted, three days prior to surgery, she was down to two cigarettes a day. The doctor told her to come back when she was smoke free for six months. Good for him. Continuing to smoke indicates she is not serious (yet) about her health. I doubt the surgery would have helped her in the long run.
Bariatric surgery means a complete change of lifestyle. The patient is a major part of the process, as is his or her willingness to make changes in a lifestyle that has led to morbid obesity. I’ve been told the surgery costs about $23,000. It includes a four day stay in the hospital, plus numerous checkups and post-op visits.
The benefits include not only weight loss, but a lessening of Type 2 diabetes, not to mention minor things such as alleviated back pain and a reduction of arthritic knees. As well, the medical community benefits, too, because obese and aging patients will take a high proportion of Ontario’s medical dollars if those people continue on their self-indulgent ways.
I have seen patients who have had the surgery at places with less stringent requirements. Within a year, they are again just as obese as they ever were. There is no helping a patient until that patient is willing and determined to help himself.
I wholly support people obtaining bariatric surgery, but I also support my local system of offering it only to those people who are really serious about getting health.
My own wait was about 18 months, and, while taking constant tests, being interviewed, and reviewed, I was sometimes frustrated. But, at the same time, all that did was drive home to me the importance that this is something that is permanent (weight loss AND a lifestyle change. I’ve had my six month check-up and have reached 110 per cent of my weight loss goal. I’ve goin from 260 units of insulin a day to 20 units, and I will likely be off it permanently by the end of the year.
I wish everyone the very best as they try it – but only those who really want to change and live. Meanwhile, I’m looking forward to showing my 11-year-old son that once upon a time, his old man was a pretty good hockey player.
For clarity, I will state right up front that I am a patient of Dr. Freedhoff’s. I received both pre- and post-op care, both medically and nutritionally, while receiving my bariatric surgery at a US-based bariatric practice (based in Ypsilanti, MI). The wait in 2008 (when I applied to OHIP) was 2-3 yrs in Ontario and I received excellent care within 6 months in Michigan. The cost of travel to & from Michigan was a pittance (including 8 nights hotel for my mom who accompanied me) compared to waiting for a slot in Ontario.
I had my surgery in March 2009 and have been at my weight loss goal since spring 2010. So in 18 months from the time of application, I was at goal, just slightly above a “normal” BMI however I was active (to the point of becoming a fitness instructor and running 5Ks throughout the summer of 2010), off all medications, sleep apnea gone. I was back to being a 100% contributing member of my family and I was no longer a drain on the OHIP system compared to where I was heading in the fall of 2008.
This is life saving surgery – people in some cases can wait 2 yrs – but in many cases they cannot. We need to help Ontario residents reduce the health care burden and if sending surgical patients out of country to save a dime down the road, doesn’t that fiscally make sense?? For those wanting and willing to travel to the US (and we’re talking NY or MI for that majority of Ontarians in this case), why make them wait and make the health care system here carry the costs when they can “fixed” sooner than later?
To truly answer the question of whether there’s a need to increase spots, it’s important to note that currently wait times in many parts of Ontario are nearing 2 years, with wait times getting longer, not shorter.
This isn’t knee surgery. People die on this waiting list. Co-morbidity leads to permanent damage and disability on this waiting list.
Moreover, rather than save money, the current strategy costs money, with estimates of the current two-year wait in terms of direct and indirect costs running $21,600 – 25% more than the $17,200 price tag of the surgery itself!
Ontario is unlikely ever to build sufficient capacity to handle all cases. We simply don’t have sufficient OR time available to us to meet this rapidly growing need. Instead of spending money on Ontario based surgery, we should be spending money on Ontario based pre and post-surgical education programs, and then creating surgical partnerships with American Centres of Excellence.
Having discussed this directly with one such American centre, they felt that they could provide the surgical services for $15,000 were I to be able to provide patients with pre and post operative medical care and nutritional education.
Seems to me an expeditious surgery, for a lower price, at a more established centre, combined with Ontario based medical care, such that patients will receive life-saving, disease curing, tax dollar saving surgery, rather than a growing wait list and costs that are at least double what an American partnership would cost would be the ethical and fiscally prudent path to take.
There will still be plenty of patients who do not want, or simply can’t travel. Let’s keep our current capacity, and simultaneously take advantage of the expertise and the costs available to us just across the border.