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Clinical comment: Access to surgery

Following his recent paper, "Laparoscopic bariatric surgery can be performed safely in secondary health care centres with a dedicated service corridor to an affiliated tertiary health care centre" (Canadian journal of surgery. 2013 56(4):E68-74), Dr Nicolas Christou discusses the recent developments in Canada regarding access to bariatric surgery...

Under Canada’s publicly funded system, if two 40-year-old mothers, each with three children, require life-saving surgery, one a bariatric procedure for obesity and the other a mastectomy for breast cancer, it is almost always the latter who gets the surgery within a reasonable time period. The reason is that society views the obese mother as “a big fat slob who should go on a diet”. Politicians think, “Obesity is not a sexy political issue”. Policy-makers and the public don’t understand that obesity is a highly complex chronic disease, with causes rooted in a patient’s biology, metabolism and mental health. As a result, bariatric surgery is not well funded in most of Canada.

Bariatric surgery is the only known treatment that will reduce the risk of dying of cancer by 60%, from a diabetes complication by 90%, or reduces total mortality risk by 40% to 60%. There’s almost nothing else we do in medicine that’s so effective and has such a dramatic impact on one’s health. Remarkably, though, Canada only performs about 3,500 procedures per year in public hospitals. Private-pay clinics (mostly adjustable gastric banding) account for another 1,500 procedures per year. The country is only touching the tip of the iceberg in terms of dealing with the demand in the population.

Ontario is the only province willing to make a significant attempt at addressing the country’s shortcomings in this area. In July 2008, it announced $741 million in new funding for a comprehensive, four-year diabetes strategy, of which approximately 10% was targeted toward access to bariatric services. 

This $75-million initiative increased the province’s capacity for weight-loss surgery several fold over the last five years to about 2,500 cases per year or 250% increase in 2012-13.

The province of Quebec is unique within Canada’s health care system because of the Chaoulli v. Quebec (Attorney General), 2005 SCC 35, [2005] 1 SCR 791 decision1 by the Supreme Court of Canada which ruled that Section 15 of the Health Insurance Act and section 11 of the Hospital Insurance Act, which outlaw private medical insurance, violate the right to personal inviolability as guaranteed by the Quebec Charter of Human Rights and Freedoms. 

The decision proved to be highly contentious by its political nature and its conflict with the present government's policy on health. There are those who argue that this decision could potentially lead to the dismantling of the Canadian Medicare system, while others suggest that this could be a much-needed wake-up call to repair the ailing system.

Although in 2005 Quebec performed the most obesity surgeries in Canada, the average wait time for a procedure in the province was ~7 years.  To address this, the Quebec Minister of Health convened a panel of experts to come up with a plan to increase capacity for bariatric surgery in the province and thus reduce the wait. The report tabled in 2006 recommended the creation of 4 centers of excellence in bariatric surgery that would anchor the 4 RUIS (Réseau Universitaire Intégrée Sante) or integrated health regions in the province. These centers would be located in tertiary academic hospitals that would be able to treat all bariatric surgery cases and all bariatric surgical complications irrespective of complexity.

The expert panel also recommended the creation of secondary bariatric surgery centers that would perform bariatric surgery on uncomplicated bariatric surgical patients (e.g. Body Mass Index less than 50 kg/m2, minimal obesity associated comorbidity and ASA class 1-3). These secondary bariatric surgical centers would have a formal association with one of the tertiary centers within their respective RUIS for dealing with complications of bariatric surgery as well as academic and research support.

In response to the Chaoulli decision, the Minister of Health also tabled a law, which created a mechanism for guaranteeing surgery within a timely fashion. If the public healthcare system could not provide the required surgery (initially for hip and knee replacements but eventually others such as bariatric surgery) within a predefined timeframe (Figure 1), than patients would be given the option to utilize the newly created CMS (Centre Médicale Spécialisée) clinics. Two types of CMS were proposed based on the funding model.  Privately delivered publically funded or privately delivered privately funded.

As part of this initiative a pilot project was started to determine whether a CMS could carry out bariatric surgery in a safe and timely manner. The results of this pilot study show that the model works in this particular CMS and should be tested further with more secondary centers before wide application.

Figure 1: Bariatric surgery waiting time guarantee

Reference

[1] Chaoulli decision1 accessed November 16th 2013.