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Supply and demand

Canadian public bariatric surgery infrequent, inequitable

Only 0.1% of Canadians eligible for publicly-funded bariatric surgery receive it each year, says a new report. Photo: Flickr.com/alexindigo
New study: demand for bariatric surgery far outstrips supply
Those who do receive surgery often healthier, richer than eligible non-recipients

The number of eligible bariatric surgery candidates in Canada outnumbers the number of publicly-funded procedures performed annually almost one thousand times over, and the most eligible candidates often go without surgery, according to a report in the International Journal for the Equity of Health.

The paper, “Characteristics of the population eligible for and receiving publicly funded bariatric surgery in Canada”, authored by Raj Padwal of the University of Alberta, et al, examined the sociological and health characteristics of residents of 12 out of the 13 provinces and regions of Canada, finding that in the period 2007-2009, around 1,515,300 Canadian residents were eligible for bariatric surgery, but in 2008, only 1,882 publicly funded patients received surgery.

1,515,300 Number of Canadians eligible for bariatric surgery in 2009 1,882 Number of publicly funded bariatric surgeries in the same period

The study also found that obesity-related comorbidities were more common in those who were eligible for bariatric surgery but did not receive it, compared to those who did receive bariatric surgery. Further, parallelling the US, surgery-eligible individuals were more likely to have lower education levels and income status, while those who went on to receive surgery were more likely to be of a higher socioeconomic status.

In Canada, the waiting period for publicly-funded bariatric surgery can exceed five years.

This disparity led the authors to saying that their study “raises a number of questions regarding the adequacy and appropriateness of publicly funded bariatric surgery care delivery in Canada,” saying that four out of five founding principles of the Canada Health Act, which outlines the objectives of publicly funded health delivery in the country, are not currently being met.

“We propose that future efforts should focus on fully characterizing these care gaps; clarifying the role of privately delivered care; examining the value of prioritization methods to streamline and optimize care; and ensuring accessibility for suitable candidates seeking bariatric surgery,” wrote the authors.

The founding principles which the authors say are violated are:

  • Comprehensiveness - all services deemed essential should be provided
  • Public administration - the service should the need for private service delivery
  • Universiality - all residents should receive equal care, and
  • Portability - services should be provided across all provinces and territories.

The authors recommended that future efforts should focus on fully characterising the gaps in care, clarifying the role of private care, examining the value of prioritisation methods to streamline and optimise care, and ensuring accessibility for suitable candidates seeking bariatric surgery.

Methodology

To identify surgery-eligible Canadians, the authors took data from the Canadian Health Measures Survey, a population-representative, cross-sectional survey of 5,610 Canadians aged 6-79 years, conducted between 2007-2009 from 15 sites across five of Canada’s 13 provinces and regions.

The study definied eligibility for bariatric surgery under the study as patients aged 20-60 years old who had a BMI ≥ 40, or a BMI between 35 and 39.9 with a major comorbidity (hypertension, diabetes, dyslipidemia or osteoarthiritis).

Survery participants’ height and weight were measured, and diagnosis of comorbidities was based on self-report. Subjects were also asked to rate their mental health and quality of life.

The study authors then extrapolated the results of the study to represent the entire Canadian population aged 20-60 (around 20.71 million in 2009).

Surgical data was taken from two databases: The Canadian Institute for Health Information Discharge Abstract Database and the National Ambulatory Care Reporting System.

Results

The authors estimates that there were around 1,515,300 surgery-eligible Canadian adults in 2009, compared to 19,196,200 ineligible adults. Of those not meeting the criteria, 3,419,200 were obese.

Surgery-eligible Canadians had a mean BMI of 40.1 (95% CI 39.3 to 40.9) and, compared to the surgery-ineligible obese population, were more likely to be female (62 vs. 44%), 40–59 years old (55 vs. 48%), less educated (43 vs. 35%), in the lowest socioeconomic tertile (41 vs. 34%), and inactive (73 vs. 59%).

The study also found that the prevalence of obesity-related comorbidities was generally lower than in the surgery-eligible population, with the exception of type 2 diabetes. For example, the prevalence of dyslipidemia was 2% (vs. 63% in the surgery eligible) and hypertension, 13% (vs. 39% in the surgery eligible). In contrast, the prevalence of type 2 diabetes was 21% in the surgical recipients versus 15% in the surgery eligible population.

The mean BMI for the obese, surgery-ineligible population was 32.7 (95% CI 25.7 to 26.5).

Women were also four times more likely to undergo surgery compared to men, a discrepancy which is explained partly by the fact that women in the country were two times more likely to be severely obese than men.

The authors estimated that 0.1% of the surgery-eligible Canadian population received bariatric surgery between 2007-2009.

The authors noted that the study did not look at figures for private bariatric surgery, which is available in four provinces, saying that the total number of bariatric surgeries performed in Canada is not known. The study also does not contain figures from Quebec, which does not submit data to the outcome databases used.

The other authors of the study were: Hsui-Ju Chang, Scott Klarenbach, Arya Sharma, and Sumit Majumdar, all from the University of Alberta, Canada.

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