Bariatric Surgery in a Public Health System:

Transcription

1 Bariatric Surgery in a Public Health System: Reflections on the Canadian Challenge Daniel W Birch MSc MD FRCSC FACS Professor of Surgery, University of Alberta Director CAMIS Royal Alexandra Hospital Edmonton Alberta

2 Declaration of Conflict of Interest I, Daniel W Birch declare that in the past 3 years: I have received manufacturer funding from the following companies*: Johnson & Johnson/EES Stryker I have done consulting work for the following companies*: Johnson & Johnson /EES, Covidien, Bard, Baxter I have done speaking engagements for the following companies*: Johnson & Johnson/EES, Bard I or my family hold individual shares in the following*: None *pharmaceutical or medical/dental equipment 2

3 Outline The Challenges The Canadian Problem of Obesity The Canadian General/Bariatric Surgeon The Ideal Procedure for Canadians Public vs Private Models of Care Implications of Inadequate Access to Bariatric Surgery The Canadian Paradigm

4 The Epidemic of Obesity Results from the 2004 Canadian Community Health Survey: Nutrition (CCHS) indicate that 36% of Canadians are overweight (BMI ) and 23% are obese (BMI>30) 14% increase in obesity from 1978/79 In children aged 2-17 years, 18% are overweight and 8% are obese Tjepkema M, Shields M, Le Petit C, Berthelot J. Health Reports (Statistics Canada, Catalogue );Vol 17 (3) August, 2006

5 Canadian Demographics One million people across Canada are severely obese Vancouver (metro): pop 2,249, %: 56,243 morbidly obese people Toronto (metro): 5,555, ,897 morbidly obese Edmonton (metro): 1,034,945 25,873 British Columbia: 4,402, ,073 morbidly obese

6 Demographic impact on Outcomes? Is the severely obese Canadian different? ~ 30% of surgical cohort unemployed/aish/disability Socioeconomic Status: Employment Socioeconomic status: Low income Full time Part time Retired Student Unemployed SA LTD 12 Percentage (%) 10 Percentage (%) AWWC Surgical Cohort Canada 0 AWWC Surgical Cohort Canada

7 Edmonton Outcomes LAGB 178 patients, BMI 44 kg/m 2 OR time 56min, LOS 1.4d Band migration rate 5.6% Re-operation rate 4.6% Chiu JS, Shi X, Karmali S, Birch DW. Outcomes of the Adjustable Gastric Band in a Publicly Funded Obesity Program. Can J Surg. In publication.

8 Edmonton Outcomes LSG 116 patients, BMI 44 kg/m 2 OR time 96min, LOS 2.4d 0 Leaks, 1 bleed, no mortality Gill RS, Switzer N, Driedger M, Shi X, Vizhul A, Sharma AM, Birch DW, Karmali S. Laparoscopic sleeve gastrectomy with staple line reinforcement in 116 consecutive morbidly obese patients Obes Surg Jan 19

9 Edmonton Outcomes RYGB 293 patients, Initial BMI ~ 55kg/m 2, pre-op 50kg/m 2 OR time 160min, Median LOS 3d Anastomotic leak ~ 5% Refined technique (stapled) 0% Mortality 0.7% Whitlock K, Gill R, Ali T, Shi X, Birch D, Karmali S. Early Outcomes of Roux-en-Y Gastric Bypass in a Publically Funded Obesity Program. In submission BJS.

10 A Decision Aid for Bariatric Surgery Band Sleeve Gastric Bypass Safety Reversibility Complexity Nutritional impact Foreign Body Restricted Meds Long term data Weight loss (50 lb) (80 lb) (100 lb)

11 The Canadian General/Bariatric Surgeon Description?

12 Laparoscopic Gastrointestinal Surgeon (in the daytime) Biliary Tract: cholelithiasis (cholecystectomy/cbde) Esophagus: GERD, Achalasia (fundoplication/myotomy/para) Stomach: cancer, obstruction (gastrectomy/bypass) Small bowel: IBD Appendix: appendicitis (appendectomy) Colorectal: cancer, IBD, diverticula, stoma creation/reversal (colectomy, APR) Abdominal hernias: groin, incisional (repair with mesh) Solid Organ: tumors, ITP (splenectomy) Obesity: RNY Gastric Bypass, Adjustable Gastric Band, Sleeve Gastrectomy, Robotics, Stomaphyx

13 Trauma Surgeon (in the nightime)

14 Edmonton The City of Champions 1m population Edmonton Eskimos 13 Grey Cups Edmonton Oilers 5 Stanley Cups S Mackaay

15 Edmonton is more than just cold...

16 The West Edmonton Mall

17 University of Alberta students from across Canada and the Territories and 116 countries 18 Faculties, 5 campuses: North, South, Enterprise Square, Saint-Jean, Augustana Faculty of Agriculture, Life and Environmental Sciences Faculty of Arts Faculty of Business Augustana Campus Campus Saint-Jean Faculty of Education Faculty of Engineering Faculty of Extension Faculty of Graduate Studies and Research Faculty of Law Faculty of Medicine and Dentistry Faculty of Native studies Faculty of Nursing Faculty of Pharmacy Faculty of Physical Education School of Public Health Faculty of Rehabilitation Medicine Faculty of Science

18 Faculty of Medicine and Dentistry 20 Departments Anesthesiology & Pain Medicine Biochemistry Biomedical Engineering Cell Biology Dentistry Emergency Medicine Family Medicine Laboratory Medicine & Pathology Medical Genetics Medical Microbiology & Immunology Medicine Obstetrics & Gynecology Oncology Ophthalmology Pediatrics Pharmacology Physiology Psychiatry Radiology & Diagnostic Imaging Surgery Department of Surgery (10 divisions) Cardiac Surgery General Surgery Neurosurgery Orthopedic Surgery Otolaryngology - Head and Neck Surgery Pediatric Surgery Plastic Surgery Surgical Research Thoracic Surgery Urology

19 Royal Alexandra Hospital Campus Robbins Pavilion Quick Facts: Building-dense campus: 15 buildings in operation 26.5 acres Beds 760 (ip) 87 (day) 27 OR s Employees: 6,077 Physicians: 454 Volunteers: 300 Budget 280 Mil Active Treatment Centre Emergency Centre G-OR Suites Orthopedic Surgery Centre

20 Royal Alexandra Hospital BEDS Inpatient Day Surgery Medicine 248 Women s Health Mental Health Critical Care Cardiac Sciences Children s Health Total 760* 87 8 ANNUAL ACTIVITY Inpatient 36,000 Outpatient visits 200,000 Emergency visits 62,000 OR s cases 30,000 Deliveries 5000

21 Royal Alexandra Hospital Campus Robbins Pavilion Quick Facts: Building-dense campus: 15 buildings in operation 26.5 acres Beds 760 (ip) 87 (day) 27 OR s Employees: 6,077 Physicians: 454 Volunteers: 300 Budget 280 Mil Active Treatment Centre Emergency Centre G-OR Suites Orthopedic Surgery Centre

22 The Canadian General/Bariatric Surgeon Highly trained Open/MIS surgery (some advanced MIS procedures) Head/neck, breast, colorectal, esophageal, endoscopy, integumentary, vascular, trauma... Peds, plastics, etc Rural/Urban/Remote Academic/Community based (small/large centres) General Surgical team typically non-existent No/little control over budgets Too much work already... Absolute heterogeneity across the country (2500 overall) Approximately 65 Canadian surgeons currently involved in Bariatric Surgery

23 Canadian Training in Bariatric Surgery How many Canadian General Surgery Residents are engaged in a formal, structured training program in Bariatric Surgery? Trained surgeons produced through Advanced MIS/Bariatric Fellowships (not all will practice bariatrics, or stay in Canada, or get a job!)

24 How to Introduce Change in Medical/Surgical Care Or... How to turn a supertanker in one easy lesson Some pieces to the puzzle: Clinical champion (zealot / evidence-based maniac) Adequate leadership support (resource allocation) Adequate collegial support (allow change process) Lead, follow or get out of the way...

25 Bariatric Surgery What do people see?

26 Obesity: The New Kid on the Block Most individuals (politicians, leadership, decision makers, health care professionals) fundamentally do not agree with surgery for severe obesity Where do the resources come from? Re-allocation? Who loses? Diabetes? Joint Replacement? Not many increases in provincial health care budgets Alberta - new funding Ontario - out of country expenses for surgical management becoming excessive

27 Treatment Bias Against obesity management i.e. it is not a disease, let the individual take responsibility... Against Bariatric Surgery i.e. anecdotes and historical, I remember... Towards their own resources/site/turf/agenda i.e. the pie is only so big, I just don t have the resources...

28 Volume of Bariatric Procedures in US and Canada Can we dramatically increase volumes in a Canadian Healthcare Environment given all of the above challenges? Santry, H. P. et al. JAMA 2005;294: Padwal R. CMAJ 2005

29 Bariatric Surgery in the US Kohn et al Surgery 146 (2) 2009

30 Who pays for Bariatric Surgery in the US? Davis et al Arch Surg

31 Private Delivery of Bariatric Surgery Business model focus on providing surgical treatment, early management of complications Pre-op assessment model? Who provides delivery?? Family physician education, resources Post operative management? Medical care? Management of surgical complications burden (and expense!) transferred to existing local/regional bariatric surgeons and hospitals

32 Impact of Barriers or Poor Access to Bariatric Surgery Worsening of health care status of Canadians disease burden Increased Private Delivery of Bariatric Care Medical tourism: no/poor education pre-op no structured f/u serious complications managed in Canada burden of care transferred drain on Alberta resources

33 Can we make it work in Canada? Will we be able to treat obesity appropriately as an important chronic disease of Canadians? (timely, fully, without bias) Will we hit a threshold of annual procedural volume (like the US) due to provider/institution/funding saturation Throw out the play book... Public / private models of care? Major re-allocation of funding from existing budgets?