Where Does Bariatric Surgery Sit in 2018

Transcription

1 Where Does Bariatric Surgery Sit in 2018 An Australian Focus Ahmad Aly Head Upper GI Surgery Austin Health ANZMOS 2018

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3 Where Does Bariatric Surgery Sit In Modern Treatment Of Obesity Where Does It Sit In The Obesity Epidemic?

4 Where Is Obesity?

5 Where Is Obesity? Adults 60% Overweight / Obese 11,238,600 30% Obese 4,943,900 Potentially Eligible For Surgery 1,381, Class II/III

6 Obesity Community Effect 400% increase in diabetes risk Cardiovascular disease (70%); osteoarthritis (88%); and colorectal, breast, uterine or kidney cancer (47%) 1 in 8 hospital admissions 1 in 6 hospital days $8.6 Billion ($52 Billion indirect) annually 1 Baker IDI Heart & Diabetes Institute, Diabetes Australia, JDRF. Diabetes: the silent pandemic and its impact on Australia Diabetes Australia. Understanding Diabetes, Diabetes in Australia. 3 Access Economics. The growing cost of obesity in 2008: three years on. Report for Diabetes Australia. Canberra, Australian Institute of Health and Welfare. Australia s health Sax Institute. Obesity is sending over-45s to hospital at a cost of $4 billion per year. 6 Colagiuri S, Colagiuri R, Conway B, et al. (2003) DiabCost Australia: assessing the burden of type 2 diabetes in Australia. Canberra: Diabetes Australia.

7 Where Does Bariatric Surgery Sit Surgery is the most effective therapy for obesity and related disease Where it sits should be significant Are We having a big enough impact?

8 Bariatric Surgery Continues To Increase Primary Bariatric Surgery Band Sleeve Bypass Total 0

9 Current Procedure Type Band 12% Bypass 11% Bypass Sleeve Band Sleeve 77%

10 Procedure Type Bypass Sleeve Band 100,000 Bands Account for most revisions ( For now)

11 Revisional Surgery 4000 Revisions

12 BSR 20-30%

13 New Treatments / Evolution Metabolic Evolution OAGB SADI Intestinal interpositions Endoscopic Therapy Plication devices Intraluminal anastomotic techniques (magnets) DJ exclusion Primary Therapy Complication Salvage Revisonal Adjuncts

14 Greater Science Greater Insights Into Mechanisms Obesity Surgical Disease Relapse Targeted Medical Therapies more effective medications

15 Place Of Surgery In Treatment Paradigm Adjuvant Medical Therapy Preventative Specific Strategies Diets Lifestyle Strategies Medical Therapy Lifestyle Medial Therapy V Endoscopic Treatment Adjuvant Surgery Surgery Surgery Revisional Surgery Combined Multidisciplinary Metabolic Medical / Surgical Clinic

16 Weight Not The Only Trigger For Surgery Bariatric Surgery Now Sits Within Paradigms of Treatment Of Chronic Disease Not the surgeon : Here is what will get better if you have surgery But the physician: The best treatment for your liver disease is bariatric surgery

17 Australia yo BMI>35 1,2 Indicated for surgery 3 1.5% of eligible patients access surgery Only 10% in the public sector * Acknowledgement Medtronic For This Graphic

18 Place Of Surgery The Obesity Epidemic At Current Rates Of Surgery Group Age Number Percentage Population Years To Treat Class I 2,530, % Class II & III 1,381, % 62.8 All Obesity 3,911, % Population 14,451,600 Data From AIHW Report 2017

19 Solving The Obesity Crisis With Surgery? At this rate, clearly surgery is not population level intervention

20 But...Could Surgery Have A Greater Population Impact?

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22 Rationalised Data Venn et al, Aust Health Rev 2017 (Australian Health Survey Statistics) Group Age Number Years To Treat Just Diabetics Years To Treat Class I (plus uncontrolled NIDDM) 14, , Class II (plus comorbidity) 470, , Class III 396, , All Obesity 882, , Venn et al Aust Health Rev 2017

23 Procedure ICER Probability of Cost Effectiveness Gastric Banding $24,454 64% Sleeve Gastrectomy $27,523 71% RYGB $22,645 75% Increases significantly if focus on diabetes (cost per QALY halved) James et al SOARD 2017

24 Impact On Epidemic. Bariatric Surgery Uniquely Placed Now To Aggressively Target Diabetes Potential for significant and rapid community level impact

25 What Do Diabetics Think? Sawer et al SOARD diabetics surveyed (Pennsylvania) 28% believed effective for diabetes 14% believed safe Less than 20% willing to be randomised to surgery for treatment of diabetes and or obesity

26 Where Does Bariatric Surgery Sit With Community And Referrers?

27 Attitudes Toward Bariatric Surgery Penetrance Stable 1-2% Obesity under recognised by patients and health practitioners Not talked about Stigma lifestyle choice, surgery is cheating Role of surgery : last resort

28 GP Attitudes They want it [referral for bariatric surgery] more than we want to do it I wouldn t refer someone for bariatric surgery if I didn t think that they d adequately explore [other] options Refer more readily for lifestyle interventions even though lack of success acknowledged Kim et al BMC 2015

29 GP Attitudes UK GP s (McGlone et al SOARD 2018) 49% had not made a referral for surgery in last 12 months Younger doctors more prejudiced Most over estimated mortality of bariatric surgery up to 10 fold Kim Study (Aust) Readiness to refer influenced by case experience complications / efficacy (rather than literature)

30 For patients we have to overcome stigma For referrers we have to overcome safety concerns

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32 BSR Data PLEASE ENROL & CONTRIBUTE

33 Reducing Stigma Advocacy Education Referrers Community

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35 Can No Longer Advocate In Silo s Bariatric Surgery Public Health Medical Therapy Dietary Intervention Exercise Enthusiasts Allied Health COALITION APPROACH OF UNIFORM ADVOCACY

36 ANZMOSS Advocacy Advocacy Non Surgical Clinical Voices COSiPH Physician advocacy Obesity coalition AMA obesity policy RACS position statement Government (MSAC)

37 ANZMOSS Advocacy Media (all types) Education Of Health Practitioners Influence Policy Makers Clear Messaging

38 Advocacy Must Continue Obesity is not a lifestyle choice Quality, Efficacy and Safety Of Bariatric Surgery Must Provide High Quality Surgery

39 Access As The Biggest Detractor Patients ACCESS Stigma Safety

40 Where Does Bariatric Surgery Sit With Respect Access?

41 Access Issues MSAC review of bariatric item numbers 950 separations in public sector 10% of all surgery 4% fully publically funded 0.45% 0.40% 0.35% 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% 0.00% 0.05% Publicly Funded Bariatric Surgery in Australia Proportion of indicated patients (BMI>35, 18-64yo) 0.27% 0.05% 0.43% 0.16% 0.14% NSW Vic Qld WA SA Australia 0.18% Total Eligible Population

42 Perhaps The Greatest Potential Agent for Advocacy Public Bariatric Surgery Equity Training Quality & Safety Normalisation Obesity & Bariatric Surgery Acceptable

43 Current State Of Play Summit 2017 Taskforce 2018 National Framework Document ANZOS AMA Obesity Australia RACS RACGP MSAC 3 New Centres NSW 1 QLD Readiness In Government To Listen Not Why But How

44 Where Does Bariatric Surgery Sit With Payers And Policy Makers? (Surely They See The Cost Benefit)

45 Insurance Providers Patients Drop Insurance After Surgery Insurance Provider Can t Meet Costs Further Reduces Access To Surgery Early Access To Superannuation Patients Can t Afford Shift Bariatric Surgery To High Premiums

46 Government Well aware of the obesity crisis & implications Increasingly aware of the benefits of bariatric surgery Remain concerned at cost of providing surgery (volume) We need to demonstrate sustainability and bang for buck

47 Political Interest Early Access To Superannuation Treasury Review Senate Select Committee In Obesity MBS Bariatric Item Number Review MSAC DOH greater need for public bariatric surgery

48 Political Interest & Scrutiny Strong Support For Bariatric Registry Clearly invested Australian real world data on outcome and safety Critical venture and will guide government policy formation MSAC tightening on procedures Endoscopic sleeve plication item denial Balloon One Anastomosis Bypass We have a clear and ethical responsibility to introduce new procedures We in a Are rigorous Being and Watched transparent Closelymanner

49 Where Does Bariatric Surgery Sit Threshold of recognition and impact commensurate with efficacy Ready to make a significant contribution No longer a silo Greater integration into comprehensive obesity strategy Greater integration into the paradigm of chronic disease care Policy makers increasingly invested ; scrutiny

50 Where To Continued advocacy / destigmatisation Increase Access particularly public Maintain & Improve quality and standards BSR Vital Public hospital training programs Increasing technology / craft development Responsible introduction