Variation in public‐funded bariatric surgery intervention rate by New Zealand region

Provision and outcomes of publicly funded bariatric surgery in a metropolitan versus a provincial population of New Zealand

BACKGROUND

Obesity is an important health problem worldwide. The prevalence of obesity in Aotearoa New Zealand (AoNZ) is the third highest amongst OECD countries. Previous studies have demonstrated inequity in the provision of bariatric and metabolic surgery (BMS) across AoNZ, but detailed data regarding patients and surgical outcomes is lacking. The aim of this study is to examine the rates and outcomes of BMS between patients domiciled in a metropolitan versus provincial area in AoNZ.

METHODS

A 5-year retrospective observational cohort study of all patients who received BMS domiciled in a metropolitan or a provincial area in the Northern region of AoNZ was performed. Interrogation of patient electronic medical records and clinical notes was performed to collect the required baseline characteristics, secondary outcome measure data and confirm domicile.

RESULTS

The rate of BMS was 6.1 times higher in the population with class III obesity domiciled in the metropolitan versus the provincial population. Patients in the metropolitan area were less obese, had lower rates of diabetes and had a wider range of procedures performed. Māori were underrepresented in both cohorts. There was a higher resolution of diabetes in the provincial patients.

CONCLUSION

This study has highlighted significant differences in the rate, type and outcomes of BMS between a metropolitan and provincial area in the Northern region of AoNZ. This represents a significant health inequity. Changes in national and regional policies are needed to ensure equitable care for patients with obesity in AoNZ.

Development of the national bariatric prioritization tool in Aotearoa New Zealand

BACKGROUND

Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity-related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence-based, fair, implementable and transparent.

METHODS

The development of the tool involved a validated step-by-step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings.

RESULTS

Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67.

CONCLUSION

The tool as presented is evidence-based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required.

Bariatric Surgery and Psychological Health: A Randomised Clinical Trial in Patients with Obesity and Type 2 Diabetes

PURPOSE

This study investigated the impact of either Roux-en-Y gastric bypass with silastic ring (SR-RYGB) or sleeve gastrectomy (SG) types of bariatric surgery on psychological health and explored the role of pre-existing depressive symptoms on weight loss.

MATERIALS AND METHODS

A total of 114 participants with obesity and type 2 diabetes were randomized to receive SR-RYGB or SG at a single centre. Data from the Hospital Anxiety and Depression Scale (HADS), RAND 36-item Health Survey and body weight were collected before surgery and annually for 5 years.

RESULTS

Sixteen patients were lost to follow-up at 5 years. Of the 98 patients who completed 5-year psychological follow-up assessments, 13 had mild to severe depressive symptoms (SR-RYGB n = 6, SG n = 7). SR-RYGB and SG resulted in similar psychological health improvement but percent weight loss at 5 years was greater for SR-RYGB by 10.6% (95% CI: 7.2 to 14.0, P < 0.0001). Scores for depressive symptoms and most RAND-36 domains improved significantly from baseline to 5 years in both groups. Patients with pre-existing depressive symptoms had similar percent weight loss at 5 years compared to patients without depressive symptoms, irrespective of procedural type.

CONCLUSION

Patients receiving either SR-RYGB or SG had comparable psychosocial functioning, which was maintained to 5 years post-surgery. Pre-existing depressive symptoms did not affect weight loss achieved at 5 years. These findings confirm previous longitudinal studies demonstrating that bariatric surgery is generally associated with improved psychosocial functioning.

Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis

OBJECTIVE

The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance.

METHODS

This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques. Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations.

RESULTS

Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases ('threshold modifiers') which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult.

CONCLUSIONS

This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency - especially where evidence is uncertain, variable or lacking.

Variation in publicly funded bariatric surgery in New Zealand by ethnicity: cohort study of 328,739 patients

BACKGROUND

New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities.

OBJECTIVES

To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities.

SETTING

New Zealand primary care.

METHODS

A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities.

RESULTS

A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality.

CONCLUSIONS

Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care.