There are large differences between European countries in terms of accessibility to metabolic surgery and quality indicators of metabolic surgery are greater than the similarities, according to European researchers. They claim that a lack of funding, education and structure fuels this disparity, and criteria should be standardised on a European level with clear guidelines and to audit such differences. The findings were reported in the paper, ‘First Inventory of Access and Quality of Metabolic Surgery Across Europe’, published in Obesity Surgery.
The study aimed to gain more insight into the accessibility, patient pathway and quality indicators of metabolic and body contouring surgery. The researchers sent expert representatives of metabolic and bariatric specialty from all 51 countries, an electronic self-administered online questionnaire on their data and experiences exploring accessibility to and quality indicators for metabolic surgery and plastic surgery after weight loss. Specifically, the 37-item questionnaire was developed exploring guidelines for metabolic and plastic surgery, the patient pathway, tariffs for surgery, funding for surgery, metabolic surgery performance and follow-up, metabolic registries and research, subjective ratings of the system, as well as evaluation and future desired goals of the healthcare system.
The report that of the 51 European countries, three did not perform any metabolic surgery in 2015 (Liechtenstein, Montenegro, Vatican City) and there were no responses from seven countries (Bulgaria, Cyprus, Kosovo, Monaco, San Marino, Slovakia and the Czech Republic). One country (Czech Republic) provided an incomplete response and was, therefore, discarded from the final analysis. In total, 45 complete responses were collected from 41 countries.
Outcomes
There are an estimated 810 hospitals that offer metabolic surgery in Europe, with the highest number in France (150) and lowest in Malta (one). There are an estimated 1,786 surgeons performing bariatric and metabolic procedures. In total, an estimated 80,355 procedures were performed in the 26 responding countries per year, with sleeve gastrectomy (SG) the most common procedure (SG 40,981; RYGB 30,873; AGB 5,889; OAGB 1,339; revision 817 procedures).
A total of 28 countries (68%) had guidelines on eligibility criteria for metabolic surgery, whilst 46% had reimbursement criteria (51% did not, 3% unknown). In the countries that had national guidelines on inclusion criteria for metabolic surgery, 59% adhered to these, 20% did not and there was a large variation between clinics (21%). Sixty-eight percent of responding countries complied with IFSO guidelines, 17% did not comply and in 15% there was variation between clinics within the country. For plastic surgery, 41% had eligibility criteria and 31% reimbursement criteria. There were many responses that said national guidelines were vague and often individually set or set per clinic.
In most countries, patients could self-refer themselves (81%), be referred by their general practitioner (61%) or be referred by other specialists (endocrinology, gastroenterology, etc 66%). Multidisciplinary team (MDT) meetings were mandatory in 78% of the countries, however, 12% of countries did not mandate MDTs and a further 12% had variable practice across the country. It was common for multidisciplinary meetings not to be performed in private clinics for metabolic surgery. In the preoperative period, medical or conservative management was started by 61% of the respondents and this period generally varied from one to 12 months.
Criteria for referral for plastic surgery were present in 51% of countries. These were, however, very diverse (BMI < 30 after metabolic surgery, stable weight for between six and 24 months depending on the country, skin problems and patient’s decision).
In 45% (18/40) of European countries, pure metabolic surgeons existed to perform metabolic surgery, but surgery was often performed by general surgeons (24/40, 60%): upper GI (17/40, 43%), GI (13/40, 13%), colorectal (2/40, 5%), endocrine (4/40, 10%), HPB (2/40, 5%), trauma (1/40, 2.5%) and plastic (2/40, 5%) surgeons. A specialised metabolic training programme was available for surgeons in 23% of countries.
Other findings included:
Bariatric complications requiring emergency surgery, 70% of countries reported that a general GI surgeon would take the patient back to theatre, whilst 28% reported that a bariatric surgeon would re-operate.
Waiting times (referral to the decision to perform metabolic surgery) was <6 months (70%), less than one year (10%) and over one year (20%).
The mean tariff for Roux-en-Y gastric bypass (RYGB) was €6559±4039 (range € 800–18,000), SG €6280 ± 3754 (range € 800–16,000), AGB € 4622 ± 2945 (range € 800–12,000), OAGB €7080 ± 4507 (range € 800–18,000), revisional surgery €7486 ± 5666 (range € 800–20,158) and for abdominal plastic surgery €4227 ± 3146 (range € 400–10,000). The conversion of local currency into euros is based on currency exchange on October 6, 2017. The average tariffs for a metabolic procedure were the lowest in Lithuania (mean €800) and highest in Italy (mean €16,000).
The access to metabolic surgery was rated fair to excellent in 68% and poor to very poor in 33% of the countries by their representatives
Using thematic analysis, the biggest problems within the metabolic access and care system were identified as being funding/reimbursement, lack of national training programme and the differences in care for public and private hospitals.
35% (n=14) of countries had a bariatric register and 63% (n=26) of countries reported estimates or registry data of annual numbers of operations.
Countries with a bariatric register were significantly more likely to have a patient organisation (p=0.006), significantly more likely to have minimum case number criteria for bariatric centres (p=0.005) and surgeons were more likely to operate in a bariatric centre (p=0.043).
“As metabolic surgery becomes integrated into the treatment pathways for metabolic diseases, future research is vital to improve quality indicators of metabolic surgery and endeavours should focus on increasing accessibility across all European countries,” the authors noted.
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