Physicians’ concerns about bariatric surgery a barrier to surgical referrals
High levels of concerns about bariatric surgery among primary care physicians seem to be a barrier to refer patients with severe and complex obesity for bariatric surgery, according to a Swedish survey. The outcomes from the survey were featured in the paper, ‘Primary care physicians’ knowledge, attitudes and concerns about bariatric surgery and the association with referral patterns: a Swedish survey study’, published in BMC Endocrine Disorders.
The study researchers from Lund University, Lund and Linnaeus University, Kalmar, Sweden, noted that since 2012 approximately 7,000 bariatric procedures are performed annually, and considering that only a small proportion of eligible patients undergo bariatric surgery: “It is important to understand barriers to the treatment.”
In Sweden, most patients are referred to bariatric surgery by primary care physicians. Therefore, they designed a study to assess referral patterns, knowledge, attitudes and concerns about bariatric surgery for patients with obesity among primary care physicians through an electronic questionnaire. The researchers also examined the physicians’ knowledge, attitudes and concerns about bariatric surgery, and if these factors might influence the suggested referral patterns.
An electronic questionnaire survey was emailed to all primary care physicians with potentially available email addresses in Skåne and Kronoberg regions in south Sweden. All potential participants were informed briefly about obesity and the purpose of the study, which was anonymous.
The questionnaire focused on referral patterns, knowledge, attitudes towards bariatric surgery and concerns about postoperative complications. Most of the questions were graded on a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree and 6 = do not know).
The questionnaire survey was emailed to 1,100 primary care physicians in Skåne and Kronoberg regions and 157 responded (14%). Of the 157 respondents, 41% (n=65) were male and 58% (n=91) female (1 missing). Most of the respondents (n=105, 67%) claimed to be specialists in general practice, with 53 answering that they had worked more than ten years in primary care. Most (n = 120, 77%) worked in public primary care.
Most of the physicians (n=111, 71%) stated that they agreed or strongly agreed to referring patients to bariatric surgery if patients met the required national referral criteria. Seven percent (n = 11) actively suggested bariatric surgery to patients, compared with 84% (n = 132) who answered the patients most often request referral to bariatric surgery. Most physicians (n = 63, 40%) said women request referral for surgery more often than men.
A small but significant 11% (n=17) said that they had not referred anyone for bariatric surgery during the last five years, with 64% (n=100) referring 1–5 patients for surgery in the last five years. Most of the physicians (n=94, 60%) had denied referral for bariatric surgery due to non-eligibility for bariatric surgery, 25% (n=39) had denied referral due to uncertainty if the patient could follow the post-operative advice and 19% (n=30) had denied referral due to patients’ cognitive problems.
A vast majority of respondents (n=141, 90%) agreed or strongly agreed that bariatric surgery had positive effects on type 2 diabetes, obstructive sleep apnoea (n=138, 88%), hypertension (n=129, 82%) and joint pain (n=118,75%). However, only 25% (n=39) agreed or strongly agreed that bariatric surgery is the only effective treatment patients with severe and complex obesity. A small majority 57% (n = 89) answered correctly that perioperative mortality is <1%.
Nearly half of the physicians (n = 75, 48%) had a positive attitude to bariatric surgery as a treatment for obesity related disease. According to 46% (n = 72) of the physicians the advantages of bariatric surgery outweigh the risks.
Nearly half of the physicians (n=66, 42%) stated that they were not concerned about the risks associated with bariatric surgery, with half concerned about postoperative medical (n=78, 50%) and surgical complications (n= 79, 51%), and 46% (n=71) stated that they were concerned about psychiatric side effects after bariatric surgery. Interestingly, 69 physicians (44%) indicated that they needed more education about obesity and bariatric surgery.
The authors reported significant positive correlations between high knowledge and referral patterns (p<0.001) and between high knowledge and positive attitudes towards bariatric surgery (p<0.001). They also found significant reverse correlations between concerns and referral patterns (p<0.001) and between knowledge and concerns (p<0.001) - poor knowledge was associated with more concerns, and more concerns was associated with lower referral to bariatric surgery.
The authors noted that physicians’ knowledge about obesity and bariatric surgery was related to concerns and attitudes about bariatric surgery and high levels of concerns and negative attitudes, seemed to be a barrier for referring patients with severe and complex obesity to bariatric surgery.
“Since there is evidence showing increased life expectancy after bariatric surgery, primary care physicians need to be more aware of benefits of surgical treatment and should consider the bias that they meet more patients in daily practice with postoperative complications and unsuccessful results rather than patients who do not encounter much problems and where benefits outweighs the complications,” they concluded. “Primary care physicians should also be more active to suggest surgery as obesity treatment for their patients, especially male patients who are not usually the main drivers in requesting bariatric surgery. More evidence-based education and training in the field of obesity and its treatment is probably warranted.”
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