Research ArticleWeb exclusive

Factors influencing primary care provider referral for bariatric surgery

Systematic review

Boris Zevin, Nardhana Sivapalan, Linda Chan, Nicholas Cofie, Nancy Dalgarno and David Barber
Canadian Family Physician March 2022; 68 (3) e107-e117; DOI: https://doi.org/10.46747/cfp.6803e107

Abstract

Objective To identify barriers to and facilitators of primary care provider (PCP) referral for bariatric surgery in patients with obesity.

Data sources MEDLINE, EMBASE, and PsycINFO databases were searched and reference lists of included articles were screened to identify additional relevant articles. Two reviewers independently reviewed citations and full-text articles, and appraised the quality of the included articles using the Critical Appraisal Skills Programme Tool Qualitative Checklist and the Appraisal Tool for Cross-Sectional Studies. They extracted data on the study characteristics and the barriers to and facilitators of PCP referral for bariatric surgery. Appraisal discrepancies were resolved through consensus among authors.

Study selection Overall, 882 citations were identified and 18 articles were then selected for this review.

Synthesis Barriers included fear of surgery complications and side effects, cost, lack of availability, perception that surgery is a quick fix or a last resort, and prior negative experiences. Facilitators included direct requests from patients, patient motivation, previously failed weight-loss interventions, and obesity-related comorbidities. Those PCPs who were knowledgeable about the risks and benefits of bariatric surgery were more likely to refer their patients.

Conclusion Education and continuing professional development programs regarding bariatric surgery are needed to improve PCP knowledge and capacity to manage patients with obesity. Also, educating the general public on obesity, weight management, and available treatment options can empower patients and families to manage their weight and pursue evidence-informed treatments.

Obesity, defined as having a body mass index (BMI) greater than or equal to 30 kg/m2, is a rising epidemic worldwide.1-3 It is associated with reduced quality of life4 and its metabolic effects can lead to obesity-related comorbidities such as cardiovascular disease, hypertension, type 2 diabetes mellitus, osteoarthritis, reproductive disorders, respiratory disorders, and some cancers.5 These comorbidities are associated with substantial reduction in life expectancy and increased health care use and cost.5 Obesity-related comorbidities can improve and possibly resolve following weight loss.5

Currently, there are 3 main options for weight loss in patients with obesity: lifestyle changes, pharmacologic interventions, and bariatric surgery. Of these treatments, bariatric surgery has been shown to be more effective than non-surgical therapies.6 Bariatric surgery results in weight loss through complex mechanisms including alteration of bile flow, stomach size, anatomy and flow of nutrients, the vagus nerve, enteric gut and adipose hormones, satiety, lipid and cholesterol metabolism, incretins and glucose, energy metabolism, gut microbiota, and endoplasmic reticulum stress.7

Bariatric surgery greatly decreases overall mortality and the development of new health-related conditions in patients with morbid obesity (BMI ≥35 kg/m2).8 One year after bariatric surgery, patients lost 23% of their total body weight after sleeve gastrectomy and 31% of their total body weight after Roux-en-Y gastric bypass.6 These results were sustained over 3 to 10 years.9-11 Obesity-related comorbidities resolve or improve in 75% to 90% of cases following bariatric surgery. Type 2 diabetes improves or resolves in more than 80% of patients.9-12 Hyperlipidemia, hypercholesterolemia, and hypertriglyceridemia improve in more than 70% of patients.9-12 Hypertension improves or resolves in more than 75% of patients, and obstructive sleep apnea resolves or improves in more than 80% of patients.9-12

Despite mounting evidence for the effectiveness of bariatric surgery to treat patients with obesity and obesity-related comorbidities, it is only available for 0.58% (or 1 in 171) of eligible adult Canadians per year.3 Primary care providers (PCPs), as gatekeepers to bariatric surgery, contribute to the lack of access to bariatric surgery for eligible patients.13 We conducted a systematic review of the literature to identify barriers to and facilitators of a PCP’s decision to refer their patients with obesity for bariatric surgery.

DATA SOURCES

The protocol for this review is registered in the National Institute for Health Research PROSPERO database for systematic reviews relating to health (PROSPERO registration number: CRD42018088704). We identified articles through searches conducted between November 2017 and February 2018, using MEDLINE, EMBASE, and PsycINFO databases. We used the following MeSH terms in our search: family physicians, family practice, primary health care, primary care physicians, bariatric surgery, gastric bypass, and gastroplasty. Additionally, we used wildcards and Boolean non-MeSH terms including family pract$, general practice$, family medicine, family physician$, primary care, family doctor$, primary medical care, general physician$, general practitioner$, primary care practitioner$, and (bariatric or gastric* or obes* or metabolic or weight) within 2 words of (surger* or operation*). We did not place any limits on our search and searched the reference lists of included articles for additional articles. Two reviewers (L.C., N.C.) independently screened the citations and full-text articles to identify relevant articles of interest.

We selected articles for this review based on a set of inclusion and exclusion criteria. To be included in the review, an article needed to have been peer-reviewed, have been published in English, have PCPs as participants, and have examined factors that affected referral of adult patients for bariatric surgery. Articles were excluded if they focused on a pediatric population; looked at obesity management in general without a focus on bariatric surgery; did not explore factors that affected referral for bariatric surgery; or were review articles, abstracts, case reports, editorials, or pilot studies.

We appraised the methodologic rigour of each of the included studies using 2 critical appraisal tools. We used the Appraisal Tool for Cross-Sectional Studies to assess cross-sectional surveys and the Critical Appraisal Skills Programme Tool Qualitative Checklist to assess qualitative studies. We used the appraisal items in these tools to determine the validity and reliability of the study results. Two authors (L.C., N.C.) individually appraised each of the included studies for quality. Discrepancies between appraisals were resolved through consensus. We determined the methodologic quality of each individual study to be high, average, or low based on the results of the appraisal tools. We assessed the risk of bias across studies by ranking all included studies based on their methodologic strength.

Two reviewers (L.C., N.C.) independently extracted data from the included articles and resolved differences through consensus. Data extracted were summarized according to study design, study location, study population, study aims, sample size, and unique barriers to and facilitators of bariatric surgery referrals among PCPs. Since this was a systematic review of published studies no ethics approval was required.

SYNTHESIS

Our search strategy identified a total of 1128 citations, of which 882 were non-duplicate citations. We screened the 882 citations by applying our inclusion and exclusion criteria to their title and abstract, which resulted in 38 citations for full-text review. Following full-text review, we identified 18 unique articles that were included in this systematic review. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram is depicted in Figure 1.

Figure 1.
Figure 1.

PRISMA flow diagram

We identified 15 cross-sectional surveys conducted at local, provincial or state, or national levels (Table 1).14-28 Sample sizes in these studies ranged from 57 to 484 participants and response rates ranged from 12.4% to 80.0%. The appraised quality of cross-sectional surveys varied from high to low (Appendix A: Table 1, available from CFPlus*). We also identified 3 qualitative studies that used focus groups and interviews of 10 to 16 PCPs that explored barriers to and facilitators of bariatric surgery referral (Table 2).29-31 The appraised quality of all 3 qualitative studies was high (Appendix A: Table 2*).

View this table:
Table 1.

Characteristics of included cross-sectional surveys

View this table:
Table 2.

Characteristics of included qualitative studies

Study outcomes

We identified the following barriers: limited experience, knowledge, and education regarding bariatric surgery, concerns about risks of operative morbidity and mortality, concerns about follow-up care and long-term success after bariatric surgery, presumed prohibitive cost of procedure, and unfamiliarity with current guidelines for referral. We also identified the following facilitators: high patient BMI, presence of obesity-related comorbidities, highly motivated patients, and patient request to be referred for bariatric surgery. We discuss each of these barriers and facilitators below.

Barriers to bariatric surgery referral

Limited experience, knowledge, and education regarding bariatric surgery. Ten out of 15 cross-sectional studies16-20,22-26 and 1 out of 3 qualitative studies29 addressed this topic. Primary care providers with no history of referral were less likely to discuss bariatric surgery with their patients and less likely to feel comfortable explaining procedure options and providing postoperative care.17 Those PCPs were more likely to have just started their practice and had fewer patients with obesity.17 A study from Poland found that only 8% of general practitioners had epidemiological awareness of obesity trends, knew the indications for bariatric surgery, and could apply their knowledge of bariatric surgery to make appropriate referrals.22 In another study, PCPs did not have sufficient knowledge regarding the effectiveness and safety profile of contemporary bariatric surgery, with fewer than half (44%) of all PCPs reporting that they knew some or a lot about surgical interventions for obesity.19 Similarly, a qualitative study from the United States reported that PCPs had limited knowledge about bariatric surgery and were unwilling to recommend surgery until patients had tried other weight management options.29 Similar findings were also noted from PCPs in Kuwait.16

Those with prior education about management of obesity were more likely to counsel patients about bariatric surgery.18,21 Similarly, PCPs who were aware of the National Institute of Health’s (NIH) guidelines on bariatric surgery and who completed continuing professional development (CPD) courses in obesity management were more likely to refer patients.18,21 An increase in PCPs’ knowledge of bariatric surgery, however, did not always result in increased willingness to refer patients for surgery.15 In a study of PCPs from Cincinnati, Ohio, 65% reported being familiar with the indications of bariatric surgery and 70% reported being comfortable discussing it; however, only 9% of the PCPs indicated that they frequently or almost always referred their patients with morbid obesity for surgery.15 This finding seems to suggest that additional factors may play a role in PCPs’ decisions to refer a patient.

Concerns about associated risk of morbidity and mortality of bariatric surgery. Six out of 15 cross-sectional surveys14,16,20,21,27,28 and 2 out of 3 qualitative studies29,31 addressed this topic. Perceived risks of morbidity and mortality associated with bariatric surgery were the most common concerns reported by PCPs.20,21,27 It was found that they generally overestimated the morbidity and mortality rates associated with surgery.18,20 In 1 study, PCPs reported that postoperative vitamin deficiencies were difficult to correct.15 Other studies reported that approximately 5% to 9% of PCPs believed that the risks of surgery outweighed the benefits.15,21 In a survey of PCPs in Connecticut, most PCPs underestimated the expected weight loss at 1 year after gastric bypass surgery and did not believe that it resolved or substantially improved diabetes 80% of the time.20 These misconceptions about contemporary bariatric surgery could influence a patient’s decision to consider it as an option.

Concerns about follow-up care and long-term success following bariatric surgery. Three out of 15 cross-sectional surveys15,17,21 and 2 out of 3 qualitative studies29,30 addressed this topic. Primary care practitioners reported feeling unprepared to provide good-quality, long-term medical care to patients after bariatric surgery.15,17,21 In the survey of PCPs in Cincinnati only 44% of the respondents felt comfortable providing follow-up care after surgery.15

Cost and availability of bariatric surgery. The issues of cost and insurance coverage were reported as barriers in 2 out of 15 cross-sectional surveys15,17 and in 3 out of 3 qualitative studies.29-31 In a study from Ontario, 35.7% of PCPs viewed the cost of surgery as a substantial barrier for patients accessing bariatric surgery, despite the fact that Roux-en-Y gastric bypass and sleeve gastrectomy (in select patients) are publicly funded by the Ontario Health Insurance Plan.17 Research from New South Wales in Australia found that the cost of and access to surgery were barriers for referral.31 A study from Tasmania in Australia found that a publicly funded health program for bariatric surgery had long wait lists and limited accessibility.30

Unfamiliarity with bariatric surgery referral guidelines. Primary care practitioners’ limited knowledge about NIH criteria regarding referral for bariatric surgery was reported as a barrier to patient referrals in 5 out of 15 cross-sectional surveys.16,17,20,21,25 In a study from Ontario, 39.9% of PCPs did not agree with the NIH criteria that included a recommendation for bariatric surgery in patients with a BMI greater than 40 kg/m2 without comorbidities.17 In a national survey from France, only one-third of PCPs reported knowing the national guidelines for surgery.25 Similarly, a national survey study from the United States reported moderate familiarity of physicians with the NIH guidelines, with physicians who had previously referred patients for surgery being far more familiar with the guidelines than physicians who had never referred.21

Other barriers. Prior negative experiences of patients with bariatric surgery was reported as a barrier in 1 of 15 cross-sectional surveys,24 and the perceptions of bariatric surgery as a last resort and a quick or easy fix were reported in 3 out of 3 qualitative studies.28-30 Jose et al reported that some PCPs recommended bariatric surgery only as a last resort when other obesity management approaches had failed.30 There were conflicting results regarding PCPs’ own BMIs and their referral patterns. A study from Kuwait reported increased likelihood of referral by PCPs who had a normal BMI,16 whereas a study from North Carolina reported that PCPs who referred patients for bariatric surgery had a statistically significantly higher BMI when compared with PCPs who did not.18

Facilitators of bariatric surgery referral

Patient request and motivation to be referred for bariatric surgery. Four out of 15 cross-sectional surveys18,21,25,27 and 3 out of 3 qualitative studies29-31 reported that patient request and motivation played important roles in prompting PCPs to initiate a referral for bariatric surgery.18,21,25,27,29-31 These studies also reported that 50% or more of referrals tended to be prompted by a patient request. Among PCPs in France, 64% of bariatric surgery referrals were initiated at the request of the patient.25 In Denmark, only 13% of PCPs reported initiating the conversation about surgery with their patients.27 In the United States, some PCPs reported that a lack of patient interest in considering the treatment was often the reason they did not suggest it as an option.21

High BMI and presence of obesity-related comorbidities. Six studies in our review reported that a high patient BMI and presence of obesity-related comorbidities were facilitators.14,17,25,27,30,31 In studies from Canada17 and France,25 PCPs reported that high patient BMI, presence of obesity-related comorbidities, and multiple attempts at dieting were the most common factors that influenced their decision to refer patients for surgery. In a national survey in Denmark,27 approximately 20% of PCPs would initiate a referral only if patients with obesity also had obesity-related comorbidities; however, 40% of PCPs agreed to refer a patient if their BMI was greater than or equal to 50 kg/m2, even if they did not have obesity-related comorbidities.

Other facilitating factors. Primary care providers were more likely to refer patients for bariatric surgery if they had patients who had successful bariatric surgery,23 if the operation was covered by insurance,30 and if previous weight-loss interventions had failed.31 They were also more likely to refer patients if they believed that surgery was safe and effective.26 More years in practice was reported to be a facilitator of referral in 1 study14 and a barrier in another.18 Similarly, male PCP sex was reported to be a facilitator in 1 study28 and a barrier in another.16

Summary of synthesis

Our analysis of the 18 articles in this systematic review revealed several barriers to and facilitators of referrals for bariatric surgery. Identified facilitators included insurance coverage, presence of high BMI and obesity-related comorbidities, highly motivated patients who request a referral, prior failure of non-operative strategies, and PCP belief in the safety and effectiveness of bariatric surgery. Identified barriers included PCPs’ limited knowledge and education about bariatric surgery, concerns about operative morbidity and mortality, concerns about follow-up care and long-term success of surgery, presumed prohibitive cost of the procedure, prior negative experiences by patients who had surgery, and limited knowledge about current bariatric surgery referral and practice guidelines.

DISCUSSION

Despite evidence that bariatric surgery results in sustained long-term weight loss,6,32 improvement and resolution of obesity-related comorbidities,5,33 and improvement in quality of life parameters,4 bariatric surgery remains an underused intervention for patients with obesity.3,34 Our results demonstrate that there is a discrepancy between the existing evidence supporting the use of bariatric surgery as an effective treatment for patients with obesity and PCPs’ referral patterns. The gaps in PCPs’ knowledge about the risks of contemporary bariatric surgery,34 poor adherence to published guidelines recommending bariatric surgery for treatment of patients with obesity and obesity-related comorbidities,35,36 and limited experience with taking care of patients after surgery appear to be barriers to referral. Delivery of educational content on obesity management at undergraduate, postgraduate, and CPD levels may help address these gaps.

Our findings also reveal that PCPs tend to view bariatric surgery as a last-resort treatment option for patients with obesity. They are much more likely to refer patients for bariatric surgery after patients have tried all other non-surgical weight management options such as lifestyle changes and pharmacotherapies. While this pyramidal approach is commonly practised among PCPs, this view of bariatric surgery as a last resort is likely influenced by stigmas surrounding patients with obesity and PCPs’ negative attitudes toward bariatric surgery. Unfortunately, obesity continues to be viewed as a self-afflicted lifestyle choice,37,38 rather than as a “chronic, relapsing, multifactorial, neurobehavioral disease, wherein an increase in body fat … result[s] in adverse metabolic, biomechanical, and psychosocial health consequences,” as defined by the Obesity Medicine Association.39 Obesity continues to be seen as a disease caused by poor choices, discounting the associated genetic and environmental components.40 The stigma of obesity holds patients responsible for their disease, which in turn may motivate PCPs to continue to suggest lifestyle changes for patients with obesity. Additionally, the stigma associated with bariatric surgery may discourage both physicians and patients from considering surgery as a treatment option.41

We can make 3 recommendations from the results of this systematic review. First, education programs regarding surgical management of obesity should target not only PCPs, but also patients. A number of articles in our review identified PCPs’ limited knowledge about bariatric surgery as a barrier to bariatric surgery referrals. Specific CPD courses for PCPs could be offered on the topics of obesity as a chronic multifactorial relapsing disease; on the risks, benefits, and clinical practice guidelines for medical and surgical treatment options for patients with obesity42,43; and the management of patients after bariatric surgery. Our findings also suggest that patients who advocated for a referral were more likely to be referred by their PCPs. For this reason, patients with obesity and their family members could be better educated on obesity as a disease and the treatment options that are currently available. With greater knowledge and comfort around obesity management, PCPs can be more confident and proactive in caring for their patients with obesity and patients can be better advocates for their own care.

Second, the practical barriers to bariatric surgery should be addressed through a health policy change. In alignment with the recommendations made by Obesity Canada in their Report Card on Access to Obesity Treatment for Adults in Canada,3 obesity needs to be recognized federally and provincially as a chronic disease, and policy changes should be enacted to increase accessibility of bariatric surgery. A consideration should be made to increase funding for bariatric surgery in light of evidence supporting its cost-effectiveness,44 which may decrease the wait times for surgery. Costs incurred by patients for preoperative and postoperative care should be made available to PCPs, allowing them to have more informed conversations with their patients about the cost of bariatric surgery.

Third, a campaign that educates the general public on obesity to destigmatize the disease and its treatments should be considered, as more than 20% of the population of Canada has obesity.3 A widespread education campaign could help shift public opinion toward more inclusive treatment options. This would build awareness of the actual causes of obesity and would promote prevention, empowering physicians and their patients to pursue effective, evidence-informed medical treatments for this disease.

Lastly, our results are in line with the paradox of primary care, which states that

compared with specialty care or with systems dominated by specialty care, primary care is associated with the following: (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.45

Care of patients with obesity as a chronic disease requires shared care models with integrated care provided by PCPs and selective care provided by bariatric surgeons. Such models of care will help maximize the value of health care for individuals and for the entire population.

Limitations

Our results are limited by the quality and detail of the information presented in the studies that contributed to this systematic review. Some of the studies reviewed did not report the magnitude of the difference in referral rates for physicians who were managing patients with low and high BMIs. Thus, we were unable to report this information in our study. In addition, the studies reviewed did not provide sufficient information that would allow us to quantify the magnitude and report the relative importance of all the barriers examined. Further, while it may be interesting to examine differences in jurisdictional guidelines regarding bariatric surgery referral patterns, most of the studies reviewed did not provide this information.

Conclusion

We conducted a systematic review of barriers to and facilitators of a PCP’s decision to refer patients for bariatric surgery. Most of the identified barriers can be addressed through education of current PCPs and through curriculum change for undergraduate medical students and postgraduate trainees. A general public education campaign to destigmatize obesity and to treat it as a chronic disease is also needed.

Notes

Editor’s key points

  • ▸ Barriers to a primary care physician’s decision to refer a patient with obesity for bariatric surgery include limited knowledge and education, concerns about operative morbidity and mortality, concerns about follow-up care and long-term success of surgery, presumed prohibitive cost of the procedure, prior negative experiences by patients who had surgery, and limited knowledge about current referral and practice guidelines.

  • ▸ Facilitators include insurance coverage, presence of high body mass index and obesity-related comorbidities, highly motivated patients who request a referral, prior failure of non-operative strategies, and general belief in the safety and effectiveness of bariatric surgery.

  • ▸ Education at the undergraduate and graduate levels and continuing professional development programs about bariatric surgery could help physicians feel more confident and comfortable in managing patients with obesity and could help limit barriers to referral.

  • ▸ Public education on obesity and weight loss is needed to destigmatize obesity and to treat it as a chronic disease.

Points de repère du rédacteur

  • ▸ Parmi les obstacles qui vont à l’encontre d’une décision par un médecin de soins primaires de demander une consultation en chirurgie bariatrique pour un patient souffrant d’obésité figurent un manque de connaissances et de formation, des préoccupations concernant la morbidité et la mortalité liées à l’opération, des inquiétudes entourant les soins de suivi et la réussite à long terme de l’intervention, les coûts prohibitifs présumés de la procédure, des expériences défavorables antérieures par des patients qui ont subi l’opération, et le manque de connaissances à propos des lignes directrices actuelles sur la pratique et la demande de consultation.

  • ▸ Au nombre des éléments qui facilitent les demandes de consultation, on peut mentionner la couverture par les assurances, la présence de comorbidités liées à un indice de masse corporelle élevé et à l’obésité, la forte motivation de patients qui demandent une consultation, l’échec antérieur des stratégies sans intervention chirurgicale, et la confiance générale en la sécurité et l’efficacité de la chirurgie bariatrique.

  • ▸ Une formation sur la chirurgie bariatrique aux niveaux prédoctoral et postdoctoral et dans les programmes de développement professionnel continu pourrait aider les médecins à se sentir plus à l’aise et confiants lorsqu’il s’agit de prendre en charge de patients atteints d’obésité, et contribuer à atténuer les obstacles aux demandes de consultation.

  • ▸ Il est nécessaire d’informer le public sur l’obésité et la perte pondérale pour déstigmatiser l’obésité et la traiter comme une maladie chronique.

Footnotes

  • ↵* Appendix A is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • Contributors

    All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.

  • Competing interests

    None declared

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Factors influencing primary care provider referral for bariatric surgery
Boris Zevin, Nardhana Sivapalan, Linda Chan, Nicholas Cofie, Nancy Dalgarno, David Barber
Canadian Family Physician Mar 2022, 68 (3) e107-e117; DOI: 10.46747/cfp.6803e107
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