Factors influencing primary care provider referral for bariatric surgery: Systematic review

Boris Zevin; Nardhana Sivapalan; Linda Chan; Nicholas Cofie; Nancy Dalgarno; David Barber

doi:10.46747/cfp.6803e107

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Table 1.

Characteristics of included cross-sectional surveys

STUDY INFORMATION	POPULATION	AIM OF STUDY	SAMPLE SIZE (RESPONSE RATE, %)	BARRIERS	FACILITATORS
Sarwer et al, Pennsylvania, 2012¹⁴	Academic medical centre physicians and community-based physicians (primary care, internal medicine, endocrinology)	Local survey to investigate attitudes about referring patients with type 2 diabetes for bariatric surgery	93 (27.4)	Concerns about complications from bariatric surgery	Experienced physicians Patient BMI >40 kg/m² Obesity-related comorbidities
Tork et al, Cincinnati, Ohio, 2015¹⁵	PCPs	To evaluate perceptions of the role of bariatric surgery in the treatment of patients with obesity and to identify possible barriers	57 (35.4)	Cost of procedure Insufficient insurance coverage Concerns about long-term follow-up care after surgery	NA
Al-Namash et al, Kuwait, 2011¹⁶	PCPs	Survey of 3 health regions in Kuwait to identify why PCPs do not refer patients with morbid obesity for bariatric surgery	259 (80.0)	Unfamiliar with referral guidelines Concerns about associated risks of morbidity and mortality of bariatric surgery Limited experience, knowledge, and education Overweight and obese physicians	Female physicians
Auspitz et al, Ontario, 2016¹⁷	FPs	Provincial survey to identify knowledge and perceptions of bariatric surgery	165 (12.4)	Lack of resources Concerns about follow-up care Limited experience, knowledge, and education Cost of surgery	High patient BMI Patient obesity-related comorbidities Patient repeat attempts at dieting to lose weight
Balduf and Farrell, North Carolina, 2008¹⁸	FPs and internists	State survey to assess attitudes, knowledge, and bariatric surgery referral practices	268 (44)	Limited experience, knowledge, and education	Patient request to be referred for bariatric surgery Younger physicians Physicians with recent medical school graduation Physicians with higher BMI
Ferrante et al, New Jersey, 2009¹⁹	FPs	State survey to assess practices and attitudes regarding care of extremely obese patients	255 (53)	Limited experience, knowledge, and education	NA
Perlman et al, Connecticut, 2007²⁰	FPs	State survey to determine the level of knowledge and comfort in treating obese patients	129 (21)	Concerns about associated risks of morbidity and mortality Belief that the patient would be unable to follow the postoperative lifestyle changes Limited experience, knowledge, and education	NA
Avidor et al, United States, 2007²¹	Physicians from 6 medical specialties: bariatric medicine, OB-GYN, internal medicine, endocrinology, cardiology, and family practice	Two surveys administered at national meetings: To quantify and characterize the perceptions and practices in treating morbidly obese patients To understand why physicians refer so few of their morbidly obese patients for surgery	Survey 1: 478 (not reported) Survey 2: 484 (not reported)	Unfamiliar with referral guidelines Concerns about perceived risks of morbidity and mortality Concerns about follow-up care and long-term complications Unfamiliar with bariatric surgeons	Patient request to be referred for bariatric surgery Patient motivation
Giaro et al, Poland, 2010-2012²²	General practitioners	Survey administered at educational conferences to assess the knowledge of bariatric surgery	282 (not reported)	Limited experience, knowledge, and education	NA
Jung et al, Germany, 2016²³	General practitioners and internists	National survey to examine the effect of stigma and knowledge on recommending weight-loss surgery and referral to a surgeon	201 (16.3)	Limited knowledge of weight-loss surgery results Stigma toward weight-loss surgery	Increased experience with weight-loss surgery
Major et al, Poland, 2016²⁴	PCPs (84.6%) and other physicians	National survey to assess knowledge of bariatric surgery and willingness to improve it in the future	206 (not reported)	Limited experience, knowledge, and education	NA
Martini et al, France, 2018²⁵	General practitioners	National survey to describe knowledge and attitude toward bariatric surgery	288 (12.9)	Unfamiliar with referral guidelines Limited experience, knowledge, and education regarding bariatric surgery	Patient request to be referred for bariatric surgery High patient BMI Patient obesity-related comorbidities Knowledge of risks and benefits of bariatric surgery
Salinas et al, United States, 2011²⁶	FPs and general internists	National survey to identify relationships between attitudes, barriers, and current practice patterns to inform educational programming	293 (30)	Lack of time during patient encounters Lack of knowledge and skill with weight management Lack of training in effective communication Lack of patient motivation	Increased physician confidence in assisting patients with weight management Increased physician confidence in managing patients after Roux-en-Y gastric bypass
Stolberg et al, Denmark, 2017²⁷	PCPs	National survey to investigate referral patterns and possible reservations regarding bariatric surgery	133 (44)	Concerns about postoperative medical and surgical complications	Patient request to be referred for bariatric surgery Patient BMI >50 kg/m²
Sansone et al, Midwest, United States, 2007²⁸	FPs, internists, and OB-GYNs	Hospital survey to explore current opinions regarding morbid obesity and gastric bypass surgery	99 (40)	Concerns about associated risks of morbidity and mortality of surgery	Male physicians

BMI—body mass index, NA—not applicable, OB-GYN—obstetrician-gynecologist, PCP—primary care provider.

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Table 2.

Characteristics of included qualitative studies

STUDY INFORMATION	POPULATION	AIM OF STUDY	SAMPLE SIZE (RESPONSE RATE, %)	BARRIERS	FACILITATORS
Funk et al, Wisconsin, 2016²⁹	PCPs	Focus groups were conducted: To understand how PCPs make treatment recommendations to severely obese patients To understand how PCPs prioritize the recommendations made to severely obese patients To investigate how PCPs approach bariatric surgery as a treatment option and the challenges they encounter during the referral process	16 (61.5)	Concerns about associated risks of morbidity and mortality Cost and insurance coverage Limited knowledge about bariatric surgery and long-term effectiveness Poor reimbursement of physician time for patient counseling Bariatric surgery considered a last resort Distance that a patient has to travel to the bariatric clinic Concerns about follow-up care after bariatric surgery	Patient request to be referred for bariatric surgery Patient motivation
Jose et al, Tasmania, Australia, 2017³⁰	General practitioners	Interviews to examine their role in decision making about bariatric surgery for patients with obesity and their role in postoperative monitoring and support	10 (not reported)	Negative outcomes following surgery Surgery considered a last resort Concerns about providing follow-up care after surgery Cost and insurance coverage	Patient preference and request for bariatric surgery Patient obesity-related comorbidities
Kim et al, New South Wales, Australia, 2015³¹	General practitioners	Semistructured interviews to explore decision-making factors and intentions in referring obese patients for lifestyle interventions or bariatric surgery	24 (75)	Concerns about associated risks of morbidity and mortality Surgery considered a last resort Cost of procedure Lack of availability of procedure in public hospitals	Patient expectation and request for referral for bariatric surgery Patient comorbidities Trustworthy surgeons and competent multidisciplinary team Guidelines from professional bodies