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Bariatric surgery -

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HideNorman Swan: Hello, and welcome to the Health Report with me, Norman Swan.

Today what Microsoft has discovered about how we search for health information on the internet. The link between the obesity epidemic and doctors and nurses washing their hands. And, speaking of obesity, big variations in access to life-saving surgery.

Bariatric surgery—weight loss surgery—can reverse type 2 diabetes and make a huge difference to the lives of people who are unable to reverse their slide into what's called morbid obesity.

The waiting lists in public hospitals for these operations are huge and research published in this week's edition of the Medical Journal of Australia has used information from hundreds of thousands of people aged over 45 in NSW to compare access to bariatric surgery to a person's ability to pay.

Rosemary Korda of the Australian National University was the lead investigator.

Rosemary Korda: We were looking at bariatric surgery because there were concerns about who was getting access to it and who was not. We already know that most of the bariatric surgery that's done in Australia is done in private hospitals. But up until now it's been difficult to actually quantify who's getting it and who's not getting it. So we were particularly interested in the inequalities around access to this surgery.

Norman Swan: And what we're talking about mostly is lap-banding.

Rosemary Korda: We were talking about bariatric surgery in general, but in Australia we know that the vast majority of this surgery is lap-banding.

Norman Swan: Now, you're following a quarter of a million people in this 45 and up study. What proportion of that group are obese, in other words they've a BMI of over 30?

Rosemary Korda: In our study we had about 22% of the people were in the obese range. By the time we'd excluded people who were over a certain age, we ended up with about 50,000 people in our study.

Norman Swan: What did you find when you looked at the...because you've linked their records with their permission to their hospital records in both the public and private hospital sectors, so you know what's happening to them.

Rosemary Korda: That's correct. We followed these people for up to about four and a half years, and we were able to, yes, identify who was having the surgery from the hospital records. And we're comparing them across different levels of income. And we find that people in the higher income households were five times more likely to have the surgery than those in low-income households.

We also looked in relation to other factors, but private health insurance in particular was interesting because we found that you were nine times more likely to have the surgery if you had private health insurance than if you didn't. That wasn't surprising, in a sense. But I think what was interesting is that it wasn't just a story about private health insurance. If you adjust for private health insurance in these analyses, you find that people in high-income households are still twice as likely to have the surgery.

Norman Swan: And did you assess out-of-pocket costs? Anybody listening to us who's got private health insurance knows that there are significant out-of-pocket costs.

Rosemary Korda: We didn't look at the out-of-pocket costs directly. We know from other information that the out-of-pocket costs are very high with this surgery if it's done in a private hospital, and it sort of made sense that even when you took that out of the equation, for instance even amongst people with private health insurance you still get these inequalities by income.

Norman Swan: So it's a straight line, that the wealthier you are the more likely you are if you're obese to get this surgery.

Rosemary Korda: That's correct. So again, amongst people who are potentially eligible for it, yes.

Norman Swan: And talking about eligibility, how did it rate to their BMI, their body mass index? So you're obese at over 30, but in the public system I don't think you can even get on the waiting list unless you're morbidly obese, I think around 45 or so, although the rules may be different in different jurisdictions. Did the level of BMI at which you got your bariatric surgery vary?

Rosemary Korda: Yes, considerably. We know that it's clinically recommended really for people with a BMI greater than 40, or 35 with co-morbidities...

Norman Swan: By co-morbidities you mean they've got diabetes or heart disease...

Rosemary Korda: Diabetes or, yes, heart disease or those other obesity-related health conditions. Again, the data made a lot of sense, because as your BMI went up in this study, the greater the probability that you'd have the surgery.

Norman Swan: In other areas of surgery, particularly, say, hysterectomies and other areas, there is a variation by postcode. So the likelihood of having a hysterectomy is greater in a richer suburb, for example, and that is not necessarily related to need. In other words, the difference is not explained by severity of symptoms. Do you see the same thing with bariatric surgery, that the wealthier you are the greater your capacity to pay, the lower the BMI at which you have your bariatric surgery?

Rosemary Korda: Yes, we looked at mean BMI across socioeconomic status. We didn't actually report that in the paper. And it varied slightly, so there's some indication that in the people with higher socioeconomic status, higher incomes in this study had a slightly lower BMI, but it wasn't a strong finding in this study. But I think it was more the case that people of low socioeconomic status were missing out. It's interesting if you just look by postcode, you actually find people in the middle postcodes, in terms of socioeconomic status, that's where the rates of surgery are the highest. But that reflects the level of obesity as well as the level of health service use. I think that was the neat thing about this study, that we could actually look at people only with obesity, and so we could find that once we look at people with obesity you get a very clear gradient across postcodes.

Norman Swan: And of course this creates a dilemma for the health system. There's not a jurisdiction in Australia without very long waiting lists for bariatric surgery, but potentially this is life-saving surgery.

Rosemary Korda: That's correct. And it is a wider health system issue, I guess, about inequalities in the system, and people will say, well, resources are constrained and it's not my job to say how many bariatric procedures should be carried out. But I think we do need to have a national conversation about the distribution of these services. I think there's misconception that it's for cosmetic reasons only. But in fact the indications are very clear that the people with health problems, with severe obesity, who really have very few other options, they have tried other options for weight loss and haven't been able to reduce their weight…and we know from the data that it can be life-saving surgery and it can resolve a lot of health problems.

Norman Swan: But of course in this split, inefficient health system that we've got, if the states pay for bariatric surgery it's the Commonwealth that saves the money on drugs. So there's no incentive to provide the bariatric surgery.

Rosemary Korda: Yes, I think that is a big issue. I think it's the way our health system is structured and funded that actually creates the cracks in the system. It is a bit of an unusual situation when we actually have universal healthcare in this country and everyone is covered by Medicare, the procedure's listed by Medicare but unless you have private health insurance and you can afford to pay the out-of-pocket costs, you really have very poor access to the surgery, because very few are done in public hospitals. And I think that is a problem about cost-sharing between state and federal governments, who picks up the tab for this and who benefits from picking up the tab.

When decisions are made to list something on Medicare, and this was listed because it was shown to be an effective and very cost-effective procedure, it's not considered the other part of the equation, what happens in the state system. So we have this split federal-state system, we have the mix of public and private care, we have a problem with out-of-pocket costs, and I think they all add up to people falling between the cracks. And that's a real issue, I think, when you have a health service that really can improve someone's health.

Norman Swan: Dr Rosemary Korda is a Research Fellow in the National Centre for Epidemiology and Population Health at the Australian National University in Canberra. And the 45 and Up Study is run by the Sax Institute in Sydney. And you're listening to the Health Report here on RN with me, Norman Swan.

Okay, I know what you're thinking; why don't these obese people get a hold of themselves and just lose weight? If only it were that easy. What we're talking about is behaviour change, which can be very hard to achieve.


Korda RJ et al. Inequalities in bariatric surgery in Australia: findings from 49,364 obese participants in a prospective cohort study. Medical Journal of Australia 2012;197:631-636

Dr Rosemary Korda
Research Fellow
National Centre for Epidemiology and Population Health
Australian National University
Further Information
The Sax Institute Credits
Presenter Dr Norman Swan Producer Brigitte Seega