New Bariatric Surgical Program Established at University of Toronto
Richard Reznick
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FOUR SURGEONS BRAIN-STORMING IN AN OFFICE
About two years ago, I had an
informal meeting in my office
with Laz Kline and John Hagen
from Humber River Regional
Hospital (HRRH) and Lloyd
Smith from St. Joseph's. We
spent our time discussing the
current state of affairs with respect to surgery for morbid
obesity in the Province of Ontario. And it was not a pretty
picture. Laz, John and other colleagues from HRRH
were performing about 250 cases per year, having been
designated by the government as a provincial centre of
excellence. But despite this accomplishment, other centres,
like St. Joe's had not received any funding to treat
these patients and over 1500 patients per year were exiting
Ontario for their surgery at great cost to our health
system. John and Laz's wait times were staggering and
approached two years. Further, there has been mounting,
and now overwhelming evidence that gastric bypass
surgery can be a life-saver, with a dramatic positive
impact on diabetes, hypertension, lipid disorders, coronary
artery disease and mental health. This impromptu
conversation lead to the formation of a working group as
we theorized that if we could use the collective power of
our teaching hospitals across the University of Toronto,
we could possibly achieve the number of cases needed
to have a real impact on the Ontario problem, not
overwhelm any one hospital and provide a platform for
training and research into this important area.
A UNIVERSITY DEPARTMENT CAN PLAY A COORDINATION ROLE IN CLINICAL CARE
Despite the fact that it is not usual for the University
to take a political lead in clinical matters, in this case it
made sense; and what resulted was a tremendous spirit
of cooperation between our teaching hospitals and our
Department of Surgery at U of T, ultimately resulting
in the tabling of a proposal to the Ministry. And
they agreed! MOHLTC has recently approved funding
to establish a large bariatric surgery program at the
University of Toronto, which is great news for our university,
the affiliated hospitals involved in this initiative,
and most of all, the growing ranks of Ontario patients
who will significantly benefit from weight loss surgery.
The Ministry has earmarked a total of $75 million to
expand bariatric surgery capacity in the province, as part
of its wide-ranging diabetes strategy. Recognizing the
magnitude of the need for this surgery that exists in the
Greater Toronto Area, the tremendous surgical expertise
concentrated in Toronto, and the University of Toronto's
reputation for excellence in health research and education,
the Ministry agreed to further expand capacity
in Toronto. Other provincial Centres of Excellence in
bariatric surgery include Guelph General Hospital, The
Ottawa Hospital, and St. Joseph's HealthCare Hamilton.
The new University of Toronto Collaborative Bariatric
Surgery Program will be a partnership with Humber
River Regional Hospital, University Health Network's
Toronto Western Hospital, St. Michael's Hospital, St.
Joseph's Health Centre, Toronto East General Hospital,
and The Hospital for Sick Children. The rapid creation
of a dispersed surgical program such as this one would
not have been possible without the trust and belief
in teamwork that already exists in the University of
Toronto's surgical community.
To date, the province has provided the University of
Toronto Collaborative Bariatric Program with over $3
million in capital funding for specialized equipment,
instrumentation, inpatient area renovations, and the creation
of an ambulatory obesity clinic. Once this program
is fully functional, operational funding will total almost
$12 million per annum. This money will cover supplies,
clinical support service, and inpatient and clinic staffing
costs.
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A GOOD MODEL OF CARE
A cornerstone of the collaborative bariatric surgery program
will be two ambulatory clinics which will provide
centralized triage, intake, assessment, and post-operative
follow-up care. A centralized clinic component such as
this, will allow this bariatric program to realize numerous
organizational efficiencies and cost savings, and optimize
coordination and continuity of care for patients. To
this end, Humber River Regional Hospital will expand
its current clinic to accommodate a larger volume of
patients, and will serve as the model for a new clinic to
be established at Toronto Western Hospital. The planning
process is already well underway at Toronto Western,
and it is anticipated that they will be able to open their
doors to bariatric patients by the fall of 2009. A key
facet of these two clinics is that they will be able to provide
large volumes of patients with highly-coordinated,
multi-disciplinary care. Hospital administrators, surgeons,
medical specialists, psychiatrists, nurses, dietitians, social
workers, occupational therapists and Community Care
Access Centres will work collaboratively in an interprofessional
practice environment to ensure that patients'
co-morbidities are managed properly, their obesity-related
conditions and mental health issues are fully addressed,
and they are adequately prepared for the lifelong weight
management and behavioural modification required for a
successful outcome.
Once the program is fully functional, it will serve
over 900 patients a year, in the University of Torontoaffiliated
hospitals. A total of 17 surgeons will perform
bariatric surgery. Distributing the caseload in this manner
will prevent any one hospital from being burdened
by such a large volume of bariatric patients, and will
allow participating surgeons to maintain their current
scope of practice.
With the program encompassing six surgical sites, and
two clinic locations dispersed across Toronto, efforts to
ensure communication throughout the network will be
paramount. A nucleus executive committee will be formed
with representation from the various sites, not only to
facilitate communication, but to provide the multi-site
program with effective coordination and management.
The Ministry has also created a province-wide bariatric
network, which includes an Advisory Board and various
working groups, with representation from all provincial
Centres of Excellence. This will allow for the sharing of
best practice, the development of comprehensive assessment
criteria, and the creation of a centralized patient
database to generate high-quality evidence-based research.
RESEARCH AND EDUCATION WILL BE A FOCUS
With respect to research and education, this new surgical
program will undoubtedly be able to capitalize on its
association with the University of Toronto. Numerous
opportunities exist to conduct outcomes and evaluation
research, as well as to investigate the efficacy of emerging
bariatric technologies. This new program also has very
promising academic implications, not only for general
surgeons, but for plastic surgeons, anaesthetists, psychiatrists,
medical internists, postgraduate medical trainees,
nurses, and allied health professionals. Additionally, the
new bariatric program should prove to be a natural fit
with the University' of Toronto's already established
Minimally-Invasive Surgery Fellowship Program.
Most importantly, this initiative will help the province
address the ever-increasing waiting list for weight loss
surgery, and stem the tide of Ontario patients who
undergo gastric bypass surgery outside of Canada. Each
patient who has surgery in Ontario, as opposed to the
United States, will result in savings of approximately
$10,000. With a total of 1660 patients leaving the
country for bariatric surgery in 2008/2009, (1) the time
for expansion of services in Ontario has arrived. The
establishment of the University of Toronto Collaborative
Bariatric Surgery Program will do much to curb health
care spending, and provide a large patient population
with an integrated range of services close to home.
Richard K. Reznick
R. S. McLaughlin Professor and Chair
(1) Ontario improves access to bariatric surgery: McGuinty government moving forward on diabetes strategy. News Release. February 23, 2009
http://www.health.gov.on.ca/english/media/news_releases/
archives/nr_09/feb/nr_20090223.html
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