HEAVY BURDEN
When weight-loss surgery performed at private clinics goes wrong, it is the public health system that routinely picks up the pieces
She had once dreamed of easy, medically enhanced weight loss, but Beth’s high hopes came to an excruciating end last year with a “huge pop” — from inside her body.
Like thousands of other Canadians struggling with obesity, the Toronto woman, helped by her mother, had paid for weight-loss surgery at a private Ontario clinic, won over by marketing that promised rapid, effortless slimming.
Within three years, though, she needed revision surgery after the restrictive band implanted around her stomach in 2008 slipped. Then she felt that fateful pop, followed by violent, breathtaking pain, and the clinic’s pledge of post-op care began to crumble, forcing her to visit two public hospitals for urgent help.
Beth spent a week in one f acility before the band, which had literally fallen apart inside her abdomen, was surgically removed, all costs picked up by the provincial medicare system.
“I was very angry and most of all disappointed, because my Mom had spent her retirement money on something that was a promise of health,” said the 24-year-old, who spoke on condition her full name not be published. “Eventually [medicare] had to go in and fix everything that they messed up.”
Beth’s experience, though, was far from unique, highlighting what seems to be an increasingly common collision between private and public medicine in Canada.
Surgeons working in taxpayer-funded hospitals across the country say they are routinely helping pick up the pieces of privately performed weight-loss operations.
Patients show up complaining of serious complications, unpleasant side effects or just the inability to shed pounds after an investment that can top $16,000 — and limited help from the company that originally treated them.
An Edmonton program has estimated the cost to taxpayers of treating patients who had gastric bands implanted by for-profit clinics in Canada and out of country at millions of dollars, and suspects it has seen only the “tip of the iceberg.”
“I think it’s a crisis, to be honest. It may explode at some point when all these people have ongoing issues,” said Daniel Birch, an Edmonton surgeon. “It’s a tremendous cost to the patient and to the system, with no sustainable quality-of-life change.”
A specialist in Toronto says he has never implanted a gastric band — the preferred operation in private clinics — but has removed 20 of them in the last few years. Patients typically indicate they received little support from their clinics, which seem anxious to recruit patients but less eager to provide crucial care after the operation, said David Urbach, surgical director of the Toronto Western Hospital’s bariatric unit.
“They privatize the profit and they socialize the losses,” he charged. “All the risk is borne by the public system.”
Yet the mere fact that patients are paying to undergo surgery at private clinics with uncertain success rates highlights another problem: backlogs in the public system that can force obese patients to wait years for an operation, said Dr. Birch.
And private does not ne- cessarily equal sub-standard. One private-clinic director said his own facility provides extensive care after surgery, with excellent patient outcomes that have been reported in a peer-reviewed journal. When private surgery works for patients with a medical need, it actually saves t he public system money.
The surgeon, who asked not to be named so his company was not l i nked to negative publicity, said he has even operated on patients whose public-hospital weight-loss surgery failed.
He admitted, however, that some for-profit clinics are not so conscientious, and he has had to take on many of their patients.
“It isn’t just the public system that’s dealing with the complications,” the specialist said. “They [other clinics] are my nemesis, too.”
Bariatric surgery, usually done with minimally invasive keyhole techniques, is certainly accepted as an effective, and sometimes the only, intervention for the seriously obese. As many as 70% of patients with type-2 diabetes are virtually cured of the disease after surgery, noted Dr. Chris De Gara of the University of Alberta.
There is less agreement about the best type of weightloss operation.
Private clinics usually install gastric bands, liquidfilled devices fastened around the top of the stomach to create a little pouch and make patients feel full quickly. A tube threads out to a “port” on the abdomen, allowing liquid to be added or removed from the band to tighten or loosen it.
Most common in teaching hospitals and sometimes called the “gold standard” is the more invasive Roux-en-Y gastric bypass, where a small pocket is surgically created but most of the stomach is bypassed.
Some studies have suggested as many as 40-50% of bands will fail, though that still means many patients do well, and centres in Australia have produced much better success rates by providing extensive support to band patients.
The problem, in fact, may not be the procedure itself. Surgeons in public hospitals say many private clinics seem to skimp on the crucial preparation and after-care needed to make any bariatric procedure work. The actual operation makes it harder to over-eat, but major diet, lifestyle and psychological adjustments are also needed.
“It’s very naïve to think that a simple surgical procedure will fix a complex behavioural and genetic and societal problem,” said Teodor Grantcharov, a surgeon at Toronto’s St. Michael’s Hospital.
Beth underwent a medicare-funded bypass operation in Ontario last week, saw an array of health professionals — from pharmacist to psychiatrist — beforehand and has a similar list of appointments for the next year.
In contrast, her only prep before the band was implanted was to meet with a clinic sales consultant. Afterward, she had brief visits so the device could be adjusted, a revision surgery and one appointment with a nutritionist whom she said was barely qualified.
When things go seriously wrong, it seems some clinics are reluctant, or just illequipped, to take corrective action. In a case made public by a disciplinary ruling this February, a patient of the same company and doctor as Beth’s had to visit hospitals repeatedly and be operated on by a different surgeon when her band began to erode dangerously inside her.
At a special “revision clinic” launched four years ago in Edmonton, doctors have since 2010 seen 124 patients who had gastric bands implanted outside of Alberta, the majority at a private clinic in Ontario, the rest in other countries.
The doctors removed about half the bands, and the demand is growi ng: the number of removals has doubled each year, with 13 devices taken out just in the past four months, said Dr. De Gara.
A paper published in May by his team estimated the cost to the system of treating 62 patients who had problems after private weight-loss operations in other provinces or countries was $1.8 million.
In Toronto, Dr. Grantcharov said about 10% of the 80-100 bariatric surgeries he does every year are to take out failed bands, the majority implanted at private clinics in Canada.
Illustrating the complex interplay between private and public health-care, revisions of gastric-band operations on Vancouver Island are sometimes done at taxpayer expense by the same specialist who performed the ori gi nal, private procedure, said Dr. Samaad Malik, a University of British Columbia surgery professor.
Still, if governments dedicated more resources to bariatric surgery, fewer patients would need to seek out the less-comprehensive treatment offered by some private clinics, suggested Dr. Birch.
Ontario di d boost its spending on the field in 2009, and Toronto’s Dr. Urbach maintains wait lists are now a thing of the past. Dr. Birch in Alberta is unconvinced, arguing Ontario has “not even touched” the true backlog of patients who need the operation.
In B.C., the College of Physicians and Surgeons has tried instead to bolster the standards of the for-profit clinics. It took the rare step of imposing rules for private weight-loss surgery, requiring that they be offered only as part of a comprehensive weight-loss plan, and that clinics report long-term outcomes.
“It gives patients an option,” said Dr. Heidi Oetter, the regulator’s CEO. “For many people to be told there’s a six-year wait (in the public system) to get a procedure, it’s hardly helpful to them.”
Meanwhile, in some provinces at least, many privateclinic patients are ending up back in the public system.
Beth said she was in so much pain after her band fell apart that she could barely move.
Yet it took numerous calls just to reach her surgeon, who finally suggested she go to a local hospital where he had privileges.
He appeared briefly at her bedside days later, she says, admitting the operation had been a “lemon,” but chastising her for making a fuss and stressing she would not get her money back.
Another physician removed the band, at medicare’s expense.
“I had two ER visits, plus the surgery, all done at public hospitals. It just takes all the financial weight off of [the clinic],” she said. “It’s definitely not fair that taxpayers have to worry about their mess-up.”