Division of Endocrinology and Metabolism, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
Division of Endocrinology and Metabolism, Sinai Leadership Centre for Diabetes, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
Can J Diabetes. 2022 Dec;46(8):835-842.e1. doi: 10.1016/j.jcjd.2022.06.005. Epub 2022 Jun 23.
One-third of adults in Canada are overweight and 26.8% experience obesity. Bariatric surgery confers effective weight loss and reduces obesity-related complications, including type 2 diabetes, but remains an underutilized treatment. Our objective in this study was to determine whether a gap exists in bariatric program referrals for patients with type 2 diabetes seen in endocrinology clinics at an ambulatory tertiary care hospital in Toronto, Canada.
A retrospective chart review was conducted of 843 consecutive patients with type 2 diabetes in endocrinology clinics between January 1, 2015 and December 31, 2020. Inclusion criteria were age ≥18 years, type 2 diabetes and body mass index (BMI)>35 kg/m. Exclusion criteria were recent active cancer, uncontrolled psychiatric disease or active substance use disorder within 6 months of the initial visit. Referrals to bariatric surgery were assessed within a 5-year follow-up period and compared with baseline referral rates from the Ontario Bariatric Network (OBN). An online survey of 48 endocrinologists in Toronto, Ontario, was also conducted to assess physician-level barriers to referral.
The proportion of patients with class II obesity (BMI>35 kg/m) and type 2 diabetes meeting the eligibility criteria for bariatric referral was 4.6% (n=38). A documented discussion about bariatric surgery occurred with 7 (18.0%) of these eligible patients, and 1 patient (2.6%) was referred for surgery. Aside from surgical referrals, only 2.6% of eligible patients were referred to cognitive-behavioural therapy, 36.8% were initiated on obesity pharmacotherapy and 42.1% were referred to a dietitian. Baseline OBN data demonstrated that most surgical referrals (n=6,360) were from family physicians (65.0%) and only 8.8% were from a medical specialist. Eight percent of surveyed endocrinologists reported that they discussed bariatric surgery with at least half of their eligible patients. The most frequent barrier to discussing bariatric surgery during visits was time constraints. Physicians identified that simplifying the referral process and providing bariatric surgery handouts would be helpful interventions to improve referral rates.
Our gap analysis demonstrated a low bariatric surgery referral rate by tertiary care endocrinologists. Our study also identified a large gap in the appropriate treatment of obesity with poor utilization of behavioural, lifestyle and pharmacotherapy practices. As obesity and diabetes rates increase, better education, training and knowledge translation will be necessary to overcome weight bias and prioritize obesity management.
加拿大有三分之一的成年人超重，26.8%的人肥胖。减重手术可有效减轻体重并减少肥胖相关并发症，包括 2 型糖尿病，但该手术的应用仍不足。本研究旨在确定在多伦多一家门诊三级保健医院的内分泌科诊所就诊的 2 型糖尿病患者中，是否存在减重计划转诊方面的差距。
对 2015 年 1 月 1 日至 2020 年 12 月 31 日期间内分泌科诊所的 843 例连续 2 型糖尿病患者进行了回顾性图表审查。纳入标准为年龄≥18 岁、2 型糖尿病和体重指数（BMI）>35 kg/m。排除标准为近期活动性癌症、6 个月内无法控制的精神疾病或活动性物质使用障碍。在 5 年随访期间评估了减重手术的转诊情况，并与安大略减重网络（OBN）的基线转诊率进行了比较。还对安大略省多伦多的 48 名内分泌科医生进行了在线调查，以评估医生层面转诊的障碍。
符合减重转诊条件的 2 型糖尿病伴 II 级肥胖（BMI>35 kg/m）患者比例为 4.6%（n=38）。对这些符合条件的患者中的 7 名（18.0%）进行了减重手术的讨论，其中 1 名（2.6%）患者接受了手术转诊。除了手术转诊外，只有 2.6%的符合条件的患者被转介至认知行为疗法，36.8%的患者开始接受肥胖药物治疗，42.1%的患者被转介至营养师。基线 OBN 数据表明，大多数手术转诊（n=6,360）来自家庭医生（65.0%），仅 8.8%来自医学专家。8%的调查内分泌科医生报告说，他们与至少一半符合条件的患者讨论了减重手术。在就诊期间讨论减重手术的最常见障碍是时间限制。医生认为简化转诊流程并提供减重手术手册将有助于提高转诊率。
我们的差距分析表明，三级保健内分泌科医生的减重手术转诊率较低。我们的研究还发现，肥胖的适当治疗存在很大差距，行为、生活方式和药物治疗的利用率很低。随着肥胖和糖尿病发病率的增加，需要更好的教育、培训和知识转化，以克服体重偏见并优先考虑肥胖管理。
