To refer or not to refer? A case study of GP attitudes and approaches to referral for obesity

Lin-Lee YeongA#, Professor Mark HarrisA, Professor Ian CatersonB, Dr Kyoung Kon KimC

A. Centre for Primary Health Care and Equity B. University of Sydney - Boden Institute of Obesity, Nutrition, Exercise & Eating

Disorders C. Gachon University of Medicine and Science - Department of Family Medicine # Corresponding author

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Acknowledgements

• COMPaRE-PHC Team

• Professor Mark Harris, Dr Caterson and Dr Kim

• Medicare Locals and General Practitioners

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Introduction

• 26.6% of adult patients in general practice are obese1

• Obesity highest in low SES, Aboriginal and Torres Strait Islanders, born overseas2

• In 5As, which obese patients to refer, when and to whom is a critical element3

• Referral for Bariatric Surgery:

• BMI >40kg/m2 or 35 kg/m2 and co-morbidities3

• BMI >30 kg/m2 and poorly controlled T2DM/CVD risk3

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Rationale

Morbidly obese man awarded $364, 372 as GP ruled negligent by not referring him to bariatric surgery6

• GP referrals happen infrequently4-5

• Patients seeking non-surgical options are not getting referred4-5

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• Explore attitudes of GPs towards referring obese patients for bariatric surgery

• Identify current approaches of GPs to manage disadvantaged, obese patients

Aims

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• Design: Collective Case Study as a part of a study conducted by COMPaRE-PHC in NSW

• Setting and Participants: 2 GPs in South West Sydney and 2 GPs in Illawarra-Shoalhaven

• Data collected: Semi-structured interviews

• interview questions explored GP experiences with referral, influencing factors to refer and costs to patients

• Analysis: Thematic qualitative

Methodology

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South West Sydney (SWS) Illawarra-Shoalhaven (IS) Location Dr W Dr X Dr Y Dr Z

Age 40-49 40-49 50-59 30-39

Gender Male Male Female Female

Practice Size Group e.g 6+ Solo Single Large group

Distance from

bariatric surgery 10km 2km 1km 25 km

Ethnicity of patients Overseas Overseas Australian Australian

Socio-economic Status of patients,

% private health insurance

Medium, 10%

Medium, 30%

High, 60%

Medium, 30%

Location of study, yrs in practice, yrs

in current practice Overseas, 23 , 14 Overseas, 10 , 1.5 Australia, 35 , 30 Australia , 11, 5

Language English &

Non-English

English &

Non-English English English

Demographic Characteristics

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Results

GPs who feel they have limited options for referral

GPs who feel they have a variety of options for referral

• Frustrated and negative attitudes

• Less likely to refer • Only referred patients with

financial means

• Positive attitudes • More likely to refer and

recommend surgery • Employed empathy • Negotiated with the patient • Prepared patients mentally

and physically

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• Lack of health system resources and cost

Results

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• GPs are less likely to refer patients if they believe cost is a major barrier

• Changing attitudes about the limitations of cost is important

• GPs who believe they have more options, are more likely to refer patients to surgery and help patients move past barriers

Conclusion

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• Make GPs aware of resources available and encouraging referrals

• Integrated approach where information from patients, GPs, hospitals and other programs is shared

• Continued research is required

Implications for Policy and Practice

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Take Home Message

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1. Britt H, Miller GC, Henderson J, Charles J, Valenti L, Harrison C, Bayram C, Zhang C, Pollack AJ, O’Halloran J, Pan Y. General practice activity in Australia 2011-12. Sydney: Sydney University Press, 2012.

2. Passey ME, Laws RA, Jayasinghe UW, Fanaian M, McKenzie S, Powell-Davies G, Lyle D, Harris MF. . Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial. BMC Health Serv Res. 2012;12:234.

3. National Health and Medical Research Council (2013) Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: National Health and Medical Research Council.

4. Denney Wilson E, Wan Q, Vagholkar S, Shutze H, Harris MF. Routine assessment and management of lifestyle risk factors in General Practice: Results from two randomised controlled trials" Australian Family Physician 2010; 38: 950-3

5. Harris M. PEP: An intervention to equitably implement guidelines for vascular disease prevention in general practice. 2012 Primary Health Care Research Conference. July 18-20 2012, Canberra

6. Aston, H. 2013. Obese man wins $350,000 payout from GP. Retrieved from http://www.smh.com.au/nsw/obese-man-wins-350000-payout-from-gp-20130207-2e0b6.html#ixzz2PRp3lj6x on February 10th 2014

References

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lin-lee.yeong@student.unsw.edu.au and

www. http://compare-phc.unsw.edu.au/

The research reported in this presentation is a project of the Australian Primary Health Care Research Institute which is supported by a grant from the Australian Government Department of Health and Ageing. The information and opinions contained in it do not necessarily reflect the views or policy of the Australian Primary Health Care Research Institute or the Australian Government Department of Health and Ageing.

Further Information

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Questions