What disease affects 8.3 per cent of the global adult population, absorbs 11 per cent of world health spending (including 10 per cent of the NHS’ budget) and is listed as the primary reason for a third of physician visits and 40 per cent of hospital outpatient visits in the US? Heart disease? Cancer? The answer may surprise you – it’s actually diabetes.
As the burden of diabetes rises worldwide (particularly that of type 2 diabetes, which accounts for 90 per cent of all cases), the imperative is growing for the launch of more effective prevention efforts. But it is clear that an approach geared exclusively towards prevention will not be enough; there are already 3.3 million people in the UK alone with diagnosed diabetes and as such there is a pressing need for treatment options that are both clinically proven and cost effective.
The evidence is there
One potential solution that has been gaining support in the academic community is the application of bariatric surgery to treat type 2 diabetes. Typically viewed as a treatment for obesity, the body of evidence is growing that this group of surgical procedures, which reduce weight by either shrinking or bypassing the stomach, can also be highly effective in relieving the symptoms of type 2 diabetes. Furthermore, bariatric surgery has been found to be significantly more effective than conventional medical therapy according to a number of randomised controlled trials.
The National Institute for Health and Care Excellence (NICE), the body providing national guidelines and advice to improve health and social care in the UK, also appears to view bariatric surgery as both clinically efficacious and good value for money for certain population groups.
So why, with such high-profile support for surgery featuring in the armory of diabetes treatments, were only just over 4,000 primary bariatric surgery procedures performed on patients with type 2 diabetes between 2011 and 2013? This number represents only a small fraction of patients eligible.*
Last month the Policy Institute at King’s brought together academics, policymakers, industry, clinicians and patient representatives to a ‘Policy Lab’, to debate the role of bariatric surgery for type 2 diabetes. Participants also discussed barriers to expanding its use.
The Policy Lab began by setting out the evidence base for bariatric surgery, the current guidelines for use and an explanation of a model for estimating the cost of increasing access to the surgery. We then put a handful of key questions before participants – did they think the case for expanded provision of bariatric surgery had been made? What did they see as the major obstacles to increasing the use of surgery? How might these obstacles be overcome?
Barriers to bariatric surgery
The starting point was one of broad agreement – most were convinced by the clinical case for increased bariatric surgery provision for patients with type 2 diabetes. The evidence that surgery delivers health benefits for certain groups was viewed as clear and compelling. The claim that surgery is also cost effective (in that the cost per quality-of-life year gained is low relative to other interventions) was also seen to be well-founded, although the need for longer term randomised controlled trials was raised by some.
Where debate emerged was on discussion about the barriers to surgery and potential solutions to the issue. With the NHS budget already under intense pressure, few of our participants were optimistic about the possibility of obtaining the funding necessary to meet the substantial up-front costs of surgery. It was suggested that the business case for surgery had to be made more strongly, with improved clinical data, and that it could be worth considering alternative (private) funding sources if it was clear that the surgery could deliver future financial benefits in excess of the initial cost.
The second set of barriers revolved around a lack of understanding regarding both the severity of type 2 diabetes as a disease and the outcomes of bariatric procedures. Patients, clinicians, policymakers and the wider public were all seen as falling short here, with particular concern raised that surgery was still mainly viewed as a treatment for obesity, and that the favourable risk-benefit profile had not been widely disseminated. It was suggested by some that education had to start in medical school with far better communication of the evidence and clinical guidelines to initiate a shift in attitudes.
Finally, processes for getting eligible patients through pre-surgery preparation, treatment and follow-up were identified as problematic. It was argued that the uneven geographical coverage of specialist services prevented access to surgery for many, while others made the case for the formation of multidisciplinary teams to coordinate patient care.
One issue that surfaced and seemed to merit addressing was the relative lack of integration of bariatric surgery within the type 2 diabetes clinical care pathway. For example, the use of surgery as a treatment for type 2 diabetes features prominently in NICE’s obesity guidelines, but is not included in those issued for the management of type 2 diabetes. This is in spite of evidence that a significant proportion of type 2 diabetes cases occur in people who would be classed as overweight, but not obese, according to their BMI. As such, the option of surgery for type 2 diabetics who would never normally be considered on weight grounds may need to be part of the story.
Follow the evidence
The outcomes of this Policy Lab were presented by Professor Jennifer Rubin, Director of Analysis here at the Policy Institute, on the final day of the World Congress on Interventional Therapies for Type 2 Diabetes, and we were delighted to find delegates eager to engage with the issues raised. The appetite for evidence-based policymaking in health is strong and, while there is always more data to be gathered, we thinks it’s important that what is out there is pored over and challenged so that the evidence base can be improved and used to inform the policies that impact on the lives of thousands every day.
Rachel Hesketh is a Research Assistant at the Policy Institute
*According to the 2012-13 National Diabetes Audit, almost 24 per cent of patients with type 2 diabetes have a BMI over 35 (meaning they should be offered an expedited assessment for surgery under NICE guidelines) and a further 29 per cent have a BMI between 30 and 35 (and therefore can be considered for surgery). This is of an approximate population of type 2 diabetics of 2.97m in the UK (90 per cent of 3.3m). Therefore the eligible population could be up to nearly 1.6m.
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