Primary Care Physician Approaches to Severe Obesity Treatment and Bariatric Surgery: A Qualitative Study

Background: Bariatric surgery is the most cost-effective treatment for severe obesity, yet less than 1% of U.S. adults undergo bariatric surgery annually. Reasons for low utilization are unclear although previous investigators have found that the most powerful predictor of whether a patient would consider bariatric surgery was if the primary care physician (PCP) recommended it. To better understand how PCPs prioritize the care they provide to their severely obese patients – who often have multiple comorbidities we conducted focus groups with PCPs in Wisconsin. Specifically, we investigated how PCPs approach bariatric surgery as a treatment option and explored the challenges they encounter while providing care. Methods: We conducted three 90-minute focus groups with PCPs in a rural setting (Mauston), mid-sized city (Madison), and large city (Milwaukee) in Wisconsin. PCPs were eligible to participate if they managed adult patients (450% of their practice) and had seen at least five severely obese patients (BMI 435 or higher) in their clinic over the past 6 months. During the focus groups, participants were given a clinical vignette of a severely obese patient with multiple comorbidities and were asked a variety of questions about how they would prioritize treatment. All questions were guided by a focus group script, and the moderator used open-ended follow-up questions to pursue emerging themes. Participants completed a demographic questionnaire prior to completion of the focus group. Sessions were audio-recorded and transcribed. Data were analyzed using a directed approach to content analysis, in which emergent themes were identified and finalized through a process of consensus among three coders. Results: Participants in the three focus groups (n1⁄416) had a mean age of 46 (SD 11), 50% were female, and 94% were white. We identified four general approaches that PCPs use when prioritizing treatment for severely obese patients with multiple comorbidities: 1) Treat the disease that is the “easiest” to address, which is often hypertension or diabetes; 2) Treat the disease that is perceived as the most dangerous; 3) Let the patient set the agenda; 4) Address obesity first because it is the “common denominator” underlying many of the comorbid conditions. Challenges to implementing the plan included patient characteristics (low socioeconomic status, prior weight loss failures, being in denial about their obesity), provider factors (feeling ineffective in their ability to help patients lose weight), and systemic factors, particularly uncertainty regarding insurance coverage for obesity-related services. PCPs rarely – if ever – brought up the idea of bariatric surgery with their patients. This hesitancy stemmed from five main concerns: 1) Wanting to “do no harm”; 2) Questioning the long-term effectiveness of bariatric surgery; 3) Having limited knowledge about bariatric surgery; 4) Not wanting to recommend bariatric surgery “too early”; 5) Not knowing if the patient’s insurance would cover it. Once the PCP and patient agreed to pursue bariatric surgery, challenges to executing the plan during the pre-operative, operative and post-operative phases included meeting the preoperative requirements, living far from a bariatric surgery program, and the need for PCPs to be involved in post-operative care. Conclusions: PCP approaches to prioritizing care are pragmatic and mostly derived from previous experiences with patients. Three of the four prioritization approaches typically place the treatment emphasis on health conditions other than obesity. The five main concerns that PCPs have about bariatric surgery referral can be effectively addressed by provider and patient education, research, policy change, and publicity to highlight the literature regarding safety and effectiveness of bariatric surgery. Given that obesity often underlies many patient comorbidities, future research should focus on providing effective weight management options for PCPs in clinic and health system re-design that supports comprehensive weight management treatment. *This research was conducted as part of a 2014 ASMBS Research Grant award to Dr. Funk