Duodenal Switch in Ontario

The regulations for Duodenal Switch in Ontario have changed. It is very unfortunate Ontario has taken this route when Canada has one of the best Duodenal Switch surgical teams in the world just a few hours from Ottawa, in Laval, Quebec. DS is no longer OHIP covered for patients with a BMI less then 60 and all referrals for Out of Country DS surgery must go through one of the provinces new Bariatric Assessment Centres. The other option for Ontario residents not meeting OHIPs criteria is to self-pay. Details on this decision and the new procedure for approvals are outlined below.

• Laparoscopic Roux-en-y gastric bypass is the gold standard
  
• Due to higher rates of morbidity and mortality, duodenal switch should only be considered for super-obese patients (BMI >60)
  
• Only patients assessed and prepared by an Ontario Centre of Excellence (CoE) should be considered for this surgery. This procedure requires appropriate long-term follow up through an Ontario C0E to ensure appropriate nutritional support and therefore, should be avoided if long-term follow up may be difficult
  
• This procedure is currently not performed in Ontario, therefore, it is determined by an Ontario CoE that a patient requires this procedure, approval for out-of-country (OOC) or out-of-province surgery should be considered
  
• This procedure should be performed only in a high-volume facility and for the purposes of OOC only in a facility with CoE accreditation.

Out of Country Prior Approval Program

The Out-of-Country Prior Approval Program provides full funding for insured OOC health services when regulatory requirements are satisfied. Two of these requirements are:

Bariatric Surgery Criteria

Amendments to the Schedule, approved on November 4, 2009 and effective October 1, 2009 include the following section on bariatric surgery: S120 (gastric bypass or partition) and S189 (intestinal bypass) are insured services only when all of the following four criteria are satisfied:

1. Presence of morbid obesity that has persisted for at least the preceding 2 years, defined as:

a. Body Mass Index (BMI) exceeding 40;

or

b. BMI greater than 35 in conjunction with any of the following severe co-morbidities:

i. Coronary heart disease;
ii. Diabetes mellitus
iii. Clinically significant obstructive sleep apnea (i.e. patient meets the criteria for treatment of obstructive sleep apnea);

or

iv. Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management);

2. The patient's bone growth is completed (18 years of age or documentation of completion of bone growth);

3. The patient has attempted weight loss in the past without successful long-term weight reduction;

and

4. The patient must either:

a. be recommended for surgery by a multidisciplinary team at a Regional Assessment and Treatment Centre Ontario;

or

b. participate in a multidisciplinary regimen of at least three months duration where the patient's participation meets all of the following requirements:

i. Consultation with a dietician or nutritionist;
ii. Reduced-calorie diet program supervised by dietician or nutritionist;

and

iii. The patient's permanent medical record must contain documentation of the patient's participation in the multidisciplinary surgical preparatory regimen at each visit.

Regional Assessment and Treatment Centres

The Regional Assessment and Treatment Centres (RATCs) mentioned in the Schedule are an integral component of the ministry's three-year $75 million initiative to increase the number of bariatric surgeries performed in Ontario. Five RATCs are currently operational with others scheduled to open soon. RATCs are staffed by multi-disciplinary bariatric health care teams consisting of physicians, nurses, dieticians, social workers, kinesiologists and mental health workers.

Patients who are determined to be suitable candidates for bariatric surgery will be referred by physicians working in the RATCs to one of 4 Ontario Bariatric Centres of Excellence (comprising 9 surgical centres). Physicians working in RATCs may also submit applications for funding of OOC bariatric surgery to the OOC Program for adjudication according to the regulations. With an increase in the number of bariatric surgeries performed in Ontario from 429 in 2008/09 to a projected 1,118 in 2009/10, wait times for this service in Ontario have been significantly reduced and it is anticipated that it will be necessary for relatively few patients to travel OOC to obtain bariatric surgery.

List of Bariatric Assessment Centres

Physicians considering application for prior approval for bariatric surgery out of country or out of province on behalf of their patients are encouraged to contact one of Ontario's bariatric centres at the contact points provided below prior to applying.

Ontario Providers of Bariatric Services

St. Joseph's HealthCare Hamilton
phone number: 905-522-1155 Ext 33240
fax number: 905-521-6152
website : www.stjoes.ca

Humber River Regional Hospital
phone number: 416-747-3720
fax number: 416-747-3731

Guelph General Hospital
phone number: 519-837-6440 ext. 2700
fax number: 519-837-6773

The Ottawa Hospital
The Weight Management Clinic
phone number: 613- 761-5101
fax number: 613- 761-5343
website: www.weightclinic.ca

Toronto Western Hospital (UHN)
phone number: 416-603-5800 ext. 6145
fax number: 416-603-5142
website: www.uhn.ca

Windsor Regional Hospital Regional Bariatric Assessment and Treatment Centre
phone number: 519-971-9206
fax number: 519-971-9566
website: www.wrh.on.ca

Sick Kids (SickKids Team Obesity Management Program)
For patients 12 - 17 yrs old
phone number: 416-813-7654 ext.28366
fax number: 416-813-8770
website: www.sickkids.ca

UPDATE MAY 14, 2009

This is a letter that was faxed to a pre-op Duodenal Switch patient's doctor in Ontario regarding suspension of approvals for DS:

On April 8, 2009 the ministry issued a letter approving duodenal switch surgery for the above-named patient. While this approval remains valid, please note the following:

On May 14th, 2009 the newly formed Ontario Bariatric Network Advisory Board responded to a request from the Ministry regarding the clinical indications for the duodenal switch procedure. The recommendation is as follows:

The Advisory Board of the Ontario Bariatric Network does not recommend duodenal switch for approval in Ontario. A special working group is being created to review the literature on this and other surgical variants to make recommendations on indications. Pending completion of this review, the Board recommends freezing approvals OOC (out-of-country) for duodenal switch due to high complication rate and difficulty of repatriation, high morbidity/mortality and long term requirements for intense follow up.

As the Advisory Board is comprised of clinical and administrative representatives from all Ontario bariatric centres and regional bariatric assessment and treatment centres, the duodenal switch procedure currently does not satisfy the regulatory requirement of "generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person". (Regulation 552, Section 28.4 (2) (a) under the Health Insurance Act). As a consequence and at least until the ministry has received a report from the special working group mentioned in the recommendation, the ministry has suspended the approval of applications for funding of OOC bariatric surgery where the duodenal switch procedure has been specified.

As indicated above, while the ministry has suspended the approval of applications for funding of duodenal switch surgery, the approval of funding for the above-named patient preceded the suspension and therefore remains valid. Nevertheless, the ministry strongly advises physicians to consider delaying duodenal switch surgery for their patients at least until the special working group has issued its report on bariatric surgical variants and their appropriate indications. Alternatively, physicians are advised to call the ministry to request an alternative procedure, upon such a request, a replacement approval letter will be issued on an expedited basis.

At this time, it is not known when the special working group will issue its report, however, the recommendations of the report will be posted to the OOC Prior Approval Program website when they become available. The link to the site is:

http://www.health.gov.on.ca/english/public/program/ohip/outofcountry/prior_approval.html

Information may also be obtained by calling the program at 1-888-359-8807.

OHIP Out of Country (OOC) Application Form
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/AttachDocsPublish/014-1442-84~4/$File/1442-84_.pdf

Don't Have a Doctor to Sign?
If you are trying to find a family doctor you can make use of The College of Physicians and Surgeons of Ontario web site. You can search for doctors taking new patients in your city. Check the site often as the information is updated regularly.

In the Mean Time
There are things you can do while you are waiting to hear from OHIP to speed up the process for booking surgery. Find out about pre-op testing from your surgeon's office. If you think you may have to have a sleep test done start that process right away; they can take a while to book and there is a long processing time for results. Remember to ask to be put on the cancellation list.

OHIP OOC contact info
Phone: (888) 359-8807
Fax: (613) 536-3181
Email: oocpriorapprovalinq@moh.gov.on.ca