Background

Metabolic surgery (MBS) is underutilized (1%) despite evidence of safety and efficacy. MBS is most often pursued when recommended by primary care providers (PCP). No qualitative studies exist examining determinants of treatment decision-making and MBS accessibility from the PCP perspective.

Methods

PCPs from an academic health system participated in semi-structured interviews regarding experiences referring for MBS. Interviews analyzed using the Theoretical Domains Framework - groups behavioral theories of treatment implementation into assessable domains (e.g., knowledge, emotion, beliefs about capabilities, etc.). We utilized consensus-coding to analyze interviews and identify emergent themes.

Results

Twenty-four interviews were conducted. Sixteen participants (67%) were high referrers (>5 referrals/year) for MBS and eight (33%) were low referrers (<1 referral/year). The following themes were identified - Most PCPs agree obesity is a disease though perceptions of its etiology and PCPs' role in obesity care vary.

- High referrers frequently described confidence and feelings of professional responsibility in treating patients with obesity. - PCPs recognized the benefits of MBS; however, several reported skepticism among patients regarding the safety and benefits of MBS.
- Relationship-building and trust in MBS providers cited as a major determinant of treatment decision-making for both PCPs and patients. - 95% cited pre-authorization requirements as greatest external barrier to successful MBS referral.

Conclusions

Numerous barriers to MBS referral exist. Patient education about the safety and efficacy of MBS is needed. Surgeons must establish trust with PCPs and patients to assuage apprehensions about MBS. Surgeons and PCPs should continue to advocate for insurance coverage and evidence-based pre-authorization requirements for MBS.