Providers’ Knowledge and Perceptions of Bariatric Surgery: a Systematic Review

Bariatric surgery remains underutilized despite its proven efficacy in the management of obesity. Provider perceptions of bariatric surgery are important to consider when discussing utilization rates. PubMed, SCOPUS, and OVID databases were searched in April 2023, and 40 published studies discussing providers’ knowledge and perceptions of bariatric surgery were included. There were generally positive perceptions of the efficacy of bariatric surgery, although overestimations of surgical risks and postoperative complications were common. Providers’ previous training was associated with knowledge and perceptions of bariatric surgery and familiarity with perioperative management across studies. These perceptions were also associated with referral rates, suggesting that inadequate provider knowledge may contribute to bariatric surgery underutilization. We advocate for increased bariatric surgery-related education throughout all stages of medical training and across specialties.


Introduction
Obesity is a public health crisis and a notable risk factor for numerous diseases, including cardiovascular disease, diabetes, osteoarthritis, Alzheimer's, depression, and malignancies [1].The global prevalence of obesity has nearly tripled in the past 40 years, with over 1 billion people now meeting criteria for obesity [2].Within the United States (US), the prevalence among adults increased from 36 to 41.9% from 2011-2014 to 2017-2020, respectively [3,4].Bariatric surgery has been shown to result in sustained long-term weight loss, lower morbidity and mortality, and significant improvements in obesity related comorbidities [5][6][7].
Despite the literature demonstrating its efficacy, fewer than 1% of eligible candidates worldwide undergo bariatric surgery [8].This underutilization is likely in part due to healthcare access, and other economic, psychosocial, and systemic factors.Studies have previously shown negative and unrealistic perceptions of bariatric surgery among patients and the general public that may lead to underutilization [9].Furthermore, previous literature has explored referral patterns for bariatric surgery and identified provider familiarity with bariatric surgery as a possible barrier [10].
Healthcare providers other than bariatric surgeons have an integral role in caring for patients affected by obesity regarding education, treatment options, and perioperative care.We conducted a comprehensive, up-to-date, systematic review of the literature investigating the perceptions and familiarity of healthcare providers with the role of bariatric surgery in the treatment of obesity.We highlight provider knowledge of bariatric surgery, reported confidence in providing perioperative care as well as perceptions regarding its safety and efficacy.

Key Points
• Provider bariatric surgery knowledge and perceptions may impact utilization rates.
• Provider perceptions and established safety of bariatric surgery are discordant.
• Previous training is associated with greater comfort providing perioperative care.
• Perceptions and knowledge of bariatric surgery are associated with referral rates.

Methods
Per the PICO framework, among healthcare providers, we sought to (1) describe knowledge and perceptions of bariatric surgery, (2) investigate which factors are associated with knowledge and perceptions, and (3) investigate the impact of these perceptions on the extent and quality of care provided.Guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used in developing this systematic review.PubMed, SCOPUS, and OVID were searched in April 2023 with the terms "bariatric surgery perceptions," "bariatric surgery physician perceptions," "bariatric surgery provider perceptions," "bariatric surgery impressions," "bariatric surgery physician impressions," "bariatric surgery provider impressions," "bariatric surgery attitudes," "bariatric surgery physician attitudes," "bariatric surgery provider attitudes," "bariatric surgery knowledge," "bariatric surgery physician knowledge," and "bariatric surgery provider knowledge."Handsearching of citations within included studies was also conducted.A total of 7987 articles were identified and 3800 duplicates were removed, leaving 4187 articles for preliminary screening of titles and abstracts.Inclusion criteria included studies that examined provider knowledge, attitudes, impressions, or perceptions of bariatric surgery.Providers were defined as primary care providers, specialists, and allied health professionals.Exclusion criteria included non-English articles, review articles, opinion articles, guidelines, and articles about perceptions of bariatric surgery in pediatric populations.After a comprehensive screening of titles and in-article citations by two independent reviewers (Fig. 1), an abstract review was conducted for 69 articles, a fulltext review was conducted for 54 studies by two reviewers, and 40 studies were included (Table 1).Outcomes were organized into several categories, including knowledge of eligibility and procedure options (Table 2), perceptions of safety and efficacy (Table 3), and factors associated with initiating discussions about bariatric surgery and providing perioperative care (Table 4).
The quality and risk of bias of each study were independently assessed by two reviewers using the Newcastle-Ottawa Scale (NOS) for cross sectional studies.Any discordance in assigned scores between reviewers was resolved by a third reviewer.Studies are graded based on several categories, with a maximum of five points awarded for selection, two points for comparability, and three points for outcomes, resulting in a total maximum score of ten points.We noted scores of < 5, 5-6, and 7-10 to be unsatisfactory, satisfactory/good, and very good quality, respectively.The NOS score for each study is listed in Table 1.

Eligibility
Twenty-five studies [12, 14, 16, 19, 20, 22, 23, 26, 28, 30, 32-35, 37-39, 41, 43, 45-50] assessed provider familiarity with eligibility for bariatric surgery (Table 2).Six studies specifically explored familiarity with the National Institute of Health (NIH) eligibility criteria [12,14,26,33,34,45], while the remaining studies investigated familiarity of criteria or indications without specifying NIH as the source, by posing mock cases to providers, or evaluating utilization of different criteria accepted in their respective regions.On average, fewer than 50% of providers reported reading or being familiar with NIH criteria.Notably, providers with prior training in bariatric or obesity medicine were found to have greater familiarity with eligibility guidelines [12,22,26], as were providers with a history of providing referrals for bariatric surgery [14].In the USA, among the few studies identifying strong familiarity with surgical indications, Tork et al. (2015) found that 85% of surveyed PCPs in a private teaching hospital in Cincinnati strongly agreed or agreed that a BMI > 35 kg/m 2 and comorbidities were an indication for a surgical referral [23].Among physicians outside the USA, on average, a majority indicated higher familiarity with the national eligibility criteria or established indications for bariatric surgery.For instance, Major et al. (2016) and Memarian et al. (2021) found that 81.8% of surveyed PCPs in Poland and 73% of PCPs in Sweden knew the indications for a bariatric procedure or agreed that they had good knowledge of referral criteria, respectively [37,50].Of note, among 204 PCPs in a bariatric surgery center at a university hospital in Germany, older PCPs were found to have significantly higher mean knowledge of national eligibility criteria than younger PCPs (p = 0.005) [38].

General Knowledge
Twenty-two studies [12, 14, 15, 19, 20, 22, 24-27, 29-31, 33, 36, 38, 42, 45-47, 49, 50] examined knowledge of bariatric procedures (Table 2).Nine studies specifically queried physicians regarding knowledge of differences between bariatric procedure options [12, 24-26, 29, 38, 45, 49, 50], with a majority self-reporting an average level of familiarity.A history of providing referrals or previously receiving obesity medicine-related training was associated with greater knowledge of bariatric procedures and familiarity with expected surgical outcomes.Among physicians across various specialties in Greece, below 15% of surveyed providers reported "a lot" of familiarity with each of six bariatric procedures posed to them [29].At the time of the study, Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy were the most common bariatric procedures performed globally, yet 56.0% and 40.3% of surveyed physicians within this study reported no familiarity with Roux-en-Y gastric bypass and laparoscopic sleeve, respectively [29].Egerer et al. (2021) found that 86.3% of surveyed PCPs in a university hospital bariatric center in Germany reported familiarity with bariatric surgery surgical options, with male PCPs self-reporting higher knowledge of bariatric procedures compared to female PCPs (p = 0.0036) [38].Among multiple cohorts of providers with limited reported knowledge of bariatric surgery, an interest in broadening knowledge was frequently reported [19,23,24,26,37,39,45,46,49,50].

Weight Loss and Comorbidity Resolution
Twenty-seven studies [11, 12, 16, 18, 21, 23-28, 30-35, 37, 39-42, 44-46, 49, 50] examined provider impressions of bariatric surgery's short-and long-term efficacy for weight loss and resolution of comorbidities (Table 3).A majority of studies reported positive perceptions among providers regarding the utility of bariatric surgery for sustained weight loss and improving comorbidities [12, 18, 21, 23-26, 30-35, 37, 39, 42, 45, 46, 50], of which a majority surveyed primarily PCPs.Memarian et al. (2021) found that surveyed PCPs in South Sweden strongly agreed or agreed that bariatric surgery could have a positive effect on T2DM (90%), hypertension (82%), and hyperlipidemia (65%) [37].Among PCPs in Turkey, 17.9% strongly agreed and 54.9% agreed that bariatric surgery lead to the longest and greatest amount of weight loss in eligible patients [39].On the other hand, a few studies noted negative perceptions, with less than half of providers from primarily multidisciplinary cohorts perceiving bariatric surgery as an efficacious option [35,40,44,49].Among healthcare providers from multiple specialties in Italy, only 37% stated they would recommend bariatric surgery to patients as an effective modality for long-term weight management [40].A qualitative study of providers from a Veteran Affairs Medical Center in the USA reported that bariatric surgery was not perceived as necessary until obesity or its comorbidities were deemed "life threatening" [44].

Safety
Nineteen studies [12, 14, 16, 17, 22, 23, 25, 28, 30-33, 35-37, 39, 41, 42, 49] examined provider perceptions of the safety of bariatric surgery (Table 3).Only two studies found over half of surveyed providers believed bariatric surgery was a safe treatment for obesity [22,30].Most of the literature reported prevalent concerns among providers from various specialties regarding physical and psychological complications.The most reported disadvantages of bariatric surgery were related to perceptions of surgical risks and postoperative complications rather than efficacy.Seven studies assessed physician knowledge of evidence-based morbidity and mortality rates of various bariatric procedures [22,24,26,31,36,46,49]; on average, fewer than half of surveyed providers were aware of established rates.A small number of studies assessed perceived risks of surgery versus living with obesity [14,23,33,36,37].Some studies found an overwhelming majority of physicians agreed the benefits of surgery outweighed the risks [14] and that the risks of obesity posed greater health risks [33], while others found conflicting results [23,36,37].Notably, in a sample of PCPs from a private teaching hospital in Cincinnati, 50% disagreed and 12% strongly disagreed that the benefits of bariatric surgery are worth the risks [23].

Initiating Discussions, Providing Referrals, and Postoperative Management
Twenty-six studies [12, 15, 16, 20-24, 26-30, 32, 34, 36, 37, 40-43, 45, 46, 48-50] examined the frequency of providers initiating conversations about bariatric surgery and factors associated with providing referrals (Table 4).Across all studies, there was significantly greater reported confidence, comfort, and frequency of initiating conversations about bariatric surgery among physicians with prior training in bariatric and/or obesity medicine or greater reported knowledge of bariatric care [12,22,26,27,43,46,49].There was also a well-documented relationship between a history of providing bariatric surgical referrals and greater comfort discussing bariatric surgery with patients and providing perioperative care [14,24,34].Fourteen studies [14, 16, 23-26, 31, 33, 37, 38, 41, 42, 46, 49] noted that positive predictors of greater comfort included prior bariatric and/or obesity medicine training, experience with bariatric surgery, and previously providing bariatric surgical referrals.Due to small samples and a relative lack of studies, there is limited quality of evidence regarding the impact of years of clinical experience on the likelihood of discussing bariatric surgery or providing postoperative care.
The frequency of initiating discussion also varied with physician demographics.One study among surveyed PCPs in Wisconsin found that male practitioners initiated discussions with patients about weight loss management, including bariatric surgery, 76.5% of the time, while female practitioners reported doing so 37.5% of the time (p = 0.01) [36].Zevin et al. (2021) noted a positive correlation between PCP age and likelihood of initiating discussions about bariatric surgery in Ontario (r = 0.363, p = 0.003) [41].Sbraccia et al. (2021) also found that a higher proportion of PCPs of a normal weight versus PCPs who have overweight or obesity were likely to review bariatric surgery options with patients, though there was no comparative analysis conducted (58% and 44%, respectively) [40].
Additionally, eight studies found that a lack of training, perceived lack of resources, or a fear of offending the patient were commonly cited barriers to referral [22,24,28,36,48] or obstacles to discussing bariatric surgery with eligible patients [20,22,24,32,43].Concerns regarding adverse outcomes of surgery were also one of the highest rated barriers to discussing bariatric surgery or providing referrals [28,32,33,[35][36][37]41]. Knowledge of bariatric surgery further appeared to contribute to referral rates; a cohort of physicians in Michigan cited unawareness of long-term postoperative outcomes as a reason not to offer bariatric surgery to eligible patients [32].There was also variation in reported barriers to referral between physicians with and without a background in bariatric training.Interestingly, a study conducted among 76 PCPs affiliated with Massachusetts General Hospital found that a fear of offending the patient and inadequate training were the most commonly cited barriers to managing bariatric surgery patients among providers with prior training, while those with no prior training most commonly cited inadequate reimbursement [22].

Discussion
Despite its established safety and efficacy, bariatric surgery remains underutilized for the treatment of obesity.While the etiology of this underutilization is likely multifactorial, the perceptions and familiarity of healthcare providers with bariatric surgery are important factors to consider.We conducted a systematic review of the literature to assess healthcare provider familiarity with bariatric surgery, comfort with initiating discussions and perioperative management, and overall perceptions regarding its safety and efficacy.Across specialties, there was a consensus that bariatric surgery is an efficacious treatment for obesity and its associated medical conditions.However, providers often overestimated the risk profile and reported low familiarity with postoperative complication rates.Notably, prior training in obesity or bariatric medicine, greater number of years of clinical experience, and a history of providing referrals were associated with greater knowledge and greater comfort with initiating discussions about bariatric surgery and providing perioperative care.Our results highlight concerning gaps in knowledge among healthcare providers regarding the safety of bariatric surgery, and the ensuing reluctance to recommend surgical treatment for patients with severe obesity.
The role of previous obesity or bariatric training in improving provider familiarity with bariatric surgery eligibility, management, and outcomes is well-documented [12,22,26,27,43,46,49].However, despite existing efforts to incorporate exposure to bariatric care into provider training, attitudes towards bariatric surgery continue to reflect concerns about surgical risks that are neither empiric nor reflective of advances towards safer, minimally invasive approaches.These concerns may be contributing to a decreased likelihood of discussing bariatric surgery with eligible patients and providing referrals for patients with severe obesity [10, 28, 32, 33, 35-37, 41, 48].The gravity of this trend cannot be understated, considering the rising burden of the obesity epidemic and the increasingly inadequate number of non-bariatric specialists who are equipped and willing to provide high-quality bariatric management [1,22].In an effort to enhance provider knowledge, bariatric education that addresses the most significant deficits in knowledge should be a required component of provider education.
We recommend an expansion of the educational infrastructure in bariatric surgery and obesity medicine, with an emphasis on surgical safety and initiating the referral process for eligible patients.Barriers to the surgical treatment of severe obesity are multifold, but provider reluctance to offer surgical options due to inadequate training should be remedied at the training level.Providing bariatric surgeryspecific education is essential for all specialties and levels of training, given multidisciplinary teams are at the core of managing the systemic effects of obesity [51,52].Therefore, bariatric training should begin prior to specialization as a part of the core medical curriculum.We expect high demand for these educational opportunities given many students and providers have reported an eagerness to learn more about bariatric surgery [19,23,24,26,37,39,45,46,49,50].With successful implementation, this training not only has the potential to mitigate many limitations inherent to restricting bariatric training to specialists [53] but also decrease barriers to care often experienced by patients struggling with obesity and metabolic disease.
Education and instruction on optimal strategies to approaching the conversation between providers and patients regarding bariatric surgery should also be provided in all training programs.Six studies showed provider perceptions of patients' beliefs or a fear of offending patients impacted their willingness to discuss bariatric surgery as an option [21,22,33,36,44,48].Negative perceptions among providers regarding bariatric patients may also lead them to question patient motivation and ability to achieve desired weight loss postoperatively [44,54].Some providers reported a decreased willingness to discuss or refer eligible patients for a bariatric procedure if the patients did not show interest or demonstrated significant fear of surgery [12,21,28,34,45].Two studies showed providers noted higher likelihood of referring the same patient if the patient initiated the discussion and expressed a strong desire to undergo the procedure [28,49].The preconceptions held by providers may foster distrust between the physician and patient and ultimately may impact physician counseling when discussing the possibility of a referral.This may also further exacerbate pre-existing inequities in bariatric surgery, such as racial disparities due to implicit bias and systemic racism [55,56].This impact of stigma on physician willingness to provide high-quality care is not new-its adverse effects have been seen in numerous other sectors, notably for patients with HIV and mental health disorders [57,58].However, as abundant research in these realms has pointed out, discomfort should not lessen standards of screening and care for these patients.Therefore, for the management of bariatric patients, guidance on best practices to establish rapport, conveys information comprehensibly, and respectfully encourage discourse on surgical options and outcomes may improve utilization rates and relieve the burden of this condition for affected patients.
Looking to the future, recent advances in technology may provide an avenue to bridge the gap in both provider and patient knowledge of bariatric surgery management and outcomes.Notably, there is a growing body of literature demonstrating the impressive ability of recent artificial intelligence platforms in answering clinically related questions [59,60], including an ability to accurately and reliably answer commonly asked questions related to bariatric surgery [61].While the literature examining the efficacy and safety of these tools in medicine is in its infancy, it has the potential to serve as an adjunct source of information for patients and providers and may facilitate physician-patient discussions regarding a bariatric surgery referral.

Limitations
The quality of studies may have been impacted low response rates, prevalent use of self-administered surveys, and a lack of comparative analysis.There were also several studies which surveyed both patients and providers, resulting in limited extractable data for our population of interest.The NOS, though a widely recognized tool for evaluating nonrandomized studies, has been critiqued for potential biases and poor inter-rater reliability, potentially contributing to misinterpretations of cross-sectional study quality [62].Additionally, despite the use of three comprehensive databases, relevant studies published in other databases may have been inadvertently omitted.Our literature search pathway, constrained by specific keywords, may also have omitted relevant studies utilizing alternate phrasing within titles or abstracts.These limitations create avenues for future research emphasizing the importance of refined assessment tools and more robust search strategies for a comprehensive understanding of this important topic.

Conclusion
Healthcare providers perceive bariatric surgery as an effective treatment for obesity and its comorbidities but often reported concerns regarding safety and reported low familiarity with postoperative complication rates.Gaps in education may be contributing to poor referral rates and ultimately the underutilization of bariatric surgery worldwide, all of which serve as significant barriers to best practices and standard care of the patient diagnosed with severe obesity.A history of training in bariatric or obesity medicine was associated with greater knowledge of bariatric surgery, confidence initiating discussions with patients, and providing perioperative care.Given the profound systemic effects of severe obesity on patients, combined with the rising prevalence of severe obesity, we advocate for more focused bariatric training beginning prior to specialization, with an emphasis on safety and knowledge required to provide surgical referrals.Further research investigating the effect of earlier bariatric training is required to further improve provider knowledge and increase utilization of bariatric surgery.
Funding Open access funding provided by SCELC, Statewide California Electronic Library Consortium

Fig. 1
Fig. 1 Summary of literature search including inclusion and exclusion criteria

Fig. 2
Fig. 2 Summary of regional distribution and areas of emphasis of included studies

Table 1
Summary of characteristics and design for studies included in this systematic review

Table 1
50].A total of 40% studies were conducted among physicians in the USA (Fig.2).According to the NOS, 20.0% were very good studies, 50.0%were satisfactory/ good, and 30.0%were unsatisfactory.A summary of study designs, sample sizes, NOS scores, and response rates is shown in Table