Public-private differences in bariatric surgery care pathways in Australia: Implications for continuity of care.

BACKGROUND: Australian public-private bariatric surgery comparisons have largely focused on access, safety and clinical outcomes, with less evidence describing provider-specific engagement across the perioperative pathway. OBJECTIVES: To compare pre-operative engagement, provider-specific follow-up, attrition and weight outcomes between public and private bariatric surgery pathways in Australia. METHODS: This prospective multi-site observational study included adults undergoing bariatric surgery across two public and two private services in New South Wales (2021-2024). Appointment attendance across the perioperative period (12 months pre- to 24 months post-surgery) was analysed. Engagement, attrition and weight outcomes were compared using non-parametric tests, regression analyses and Kaplan-Meier and Cox proportional hazards models. RESULTS: Of 240 participants, 176 (73.3%) underwent private and 64 (26.7%) public surgery. Public patients had higher baseline weight, BMI, multimorbidity and greater socioeconomic disadvantage (all p < 0.001). They engaged longer pre-operatively (21.6 vs 2.7 months) and attended more MDT appointments (14 vs 2; both p < 0.001), with greater exposure to non-surgical doctors, dietitians, nurses, psychologists, and exercise professionals. Post-operatively, public patients attended a median of 12 (IQR 9-18) appointments compared to 7 (IQR 5-10) in the private services (p < 0.001) and remained engaged longer (18.2 vs 14.5 months). Attrition occurred later in public patients but was similar by 24 months. No statistically significant differences in relative weight loss were detected beyond 6 months. Surgical setting (B =4.344, p < 0.001) and anticipated support need (B =2.194, p = 0.035) were independently associated with post-operative attendance. CONCLUSION: Follow-up engagement appeared to be associated with surgical setting and anticipated support need, while observed weight loss outcomes were broadly similar between sectors. However, baseline differences and observational design preclude conclusions about the comparative effectiveness of the care pathways.