Equity in Bariatric Surgery: Access and Outcomes

| March 1, 2018

Column Editor: Daniel B. Jones, MD, MS, FASMBS

Professor of Surgery, Harvard Medical School Vice Chair, Beth Israel Deaconess Medical Center,  Boston, Massachusetts

Featured Student: Bryn E. Falahee, MPhil 

Medical Student, Harvard Medical School, Boston, Massachusetts

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Abstract: Obesity and the associated health risks disproportionately affect those with low socioeconomic status. However, the sociodemographic characteristics of Americans with morbid obesity do not match the bariatric surgery recipient population in he US. It is imperative that patients of all sociodemographic groups have access to equitable bariatric care. The literature has repeatedly shown that patients who receive bariatric surgery are more likely to be white, female, and have private insurance. Yet, those eligible for bariatric surgery in the US have lower family incomes, lower education levels, less access to healthcare, and are more likely to be racial minorities. More than one-third of bariatric eligible patients are either uninsured or underinsured, and 15 percent have incomes less than the poverty level. In public systems, where all patients have government-funded insurance, patients receiving surgery are still predominantly of higher socioeconomic status. Therefore, if surgical procedure rates are to represent the affected population, additional measures must be put in place to ensure surgical treatment for those who would like the procedure but might not have geographical, financial, or educational access to bariatric surgery resources. Since identifying the social determinants impacting bariatric surgery, the community has made progress in expanding access. The proportion of non-white individuals and those in the lowest income quartile undergoing bariatric surgery has increased. Yet, the populations disproportionately affected by obesity are still under-represented. Focused public health efforts are needed to equalize and expand access to bariatric care. Initial efforts may include addressing clinicians’ implicit biases, reconsidering accepted insurance policies, increasing the diversity of office staff and practitioners, providing social supports to patients, and partnering with primary care providers in community health clinics.

Keywords: Sociodemographic, access, equity, outcomes, health disparities, Medicaid, Medicare, international systems, demographics, race, income, insurance, bariatric surgery

Bariatric Times. 2018;15(3):8–11.

Introduction

Morbid obesity is one of the foremost public health crises in the United States. Obesity and the associated health risks disproportionately affect those with low socioeconomic status, racial minorities, and other traditionally marginalized groups. Bariatric surgery is the only treatment currently offered that results in sustained weight loss, as well as a reduction in related health risks, including diabetes, hypertension, and hyperlipidemia.1 However, the sociodemographic characteristics of Americans with morbid obesity do not match the bariatric surgery demographics in the US.1 It is imperative that patients of all sociodemographic groups have access to equitable bariatric care, with outcomes that match their well-off, white peers. This article assesses how the current landscape of bariatric care deals with the inequity of obesity in the population, who gets access to care, patient perceptions of bariatric surgery access, and outcomes.

A Long-Standing Problem

Population-based studies have continually shown disparities in bariatric surgery procedures. A systematic review and meta-analysis published in 2015 searched various databases for retrospective cohort studies that compared at least one sociodemographic characteristic of patients who were eligible for bariatric surgery to those who actually received surgery. The literature review revealed that patients who received bariatric surgery were more likely to be white, female, and have private insurance.2 However, this is not a recently noticed trend in the bariatric community; studies dating back more than 10 years began to ask why the demographics for bariatric surgery do not represent the population with obesity.

The research initially turned to patient selection. A study published in 2007 aimed to identify predictors of patient selection in bariatric surgery by conducting a national survey of 1,343 bariatric surgeons focused on patient age, race, sex, body mass index (BMI), comorbidities, social support, functional status, and insurance. The researchers found that younger age, older age, limited functional status, lacking social support, self-pay, and public insurance decreased the likelihood that the surgeon would operate. However, race did not influence a surgeon’s decision to operate. Therefore, the researchers concluded that further studies were needed to look at sociocultural perceptions of morbid obesity and corresponding racial disparities.3

This study highlights the importance of not only equitable care once the patient gets to the office, through unbiased selection by the surgeon, but also the necessity of finding ways to reach populations who do not make it to the office for assessment in the first place. It is not enough to treat only those who walk through the door if bariatric care strives to be equitable. It is also imperative to reach out to the populations of individuals who would benefit from bariatric care but do not come looking for it due to lack of knowledge, lack of access due to location, inaccessibility of resources, perceived cost, and the “corresponding racial disparities” alluded to in the article.

Socioeconomic Factors

Breaking the issue of access into smaller pieces, multiple studies have looked at the socioeconomic factors that make patients more likely to be candidates for bariatric surgery, but less likely to obtain bariatric surgery.

First, it is important to examine the socioeconomic factors that make people more likely to have obesity in the US. A study published in 2010 found that a total of 22 million people were identified as eligible for bariatric surgery in the US, using the National Institute of Health (NIH) criteria. The group eligible for bariatric surgery had significantly lower family income, lower education levels, less access to healthcare, and a greater proportion of racial minorities, compared to the general population. The bariatric eligible group also had significant adverse economic and health-related markers, including greater days of work lost. More than one-third of bariatric eligible patients were either uninsured or underinsured, and 15 percent had incomes less than the poverty level.4 This study, and many others, have repeatedly proven that economic factors are indisputably related to who becomes obese in the US.

The 2010 study also showed, in direct contradiction to the economic characteristics of the bariatric eligible population, that most bariatric procedures were performed in patients who had private insurance, were white, and had greater median incomes. Significant disparities associated with a decreased likelihood of undergoing bariatric surgery included race, income, insurance type, and sex.4 Therefore, while obesity is predicted by low income, lack of insurance, and adverse economic markers, including days of work lost, a patient is more likely to get a bariatric procedure if they have a greater income, private insurance, and are white.

Looking specifically at private versus public insurance, a recently published study found that, as a group, Medicare and Medicaid patients experience higher rates of obesity and related complications and are most in need of bariatric surgery. But, in more than 100,000 cases of bariatric surgery examined, the majority of patients had private insurance; Medicare and Medicaid patients accounted for a low percentage of cases (less than 15% total).5 The researchers also found that the Medicare and Medicaid patients had an increased risk of complications compared to privately insured patients.5 Again, need does not correspond with economic access.

Bariatric Care Outside the United States

Of interest, a study in Canada, where all patients have public insurance, examined who is surgery-eligible versus who actually receives bariatric surgery. The conclusions were surprisingly similar to the results in the US. The study found that patients receiving surgery were predominantly of higher socioeconomic status (SES), which was difficult to explain given Canada’s universal healthcare system.6 Instead, perhaps this points to the reality that individuals with higher SES status are more easily able to take time off from work to get surgery or more able to afford the additional child care and other expenses that come from taking time to recover from surgery. In addition, the necessary post-surgical diet changes require access to healthy food, including readily available fruits and vegetables. Fresh food is not always as accessible in poorer communities, where food deserts can be pervasive, and healthy foods can be expensive.

In addition, the Canadian study showed that women were four times more likely to undergo surgery compared to men. This pattern was not completely explained by the two-fold higher prevalence of obesity in women. However, as the researchers accurately pointed out, “Women may be more likely to seek surgery for body image reasons, and it is also possible that sex-related differences in the perceived mental and physical health impact of severe obesity may explain the higher tendency for women to seek surgery.”6

The study also found that obesity-related comorbidities were less common in bariatric surgery recipients compared to those eligible for surgery. The researchers concluded that this might be due to candidate selection bias, where surgeons or programs select patients who are healthier to undergo surgery. The inverse relationship between greater comorbidities and selection for surgery has also been found in other publically funded systems.6

Therefore, removing insurance coverage from the equation does not necessarily change who receives bariatric surgery. It is not enough to have a publicly funded system where all patients have theoretical access. As the Canadian article suggests, the rates of desirability for bariatric surgery might be higher at baseline in well-off women, but even given this assumption, more should be done to address the entire population at risk. If surgical procedure rates are to truly represent the affected population, additional measures must be put in place to ensure surgical treatment for those who would like the procedure but might not have geographical or educational access to bariatric surgery resources.

Another Canadian study examined the perceptions of patients waiting for bariatric surgery. This study found that patients’ experience of access to and wait times for bariatric surgery in Canada were highly influenced by “perceived and experienced socioeconomic, regional, and waitlist prioritization inequities.”7

In 27 in-depth interviews conducted during the study, inequity was identified as a barrier to accessing bariatric surgery, even in the publicly funded system. Participants in the Canadian study identified several factors that would contribute to a better patient experience during the wait time and decrease the perceived inequity. These factors included periodic updates from the surgeon’s office regarding their position on the wait list, access to a specialized weight-loss counselor to guide them through the waiting period and the surgery, dietician support, and further information on what to expect after surgery.7

Even without universal healthcare access, practitioners in the US can begin to implement these changes in their own clinics to improve the patient experience and create an environment that decreases perceived inequity by offering supportive care to each patient. Of course, this strategy does not alter who comes to the clinic in the first place to receive care. But, it might result in higher retention rates of individuals who initially come to the clinic, but would not feel they had adequate social supports to undergo the surgery if the additional resources were not in place.

Trends in Access

Trends in bariatric access are also important. Since identifying the social determinants impacting bariatric surgery, the community has made progress in expanding access. A study that examined trends in sociodemographic surgery utilization between 1998 and 2007 showed that the proportion of non-white individuals undergoing bariatric surgery significantly increased from 1998 to 2007.8 In addition, the proportion of individuals in the lowest income quartile increased, while those in the highest income percentile decreased.8 The researchers concluded that bariatric surgery has become more accessible in recent years, although the populations disproportionately affected by obesity are still under-represented.

Another study examined trends in populations admitted for laparoscopic gastric bypass surgery (LGBS) from 2002 to 2008. This study showed that the difference in the use of LGBS between African-American and caucasian patients declined from 2002 to 2008. However, LGBS use still remained significantly lower for African-American and Hispanic patients with obesity.9

Therefore, the bariatric community has made some progress. Moving forward, it is important to put existing facts and studies into practice to improve access to bariatric care. Clinics must employ creative approaches to recruit and retain patients from the sociodemographic populations disproportionately affected by obesity.

Suggestions for Moving Forward

Focused public health efforts are needed to equalize and expand access to bariatric care. The health disparities apparent in bariatric care cannot be erased overnight, and possibly not in the next few decades. The roots of the systemic racial and socioeconomic injustice present in the US at large continue to influence bariatric care. While the struggle with inequity in our social system continues, physicians can begin to do their part in the short term to recognize causes of inequity in their own practice and work to eradicate them.

Clinicians can identify and address their own implicit biases toward underrepresented sociodemographic patient populations. Individual practices can work to equalize access to bariatric care for sociodemographic minorities by reconsidering insurance options they accept. In addition, steps can be taken to broaden who feels welcome in the clinical space by making professional interpreters available, increasing the diversity of office staff and practitioners, and providing adequate social support networks by coordinating care with nutrition counselors or establishing support groups. Going one step further, the bariatric surgery community could increase access by publishing fliers to hang in communities that would not otherwise be aware of bariatric care, partnering with primary care providers in community health clinics to recruit patients, and working with patients to optimize their access to bariatric care through other channels, including partnerships with hospital social workers. Making small changes on a daily basis will bring the bariatric community one step closer to offering equitable care in this incredibly important area of health.

References

  1. Jackson TD, Zhang R, Glockler D, et al. Health inequity in access to bariatric surgery: a protocol for a systematic review. Syst Rev. 2014;3:15.
  2. Bhogal SK, Reddigan JI, Rotstein OD, et al. Inequity to the utilization of bariatric surgery: a systematic review and meta-analysis. Obes Surg. 2015;25(5):888–99.
  3. Santry HP, Lauderdale DS, Cagney KA, et al. Predictors of patient selection in bariatric surgery. Ann Surg. 2007;245(1):59–67.
  4. Martin M, Beekley A, Kjorstad R, Sebesta J. Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. Surg Obes Relat Dis. 2010;6(1):8–15.
  5. Hennings DL, Baimas-George M, Al-Quarayshi Z, et al. The inequity of bariatric surgery: publicly insured patients undergo lower rates of bariatric surgery with worse outcomes. Obes Surg. 2018;28(1)44–51.
  6. Padwal RS, Chang HJ, Klarenbach S. Characteristics of the population eligible for and receiving publicly funded bariatric surgery in Canada. Int J Equity Health. 2012;11:54.
  7. Gregory DM, Temple Newhook J, Twells LK. Patients’ perceptions of waiting for bariatric surgery: a qualitative study. Int J Equity Health. 2013;12:86.
  8. Pickett-Blakely OE, Huizinga MM, Clark JM. Sociodemographic trends in bariatric surgery utilization in the USA. Obes Surg. 2012;22(5):838–42.
  9. Worni M, Guller U, Maciejewski ML, et al. Racial differences among patients undergoing laparoscopic gastric bypass surgery: a population-based trend analysis from 2002 to 2008. Obes Surg. 2013;23(2):226–33.

 

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Category: Past Articles, The Medical Student Notebook

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