Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis

doi:10.1016/j.soard.2009.07.003

Surgery for Obesity and Related Diseases

Volume 6, Issue 1, January–February 2010, Pages 8-15

https://doi.org/10.1016/j.soard.2009.07.003 Get rights and content

Abstract

Background

To analyze the socioeconomics of the morbidly obese patient population and the impact on access to bariatric surgery using 2 nationally representative databases. Bariatric surgery is a life-changing and potentially life-saving intervention for morbid obesity. Access to bariatric surgical care among eligible patients might be adversely affected by a variety of socioeconomic factors.

Methods

The national bariatric eligible population was identified from the 2005–2006 National Health and Nutrition Examination Survey and compared with the adult noneligible population. The eligible cohort was then compared with patients who had undergone bariatric surgery in the 2006 Nationwide Inpatient Sample, and key socioeconomic disparities were identified and analyzed.

Results

A total of 22,151,116 people were identified as eligible for bariatric surgery using the National Institutes of Health criteria. Compared with the noneligible group, the bariatric eligible group had significantly lower family incomes, lower education levels, less access to healthcare, and a greater proportion of nonwhite race (all P <.001). Bariatric eligibility was associated with significant adverse economic and health-related markers, including days of work lost (5 versus 8 days, P <.001). More than one third (35%) of bariatric eligible patients were either uninsured or underinsured, and 15% had incomes less than the poverty level. A total of 87,749 in-patient bariatric surgical procedures were performed in 2006. Most were performed in white patients (75%) with greater median incomes (80%) and private insurance (82%). Significant disparities associated with a decreased likelihood of undergoing bariatric surgery were noted by race, income, insurance type, and gender.

Conclusion

Socioeconomic factors play a major role in determining who does and does not undergo bariatric surgery, despite medical eligibility. Significant disparities according to race, income, education level, and insurance type continue to exist and should prompt focused public health efforts aimed at equalizing and expanding access.

Section snippets

Methods

We performed an analysis of 2 nationally representative databases that contain health and health-care related information. The analysis consisted of 3 sequential phases as follows. Phase 1 of this study analyzed a nationally representative sample of morbidly obese persons to establish the baseline demographic and socioeconomic factors of the population of people who would be medically eligible for a bariatric surgical procedure. Phase 2 analyzed a second nationally representative database of

Results

Phase 1 analysis of the NHANES database identified a national weighted estimate of 22,151,116 persons eligible for bariatric surgery (BE) by the published National Institutes of Health criteria. This cohort represented 12.6% of the entire adult NHANES population. Class 2 obesity (BMI 35–39.9 kg/m²) was present in approximately 16.4 million persons, and approximately 11.3 million (69%) had ≥1 weight-related co-morbidity. Class 3 obesity (BMI ≥40 kg/m²) was identified in approximately 10.8

Discussion

We are now at a crossroads of 2 intersecting public health crises, with catastrophic potential: the widening obesity epidemic and the system-wide inequalities in access to affordable, high-quality healthcare. As physicians, we must be on the front line of efforts aimed at prevention, treatment, education, and policy formation. As surgeons, in possession of the most proven and effective therapeutic options for morbid obesity, we are particularly obligated and well-suited to educate and guide

Conclusion

The results of the present study, although not unexpected, have yielded several important and concerning findings, with wide-ranging implications. Racial and socioeconomic factors continue to exert significant influence on who does and does not undergo bariatric surgery. The resultant disparities affect millions of people with morbid obesity and obesity-related medical disease. The costs associated with our failure to adequately address this issue will be staggering in terms of excess

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

References (41)

J.R. Pender et al.
Epidemiology of obesity in the United States
Gastroenterol Clin North Am
(2005)
M.T. Halpern et al.
Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis
Lancet Oncol
(2008)
E.H. Livingston et al.
Socioeconomic characteristics of the population eligible for obesity surgery
Surgery
(2004)
A. Drewnowski et al.
Poverty and obesity: the role of energy density and energy costs
Am J Clin Nutr
(2004)
R. Sturm et al.
Does obesity contribute as much to morbidity as poverty or smoking?
Pub Health
(2001)
C.L. Ogden
Disparities in obesity prevalence in the United States: black women at risk
Am J Clin Nutr
(2009)
R.M. Dallal et al.
Comparative analysis of short-term outcomes after bariatric surgery between two disparate populations
Surg Obes Relat Dis
(2008)
H.J. Sugerman et al.
Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment
Am J Surg
(1989)
L.F. Martin et al.
Preoperative insurance status influences postoperative complication rates for gastric bypass
Am J Surg
(1991)
L.F. Martin et al.
Comparison of the costs associated with medical and surgical treatment of obesity
Surgery
(1995)

H. Buchwald

Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers

J Am Coll Surg

(2005)

N.E. Hutcher

Unrestricted insurance access to bariatric surgery: no more excuses

Surg Obes Relat Dis

(2009)

C.E. Menifield et al.

Obesity in America

ABNF J

(2008)

P.W. Sullivan et al.

The effect of obesity and cardiometabolic risk factors on expenditures and productivity in the United States

Obesity (Silver Spring)

(2008)

D.A. Long et al.

The cost of lifestyle health risks: obesity

J Occup Environ Med

(2006)

F. Wang et al.

Association of healthcare costs with per unit body mass index increase

J Occup Environ Med

(2006)

NIH conference: gastrointestinal surgery for severe obesity

Ann Intern Med

(1991)

Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke—United States, 2003

MMWR Morb Mortal Wkly Rep

(2005)

D.M. Bravata et al.

Racial disparities in stroke risk factors: the impact of socioeconomic status

Stroke

(2005)

H.F. McGruder et al.

Racial and ethnic disparities in cardiovascular risk factors among stroke survivors: United States 1999 to 2001

Stroke

(2004)

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: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or U.S. Government.

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Original articleSocioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Disclosures

Gastroenterol Clin North Am

Lancet Oncol

Surgery

Am J Clin Nutr

Pub Health

Am J Clin Nutr

Surg Obes Relat Dis

Am J Surg

Am J Surg

Surgery

J Am Coll Surg

Surg Obes Relat Dis

Obesity in America

ABNF J

The effect of obesity and cardiometabolic risk factors on expenditures and productivity in the United States

Obesity (Silver Spring)

The cost of lifestyle health risks: obesity

J Occup Environ Med

Association of healthcare costs with per unit body mass index increase

J Occup Environ Med

NIH conference: gastrointestinal surgery for severe obesity

Ann Intern Med

Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke—United States, 2003

MMWR Morb Mortal Wkly Rep

Racial disparities in stroke risk factors: the impact of socioeconomic status

Stroke

Racial and ethnic disparities in cardiovascular risk factors among stroke survivors: United States 1999 to 2001

Stroke

Original article
Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis