Socioeconomic Factors Affect Access to Bariatric Surgery

Investigators identified more than 22 million people younger than 65 years who, according to National Institutes of Health criteria, were eligible for bariatric surgery.  Race, income, sex and insurance status all influence the likelihood of a patient receiving bariatric surgery. The result is many medically eligible patients going without surgery, researchers reported.

“What we were really looking for were barriers to getting the surgery,” said Matthew J. Martin, MD, an assistant professor of surgery at Madigan Army Medical Center in Tacoma, Washington, and the study’s principal investigator. “We have a huge group of people who are eligible for the surgery based on their weight and medical problems. There are a bunch of differences between the groups who get the surgery and the groups that don’t.”
Dr. Martin and colleagues first identified the population in the United States that was eligible for bariatric surgery in the 2005 to 2006 National Health and Nutrition Examination Survey and compared those adults to the ineligible population. Those patients identified as eligible were then compared with patients who received bariatric surgery, according to the 2006 Nationwide Inpatient Sample. Their goal was to detect socioeconomic differences between patients.

Investigators identified more than 22 million people younger than 65 years who, according to National Institutes of Health criteria, were eligible for bariatric surgery. Patients had either a body mass index of more than 40 kg/m2 or a body mass index of 35 kg/m2 to 40 kg/m2 with an obesity-related illness, such as diabetes, heart disease, or sleep apnea.

When compared with the noneligible group, eligible patients who did not receive surgery were found to have reduced family incomes, lower education levels, decreased access to healthcare, and to have a greater proportion of nonwhites, with all those variables being statistically significant (P < .001). Eligibility without surgery was also linked to other unfavorable economic and health-related markers, including days of work lost (5 vs 8 days; P < .001).

The majority of the 87,749 patients who received bariatric surgical procedures in 2006 were women (81%), were white (75%), had higher median incomes (80%), and had private insurance (82%).

A total of 35% of patients eligible for bariatric surgery were either uninsured or underinsured, and 15% had incomes deemed below the poverty level.
Dr. Martin speculated that many more women than men underwent bariatric surgery because women are typically more frequent users of healthcare services. “Men usually seek healthcare later than women,” he said.

He stressed that the data point to gaps that are linked to a reduced likelihood of undergoing bariatric surgery based on race, income, and insurance type. Whites represent 67% of the morbidly obese population, but 75% of those who had surgery were white.

“A select part of the eligible population gets the surgery, and that tends to be people with better insurance, higher incomes, and people who [are] white,” said Dr. Martin. “Even controlling for insurance and income, race was an independent factor. Regardless of income and insurance, people of black race got the surgery much less than people of white race.”

The racial divide that separates whites and nonwhites is not unique to bariatric surgery, according to Dr. Martin. “That has been found for other medical procedures, such as cancer surgery, chemotherapy, and heart surgery,” said Dr. Martin. “Racial minorities receive those procedures less than whites.”

Both patients who were uninsured and underinsured had diminished access to bariatric surgery, with almost no patients who were uninsured receiving the surgery, reported Dr. Martin. The study found 0.3% of the uninsured received bariatric surgery.

“The underinsured and uninsured have obesity and other comorbidities and probably have not been treated and would have a much bigger benefit from surgery [than those who are well-insured], and [they] are not getting the surgery,” he said.

Bariatric surgery “pays for itself” in postoperative years in terms of the better health of patients and reduced medical costs to insurance companies and/or the taxpayer, said Dr. Martin.

John W. Baker, MD, president of the American Society of Metabolic and Bariatric Surgery and medical director of the Baptist Health Weight Loss Center and codirector of the Bariatric Surgery Program at Baptist Medical Center in Little Rock, Arkansas, said  “There is a disparity that if you [have a] lower income, [you don’t get surgery], and there is a racial disparity as well [that limits surgery access].”

American Society for Metabolic and Bariatric Surgery 26th Annual Meeting: Abstract PL-217. Presented June 25, 2009.