Medical DevicesNew Study Finds Social And Economic Factors Play Major Role In Determining Who Gets Bariatric Surgery
Less than one-half of one percent (0.4%) of the 22 million people in the U.S. who are medically eligible for bariatric surgery actually get the surgery, and those who do are most likely to be white females with higher incomes and covered by private health insurance, according to a new study presented here at the 26th Annual Meeting of the American Society for Metabolic & Bariatric Surgery (ASMBS).
In a retrospective analysis, the vast majority of the 88,000 people with morbid obesity who had bariatric surgery in 2006 were female (81%), white (75%), fell into higher household income categories (80%) and had private health insurance (82%) compared to those who were medically eligible for surgery, but did not have it.
Researchers used the National Health and Nutrition Examination Survey (NHANES), a nationally representative health database administered by the Centers for Disease Control and Prevention (CDC), to identify the number of people eligible for bariatric surgery in 2005-2006 and the 2006 Nationwide Inpatient Sample (NIS) to identify those that had bariatric surgery in 2006. The NIS is the largest all-payer inpatient care database in the U.S. sponsored by the Agency for Healthcare Research and Quality (AHRQ), another government agency.
"When the disparities between groups are this large, socioeconomic status is clearly playing a more significant role than medical status in determining who gets bariatric surgery and who does not," said Matthew J. Martin, MD, lead author of the study and Assistant Professor of Surgery at Madigan Army Medical Center in Tacoma, WA. Co-authors include Alec Beekley, MD, Randy Kjorstad, MD, and James Sebesta, MD, also from the Madigan Army Medical Center.
Researchers note socioeconomic disparities in health care are not uncommon and have been documented in areas such as cancer and cardiovascular treatments, but theirs is one of the first major studies to identify and examine the relationship between socioeconomics and surgical treatment of morbid obesity.
People were considered eligible for surgery if they were overweight with a body mass index (BMI) of over 40, or a BMI of 35 to 40 with an obesity-related disease such as Type 2 diabetes, heart disease or sleep apnea; criteria established by the National Institutes of Health (NIH).
The NHANES database showed that being morbidly obese was associated with significant adverse economic and health-related issues. More than one-third of people with morbid obesity were either uninsured or underinsured and 15 percent had incomes below the poverty level. Compared with the general population, people with morbid obesity had significantly lower family incomes (35% vs. 28%) and less health insurance. In addition, the morbidly obese population has more women (62% vs. 49%) and African-Americans (18% vs. 12%) and fewer men (38% vs. 51%).
The morbidly obese group is also in poorer health than the general population. Metabolic syndrome, defined in this analysis as morbid obesity plus the presence of at least two of the following conditions: hypertension, diabetes and/or hyperlipidemia, was present in 58 percent of the morbidly obese population. Nearly 30 percent of those who actually had bariatric surgery also had diabetes (29%), hypertension (52%) and chronic pulmonary disease (19%). The morbidly obese group had twice as many sick days (5.4 vs. 2.8), missed more work days (8 vs. 5) and was more underinsured (20% vs. 8%).
The NIS database found four times as many women as men (81% vs. 19%) had bariatric surgery despite findings that morbidly obese women outnumber men by a much smaller margin (62% vs. 38%). And, while whites represent 67 percent of the morbidly obese population, about 75 percent of those who had surgery were white. Whereas African-Americans represent 18 percent of the morbidly obese population and only 11 percent went on to have surgery. Inpatient mortality following bariatric surgery for all groups was 0.1 percent.
"These disparities represent significant non-medical barriers for someone needing bariatric surgery," commented Dr. Martin. "There is an over representation of white and female patients who had surgery and a corresponding under-representation of black and male patients with little or no insurance. Increasing access and breaking down the socioeconomic barriers to bariatric surgery among the underserved population has the potential to significantly impact the health and well being of millions of people throughout the U.S. The current debate about universal healthcare must take into consideration these two related epidemics - morbid obesity and the increase in uninsured and underinsured persons."
The study found significant disparities in income and insurance status. About 15 percent of the morbidly obese population was identified as being uninsured and only 0.3 percent of the uninsured went on to have bariatric surgery.
According to the ASMBS, it is estimated that 220,000 people had some form of bariatric surgery in 2008. The most common methods of bariatric surgery are laparoscopic gastric bypass and laparoscopic adjustable gastric banding.
The ASMBS is the largest organization for bariatric surgeons in the world. It is a non-profit organization that works to advance the art and science of bariatric surgery and is committed to educating medical professionals and the lay public about bariatric surgery as an option for the treatment of morbid obesity, as well as the associated risks and benefits. It encourages its members to investigate and discover new advances in bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for morbidly obese patients. For more information about the ASMBS, visit http://www.asmbs.org.
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