The effect of economic downturn on the volume of surgical procedures: A systematic review

How cesarean section rates can be reduced through an effective financial strategy: A protocol for systematic review

BACKGROUND

The incidence of cesarean section (c-section) has been increasing after the introduction of national health coverage. There is potential evidence that unnecessary c-sections can be reduced through an effective financial strategy, which would make it possible to increase health equity in the future. Consistent with global trends, the rate of c-section in Indonesia increased from 1.6% in 1991 to 17.6% in 2017, while the World Health Organization standard rate is 10% to 15%. This study aims to explore and analyze strategies to reduce c-section rates and to report evidence-based research on an effective financial strategy model for reducing these rates.

METHODS

We used a systematic review framework involving electronic databases including PubMed, ProQuest, and ScienceDirect. The following literature search terms were used: "cost-benefit analysis," "universal health care," "cost controls," "health expenditures," "out-of-pocket expenses," "c-section," and "abdominal delivery." The Joanna Briggs Institute critical appraisal checklist was used to independently assess the methodological quality. The findings were compiled using a meta-aggregation approach to summarize quantitative analysis results potentially based on different methodologies.

RESULTS

Among 883 database records, 26 studies were retained for full-text review. C-section risk factors, the role of financial system evaluation, and the application of the clinical audit cycles with assessments using Robson classification were discussed in the included papers. Several studies highlighted the crucial function of evaluating reward reimbursement schemes, suggesting that decreased c-section rates and other maternal-neonatal outcomes should be used as indicators.

DISCUSSION

This study identified an evidence base that suggests using Robson classification in clinical audit cycles to reduce c-section rates and avoid unnecessary c-sections. The other proposals for decreasing the rate were mainly focused on financial and nonfinancial strategies applied nationally and locally in hospital settings.

Economic Predictors of Plastic Surgery Expenditures: A 14-Year Analysis of Unemployment, Disposable Income, and Stock Indices

Macroeconomic conditions significantly affect consumer spending patterns, including aesthetic surgery expenditures. This study examines the longitudinal relationship between unemployment rates, disposable income, stock indices, and aesthetic surgery spending from 2006 to 2019. Data on aesthetic surgery expenditures were collected from the American Society of Plastic Surgeons, whereas unemployment data were obtained from the US Bureau of Labor Statistics, disposable income from the US Bureau of Economic Analysis, and stock indices from the Federal Reserve Economic Data. Time series correlational analyses and Granger causality tests were used to explore these relationships. Unemployment was inversely related to total aesthetic surgery expenditures and most individual procedures. However, Granger causality tests did not reveal a significant predictive relationship between unemployment and aesthetic procedure spending for most procedures. Disposable income was most strongly associated with expenditures on injection procedures and had nonsignificant relationships with more invasive procedures, including breast augmentation, liposuction, abdominoplasty, and blepharoplasty. The analysis demonstrated a significant positive relationship between the NASDAQ, S&P 500, and Dow Jones with all aesthetic procedures, except rhinoplasty. Granger causality tests revealed significant predictive relationships for several procedures at different lags using disposable income and stock indices as predictive variables. These findings highlight a nuanced relationship between macroeconomic conditions and consumer spending on aesthetic surgery. Overall, this paper provides new insights offering a foundation for further investigation into aesthetic plastic surgery consumption on an individual level, rather than on an aggregate.

Level of Evidence 5

(Risk).

The Role of the Biosafety Cabinet in Preventing Infection in the Clinical Laboratory

Clinical laboratories are essential in healthcare to better diagnose, treat, and track medical diseases. However, handling infectious organisms and possibly infectious materials in these laboratories puts the safety of laboratory workers and the general public at risk. By controlling the distribution of infectious substances and stopping the spread of diseases, biosafety cabinets (BSCs) have become crucial tools in guaranteeing laboratory safety. The prevention of infections is most important in medical and laboratory settings. In clinical laboratories, biological and infectious agents are handled, posing threats to healthcare workers and the general public. To avoid infections, proper training of the BSC is essential. Laboratory employees are instructed in aseptic procedures, proper hand posture, and efficient personal protection when working in the cabinet. These instructions decrease the chance of contaminating the surrounding area. Additionally, user ergonomics are taken into account while designing BSC, reducing operator fatigue, and guaranteeing that staff can execute tasks precisely for extended periods. This review highlights the importance of biosafety cabinets in maintaining a secure laboratory environment and explains their crucial function in infection control.

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

Plastic Surgery Training: Trends in Hand Surgery Fellowship in the Setting of a Pandemic

Given the diminishing presence of hand surgeons trained in plastic surgery, we evaluated the associated trends in annual hand meeting educational content and postgraduate job offerings, and analyzed the effect of the coronavirus disease 2019 (COVID-19) pandemic on trainees in hand surgery.

Methods

Hand meeting registration and educational content were analyzed over the past 10 years. Current hand surgery job offerings were evaluated for training requirements, and the annual rates of subspecialty certificate in surgery of the hand board certifications were compared across training backgrounds.

Results

Top categories of annual meeting educational content were "bone/joint," "other," and "professional development." A majority of American Society for Surgery of the Hand presidents had training backgrounds in orthopedics (55%), followed by plastics (23%) and general surgery (22%). The job offerings on the American Society for Surgery of the Hand and Association for Surgery of the Hand websites specified more training requirements in orthopedics than in plastics. Additionally, there were two to three times as many examinees taking the surgery of the hand examination from orthopedic surgery compared with plastics, with an overall higher pass rate. Hand fellowship programs were also predominantly offered for orthopedic surgery (80.8%).

Conclusions

Optimization of training, society membership, and clinical practice profiles may increase the presence of plastic surgery-trained hand surgeons. The extent of the economic impact of the COVID-19 pandemic is yet to be fully determined, but our analysis suggests that a lucrative market for reconstructive/hand surgery may exist in the face of economic downturn.

Impact of COVID-19 on the patient referral pattern and conversion rate in the university versus private facial plastic surgery centers

Purpose

To compare the number of referrals and conversion rate between the pandemic and pre-pandemic period.

Methods

The number of referrals and conversion rate between the 10-month pandemic (March–December 2020) and pre-pandemic (March–December 2019) were evaluated in the two university (mainly non-cosmetic) and private (mainly cosmetic) facial plastic surgery centers. Demographics and monthly number and type (cosmetic and non-cosmetic) of the referrals and surgeries were recorded from the both and cosmetic facial injections (botulinum toxin and filler) and the source of referrals (web- and non-web-based) from the private center. The conversion rate was a ratio of the number of the surgeries to the number of referrals.

Results

The number of referrals declined by 7.7% in the private center which was significantly higher for the non-cosmetic (26%) than the cosmetic (0.5%) referrals. It was 32% in the university center. The private center conversion rate significantly (P < 0.001) decreased for both the cosmetic (60%) and non-cosmetic (82%) procedures. It was not significantly different between the cosmetic (65%) and non-cosmetic (58%) procedures in the university center. However, the number of cosmetic facial injections (11%) and the web-based referral source (4%) increased. The recovery was better for the number of referrals (better in the private center) than the conversion rate.

Conclusion

The fall in the conversion rate was statistically significant in the private center. While the number of referrals recovered to almost the pre-pandemic level, the conversion rates, despite recovery, remained at a lower level at the end.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10792-022-02469-1.

Public Confidence for Undergoing Elective Plastic Surgery Procedures during the COVID-19 Pandemic

Background:

The COVID-19 vaccine rollout has since been followed by a gradual resumption of elective surgery. Many individuals remain cautious about visiting a hospital or clinic to undergo surgery. As plastic surgeons are starting to resume elective surgery at this time, it is important to understand the perspectives of potential patients and the concerns they may have.

Methods:

A survey was distributed to participants in the United States through Amazon’s Mechanical Turk (mTurk) during March of 2021. Participants were surveyed regarding their views on the severity of COVID-19, vaccination status, and how much COVID-19 has affected their interest in undergoing surgery.

Results:

Thirty-nine percent of respondents were either no longer willing or less willing to undergo elective plastic surgery. Seventy-three percent of respondents felt comfortable going to an office for a consultation. With regards to feeling comfortable visiting a hospital, 43.4% reported they would feel safe, 36% felt they would feel safe only if they could be discharged on the same day, and 30.6% reported not feeling safe. Fifty-two percent of respondents reported feeling comfortable undergoing surgery now or within the next year. Respondents who do not think COVID-19 is still a major health issue were more likely to still want plastic surgery.

Conclusion:

The results of this study highlight that the majority of patients, regardless of vaccination status, currently feel comfortable undergoing elective plastic surgery, particularly in an office setting. Plastic surgeons may expect to see a return in demand for elective procedures in the coming months.

Comparison of laparoscopic pyelolithotomy and retrograde intrarenal surgery in the management of large renal pelvic stones

BACKGROUND

To compare the clinical outcomes of laparoscopic pyelolithotomy (LP) and retrograde intrarenal surgery (RIRS) in the management of large renal pelvic stones.

PATIENTS AND METHODS

This study included patients who presented with a single renal pelvic stone sized ≥20 mm and who were treated primarily by LP or RIRS. The patients were grouped based on the surgical procedure they underwent. We retrospectively examined and compared the age, the longest axis, and the surface area of the stone, operation time, hospitalization time, complications, and stone-free rates of the two groups.

RESULTS

Of the 156 patients included in the study, 44 had LP, and 112 had RIRS. Patients who received LP (13 males, 31 females) had a median age of 54 (18-79) years, while those who underwent RIRS (46 males, 66 females) had a median age of 54.5 (18-79). Patients who received LP were found to have larger median stone size (30 mm vs 24 mm, P = .003), longer operation time (100 minutes vs 70 minutes, P = .007), lower complication rate (2% vs 8.9%, P = .063), longer median hospital stay (3 days vs 1 day, P < .001) and better stone-free rate at the third month (90.9% vs 67.9%, P < .001).

CONCLUSION

LP is a safe and efficient procedure that could be used as an alternative to RIRS in managing large renal pelvic stones.

Financial Decisions and Reopening a Practice During the COVID-19 Pandemic: A Survey of California Plastic Surgeons

BACKGROUND

On March 11, 2020, the World Health Organization declared COVID-19 as a global pandemic. As a response, the United States shut down public gatherings and businesses in an effort to quarantine. This included the stopping of elective operations, which greatly affected plastic surgeons and their practices during the initial shutdown.

OBJECTIVES

We aim to study the early impact of COVID-19 on the financial implications and practice patterns of plastic surgeons in the state of California during the initial shutdown of elective surgery and provide guidelines for effective management during future crises.

METHODS

A 20-question survey was sent using Qualtrics XM software to 851 surgeon members of the California Society of Plastic Surgeons. The survey was open from May 13, 2020, to May 29, 2020. Standard statistical analysis was completed to compare private practice and nonprivate practice plastic surgeons.

RESULTS

We had a total of 140 respondents to our survey for a 16.5% response rate. The majority (77.1%) of the respondents were in a private practice setting. Private practice plastic surgeons reported a higher financial impact with a 79% reduction in financial income compared with nonprivate practice plastic surgeons at a 37% reduction (P < 0.0001). Additionally, private practice plastic surgeons demonstrated a higher reduction in case volume and were more likely to lay off or furlough staff, close their practice, and apply for loans (P < 0.001).

CONCLUSIONS

Our survey study showed that private practice plastic surgeons in the state of California faced the most financial hardship during the early shutdown of the COVID-19 pandemic. It serves as a valuable snapshot in our economic history and depicts the heavy financial impact of the stopping of elective surgery. Since the reopening of practices, new guidelines have been implemented to maintain safe elective surgery while the pandemic continues. Further follow-up studies on both the state and national level need to be completed to see the continued financial effects on private and nonprivate plastic surgery practices since the reopening and resumption of elective surgery.

Using Google Trends Data to Track Healthcare Use for Hand Osteoarthritis

Background

Google Trends (GT) is a free tool that provides analysis of search traffic for specified terms entered into the Google search engine. In this study, we evaluate the association between public interest in hand osteoarthritis (OA) as determined by GT search volumes and healthcare usage related to hand OA.

Methodology

We compiled GT data from 2010 to 2017 for the following group of hand OA-related search terms: “hand osteoarthritis,” “hand arthritis,” “hand swelling,” “hand stiffness,” and “chronic hand pain.” Claims associated with hand OA codes were obtained from an administrative database (14.8 million patients) using International Classification of Diseases codes from 2010 to 2017. We performed trend analysis using univariate linear regression of GT data and hand OA claims. A month-by-month analysis of variation from yearly GT means was conducted for hand OA-related search terms.

Results

There was increased public interest in hand OA-related search terms from January 2010 to December 2017. Univariate linear regression of GT data for hand OA-related search terms compared with hand OA claims demonstrated a significant positive correlation (p < 0.001, r = 0.707). Peak public interest in hand OA-related search terms was observed in July, May, and June.

Conclusions

This study demonstrates the ability of GT to track healthcare use related to hand OA. Our data also add to the evidence for monthly variations in public interest related to hand OA. Clinics and surgery centers can employ GT data to anticipate resource utilization by hand OA patients.

The Financial Impacts of the COVID-19 Crisis on the Practices of Cosmetic/Aesthetic Plastic Surgeons

Abstract

The global pandemic of coronavirus 2019, or COVID-19, has undeniably impacted all facets of healthcare, affecting both its function and provision. Due to the cessation of all non-emergent surgical cases in the USA and worldwide, the professional lives and practices of many physicians have been negatively affected. However, among different physicians and specifically plastic surgeons, cosmetic/aesthetic plastic surgeons have been disproportionately affected by the COVID-19 pandemic as the majority of their cases are semi-elective and elective. The ability to perform semi-elective and elective cases is dependent on state and local authorities’ regulations, and it is currently uncertain when the ban, if ever, will be completely lifted. Financial constraints on patients and their future inability to pay for these procedures due to the COVID-19-related economic recession are things to consider. Overall, the goal of this unprecedented time for cosmetic/aesthetic plastic surgeons is for their medical practices to survive, to conserve cash flow although income is low to none, and to maintain their personal finances. In this paper, the authors review the financial impacts of the current COVID-19 pandemic on the practices of cosmetic plastic surgeons in the USA and worldwide, along with some potential approaches to maintain their practices and financial livelihoods.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Holmium Laser Enucleation, Laparoscopic Simple Prostatectomy, or Open Prostatectomy: The Role of the Prostate Volume in terms of Operation Time

INTRODUCTION

To compare the prostate removal speeds of 3 enucleation techniques and to evaluate how the operating times change depending on the prostate volume.

METHODS

Medical records of patients with 80-g or larger prostates who underwent holmium laser enucleation of the prostate (HoLEP), laparoscopic simple prostatectomy (LSP), or open prostatectomy (OP) due to medical treatment-resistant benign prostatic hyperplasia (BPH) were reviewed retrospectively. Patients were classified into 3 groups according to the surgical procedure. Age, BMI, prostate weights, total operation times, prostate removal speeds, hospitalization and catheterization days, complications, and improvements on functional outcomes in the 3rd month of follow-up were compared between groups. In addition, the association between prostate weight and total operation time was analyzed for each group.

RESULTS

HoLEP, LSP, and OP groups consisted of 60, 61, and 37 patients, respectively. While HoLEP was similar to OP in terms of prostate removal speed and total operation time, LSP was statistically slower and required more operation time than HoLEP and OP. There was a relationship between prostate weight and total operation time only in HoLEP.

CONCLUSION

LSP, one of the enucleation techniques in the treatment of large prostates, was slower and required more operation time than HoLEP and OP in terms of total operation time and prostate removal speed. HoLEP seems going to be the fastest candidate for the rapid removal of large prostates in the future.

COVID-19 and Orthopaedics: Recovery After the Pandemic Surge

The novel Coronavirus (COVID-19) pandemic has placed an immense strain on health care systems and orthopedic surgeons across the world. To limit the spread, federal and state governments mandated the cancellation of all nonurgent surgical cases to address surging hospital admissions and manage workforce and resource reallocation. During the pandemic surge, thousands of surgical cancellations have been required. We outline our experience through the onset and advance of the surge, detail our incident response and discuss the transition toward recovery. Level of Evidence: Level V.

Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations

PURPOSE

The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out.

METHODS

A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey.

RESULTS

The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement.

CONCLUSION

Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.

Outcomes of Refractive Surgery Consultations at an Academic Center: Characteristics Associated with Proceeding (or Not Proceeding) with Surgery

Objective

Refractive surgery volume has not rebounded despite economic recovery and literature describing safety, efficacy, and high patient satisfaction. We sought to examine characteristics of consultation seekers and status after consultation.

Methods

Charts of patients seeking refractive surgery at Johns Hopkins University from 2013 through 2016 were retrospectively reviewed for age, gender, refractive characteristics, and outcome: surgery (photorefractive keratectomy, laser in-situ keratomileusis, implantable collamer lens, or refractive lens exchange); no surgery-"lost candidate" (good candidates who were lost after consultation); noncandidates based on technological limitations or contraindications; or no surgery-possessing expectations that surgery would not meet. Associations between characteristics and status after consultation were examined.

Results

Twenty percent (142/712) of all patients were "lost candidates"; 57% (408/712) completed surgery. More women (56% or 401/712) sought consultation, but a greater percentage (63% or 195/311) of men completed surgery than women did (53% or 213/401) (p=0.02). Of consultation seekers, 60% were low myopes, 29% were high myopes (>6 diopters of myopic spherical equivalent), and 11% were hyperopes. Surgical patients' mean age was 34.2 ± 10.2 (standard deviation) years; for each additional year of age, patients were less likely to have surgery (p < 0.001). Hyperopes were ≥3 times more likely than myopes to have expectations not met by surgery or to be noncandidates than to have surgery (p < 0.005).

Conclusions

Most patients seeking refractive surgery had 6 diopters or less of myopia. About 20% of patients were lost after consultation; better counseling and follow-up of candidates may be warranted. Expectations and technology limit eligibility for many, especially hyperopes. Low surgery volume may affect training of future refractive surgeons.

Bariatric Surgery Offer in Brazil: a Macroeconomic Analysis of the Health system's Inequalities

BACKGROUND

Brazil currently holds the second place in the worldwide ranking of the largest number of bariatric surgical procedures performed. The offer of bariatric surgery in the public health system is not sufficient for its demand; it remains to be determined whether the recent economic downturn affected this offer.

OBJECTIVE

To analyze the proportion of bariatric surgeries performed by the public system in Brazil and assess the influence of macroeconomic variables over time.

METHODS

This is a nationwide analysis which correlated the estimated number of bariatric surgeries in Brazil in both public and private health-providing systems from 2003 through 2017 with the main macroeconomic variables of Brazil during the evaluated period (gross domestic product [GDP], inflation rate, and unemployment rate), and both overall and public healthcare expenditures.

RESULTS

The proportion of surgeries performed in the public system varied from 7.1% in 2014 to 10.4% in 2004. There was a significant positive correlation between the public proportion of surgeries with the unemployment rate (R = 0.55666; P = 0.03868). There were significant negative correlations between the proportion of public surgeries with the public health expenditure per capita (R = - 0.88811; P = 0.00011) and with the public percentage of healthcare expenditure per capita (R = - 0.67133; P = 0.01683).

CONCLUSION

There were direct correlations between the number of public bariatric procedures and the unemployment rate, as well as with the public healthcare expenditure per capita. Despite the increase in the number of public procedures, its proportion reveals an insufficiency of the current offer of bariatric surgery provided by the public system.

Permanence, cost and mortality related to surgical admissions by the Unified Health System

OBJECTIVE

to analyze the time trend of surgical admissions by the Unified Health System according to hospital stay, costs and mortality by subgroups of surgical procedures in Brazil.

METHOD

ecological study of time series. The variables surgical hospitalization, permanence, cost and mortality were obtained from the Department of Informatics of the Unified Health System. The trend analysis used the polynomial regression model.

RESULTS

in nine years, 37,565,785 surgical admissions were recorded. The mean duration of surgical admissions was constant (p = 0.449); the mean stay (3.8 days) was decreasing and significant (p <0.01); the mean cost (389.16 dollars) and mortality (1.63%) were increasing and significant (p <0.01). In subgroups of eye, thoracic, oncological and other surgeries, the temporal evolution of surgeries was increasing and significant (p <0.05). In contrast, endocrine glands, digestive tract, genitourinary, breast, reconstruction and buco-maxillofacial surgeries showed a significant trend of decline (p <0.05). In the other subgroups, the trend was constant.

CONCLUSION

evidence shows the trend of surgical admissions in the last decade in the country and provide subsidies for the efficient elaboration of public policies, planning and management towards universal coverage in surgical care.

Nationwide Macroeconomic Variables and the Growth Rate of Bariatric Surgeries in Brazil

BACKGROUND

The effect of nationwide economic issues on the necessary expansion in the number of bariatric procedures remains unclear.

OBJECTIVE

This study aims to determine whether there are correlations between the growth rate in the number of bariatric surgeries and the major macroeconomic variables over time in Brazil.

METHODS

It is a nationwide analysis regarding the number of bariatric surgeries in Brazil and the main national macroeconomic variables from 2003 through 2016: gross domestic product (GDP), inflation rate, and the unemployment rate, as well as the evolution in the number of registered bariatric surgeons.

RESULTS

There were significant positive correlations of the growth rate of surgeries with the early variations of the GDP (R = 0.5558; p = 0.04863) and of the overall health expenditure per capita (R = 0.78322; p = 0.00259). The growth rate of the number of bariatric surgeries was not correlated with the unemployment and inflation rates, as well as with the growth rate of available bariatric surgeons.

CONCLUSION

There were direct relationships between the growth rate of bariatric surgeries and the evolutions of the GDP and health care expenditure per capita. These variables appear to influence the nationwide offer of bariatric surgery.