Investigating racial disparities in bariatric surgery referrals

Trends in Management of Anal Fissures

BACKGROUND

It is unclear how patients with anal fissures are treated in real-world settings, particularly since patients may not see colorectal surgeons. This study describes trends in treatment with medical therapies (calcium-channel blockers [CCBs], nitroglycerin [NTG], and narcotics) and surgical treatments.

METHODS

Cohorts were created within the TriNetX database platform using codes for anal fissures and surgical interventions. Demographics were compared between patients that received surgical intervention within 1 year of diagnosis, CCB or NTG within 1 year (or preoperatively), or narcotics within 30 days or postoperatively vs those who did not.

RESULTS

121,213 patients were included of which 4.0% had surgical intervention. Factors associated with surgical intervention were male sex (OR 1.40), White race (OR 1.17), and Hispanic ethnicity (OR 1.11). Male patients were more likely to undergo sphincterotomy (OR 1.49). Female (OR 1.27), non-Hispanic (OR 1.34), and White patients (OR 1.41) were more likely to have chemodenervation. Regarding nonoperatively managed patients, non-Hispanic (OR .91) and White patients (OR .89) were less likely to receive CCB/NTG. Male (OR 1.21), non-Hispanic (OR 1.08), and Black patients (OR 1.20) were more likely to receive narcotics. Male patients that required surgery were more likely to be prescribed CCB/NTG preoperatively (OR 1.27). Non-Hispanic surgical patients were more likely to receive narcotics (OR 1.84).

DISCUSSION

Male fissure patients were more likely to undergo surgical intervention other than chemodenervation. Differences in the rates of surgery and medical therapy (especially narcotics) between races and ethnicities require exploration to enhance the care of patients with anal fissures.

Disparities in Breast Cancer Care-How Factors Related to Prevention, Diagnosis, and Treatment Drive Inequity

Breast cancer survival has increased significantly over the last few decades due to more effective strategies for prevention and risk modification, advancements in imaging detection, screening, and multimodal treatment algorithms. However, many have observed disparities in benefits derived from such improvements across populations and demographic groups. This review summarizes published works that contextualize modern disparities in breast cancer prevention, diagnosis, and treatment and presents potential strategies for reducing disparities. We conducted searches for studies that directly investigated and/or reported disparities in breast cancer prevention, detection, or treatment. Demographic factors, social determinants of health, and inequitable healthcare delivery may impede the ability of individuals and communities to employ risk-mitigating behaviors and prevention strategies. The disparate access to quality screening and timely diagnosis experienced by various groups poses significant hurdles to optimal care and survival. Finally, barriers to access and inequitable healthcare delivery patterns reinforce inequitable application of standards of care. Cumulatively, these disparities underlie notable differences in the incidence, severity, and survival of breast cancers. Efforts toward mitigation will require collaborative approaches and partnerships between communities, governments, and healthcare organizations, which must be considered equal stakeholders in the fight for equity in breast cancer care and outcomes.

Metabolic and Bariatric Surgery Utilization Trends in the United States: Evidence From 2012 to 2021 National Electronic Medical Records Network

Background

Bariatric surgery has evolved over the past 2 decades yet assessing trends of bariatric surgery utilization in the growing eligible population is lacking.

Aim

This study aimed to update the trends in bariatric surgery utilization, changes in types of procedures performed, and the characteristics of patients who underwent bariatric surgery in the United States, using real-world data.

Method

This retrospective descriptive observational study was conducted using the TriNetX, a federated electronic medical records network from 2012 to 2021, for adult patients 18 years old or older who had bariatric surgery. Descriptive statistical analysis was conducted to assess patients' demographics and characteristics. Annual secular trend analyses were conducted for the annual rate of bariatric surgery, and the specific procedural types and proportions of laparoscopic surgeries.

Results

A steady increase in the number of procedures performed in the United States over the first 6 years of the study, a plateau for the following 2 years, and then a decline in 2020 and 2021 (during the coronavirus disease 2019 pandemic). The annual rate of bariatric surgery was lowest in 2012 at 59.2 and highest in 2018 at 79.6 surgeries per 100,000 adults. During the study period, 96.2% to 98.8% of procedures performed annually were conducted laparoscopically as opposed to the open technique. Beginning in 2012, the Roux-en-Y gastric bypass (RYGB) procedure fell to represent only 17.1% of cases in 2018, along with a sharp decline in the adjustable gastric band (AGB) procedure, replaced by a sharp increase in the sleeve gastrectomy (SG) procedure to represent over 74% of cases in 2018.

Conclusions

Bariatric surgery utilization in the United States showed a moderate decline in the number of RYGB procedures, which was offset by a substantial increase in the number of SG procedures and a precipitous drop in the annual number of AGB procedures.

Safety and feasibility of destination care for bariatric surgery: a single institution retrospective study

INTRODUCTION

Increasing emphasis on value-based healthcare has prompted both employers and healthcare organizations to develop innovative strategies to supply high quality care to patients. One such strategy is through the bundled care payment model (BCPM). Through this model, our institution partnered with employers from across the country to provide quality care for their members. Patients traveling greater than 2 h driving time from the bariatric center were considered "destination" patients. To properly care for our destination patients, our institution created a "destination bariatric program." We sought to investigate comparative outcomes for the first 100 patients who completed the program. We hypothesized that there would be no difference in patient outcomes or complications between destination and local patient groups undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).

METHODS AND PROCEDURES

A retrospective cohort analysis of patients undergoing bariatric surgery at a MBSAQIP-accredited bariatric surgery center between May 2019 and October 2021 was conducted. Patients were divided into destination or local patient groups based on participation in the established destination surgery program. Patient demographics, perioperative clinical outcomes, and complications were compared and statistically analyzed using two-sample t-tests, Chi-square tests, Fisher's exact tests, and univariate logistic regressions.

RESULTS

This study identified 296 patients, which consisted of destination (n = 110) and local (n = 186) patient cohorts. Patients in the destination group had higher rates of diabetes mellitus (29.1% vs 24.2%, p = 0.029), but otherwise cohorts had similar basic demographics and comorbidities. Outcomes revealed no statistically significant associations between patient cohort (destination versus local) and ED admission (p = 0.305), hospital readmission (p = 0.893), surgical reintervention (p = 0.974), endoscopic-reintervention (p = 0.714), and patient complications in the postoperative period (30 days).

CONCLUSION

Participation in destination care programs for bariatric surgery was found to be both safe and feasible. These destination programs represent an opportunity to provide a broader patient population access to complex surgical care.

Supervised weight loss requirements disproportionately affect Black patients seeking weight loss surgery

BACKGROUND

We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery.

OBJECTIVE

To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery.

SETTING

University hospital.

METHODS

A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements.

RESULTS

A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01).

CONCLUSIONS

Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.

Bariatric Surgery and Incident Heart Failure: a Propensity Score Matched Nationwide Cohort Study

BACKGROUND

Bariatric surgery results in significant weight loss and a reduction in the incidence of cardiovascular disease in patients with obesity; however, relatively little research considers its effect on the incidence of heart failure (HF). We aimed to determine whether bariatric surgery reduces the incidence of HF in patients with obesity, compared to non-surgical management.

METHODS

A propensity-score matched, retrospective cohort study using patients records from the nationwide Clinical Practice Research Database (CPRD) was conducted. 3052 patients who received bariatric surgery were matched with 3052 patients who did not, according to propensity to receive bariatric surgery, determined through a logistic regression model. Patients were eligible if >18 years old, BMI > 35 kg/m², and no prior diagnosis of HF. The pre-defined primary endpoint was the development of new HF, and secondary endpoints were all-cause mortality and hospitalisations due to HF.

RESULTS

Patients who received bariatric surgery had a significantly lower incidence of new HF (hazard ratio 0.45, 95% confidence interval 0.28-0.73, p = 0.0011) and all-cause mortality (hazard ratio 0.56, 95% confidence interval 0.38-0.83, p = 0.0036).

CONCLUSIONS

This study provides evidence of lower rates of HF and all-cause mortality in patients who undergo bariatric surgery, compared to propensity-score matched controls. Future studies to understand the mechanism(s) involved in this reduction and explore the lifetime benefits in high-risk cohorts are paramount.

The Mediating Effect of Operative Approach on Racial Disparities in Bariatric Surgery Complications

INTRODUCTION

A laparoscopic approach to bariatric surgeries confers a favorable side-effect profile as compared to an open approach. However, literature regarding the independent association of race with access to and postoperative outcomes in laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (GS) is scarce.

MATERIALS AND METHODS

All RYGB and GS cases recorded in American College of Surgeons National Quality Improvement Program data from 2012 to 2020 were subjected to propensity score matching to assess the independent association between Black self-identified race on access to a laparoscopic approach and postoperative complications. Finally, a series of logistic regressions enabled evaluation of the mediating effect of operative approach on racial disparities in postoperative complications.

RESULTS

55,846 cases of RYGB and 94,209 cases of GS were identified. Following propensity score matching, logistic regression identified Black race as an independent predictor of open approach to RYGB (P < 0.001) and GS (P = 0.019). Black patients had increased incidence of any, minor and severe postoperative complications and unplanned readmissions in both RYGB (P < 0.001, P < 0.001, P = 0.0412, and P < 0.001, respectively) and GS (P < 0.001, P < 0.001, P = 0.0037, and P < 0.001, respectively). Open approach to RYGB was identified as a partial mediator of the independent association between Black race and any complication, minor complications, and unplanned readmission.

CONCLUSIONS

This methodology identified racial disparities in complications following RYGB and GS. Interestingly, reduced access to a laparoscopic approach mediated racial disparities in complications following RYGB but not GS. Further research might elucidate upstream determinants of health that catalyze these disparities.

A Call to Reconceptualize Obesity Treatment in Service of Health Equity: Review of Evidence and Future Directions

PURPOSE OF REVIEW

Rates of obesity and associated comorbidities are higher among Black and Latino adults compared to white adults. We sought to provide an overview of both structural and individual factors contributing to obesity inequities and synthesize available evidence regarding treatment outcomes in Black and Latino adults, with an eye towards informing future directions.

RECENT FINDINGS

Obesity disparities are influenced by myriad systemic issues, yet the vast majority of interventions target individual-level factors only, and most behavioral treatments fail to target drivers beyond eating and physical activity. Extant treatments are not equally accessible, affordable, or effective among Black and Latino adults compared with white counterparts. Asset-based, culturally relevant interventions that target the root causes of obesity and address intersectional stress-designed in partnership with intended beneficiaries-are urgently needed. Treatment trials must improve enrollment of Black and Latino adults and report treatment outcomes by race and ethnicity.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care

Importance

Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery.

Objective

To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care.

Design, Setting, and Participants

This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery.

Exposures

Telemedicine-based preoperative care.

Main Outcomes and Measures

Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure.

Results

A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02).

Conclusions and Relevance

In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Racial variation in baseline characteristics and wait times among patients undergoing bariatric surgery

BACKGROUND

Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients.

METHODS

Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups.

RESULTS

A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0 years vs. 46.6 years, p < 0.0001), disabled (16% vs. 11.4%, p < 0.0001) and have Medicaid (8.4% vs. 3.8%, p < 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p < 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157 days vs. 127 days, p < 0.0001), despite having higher rates of patients with a body mass index above 50 kg/m2 (39.0% vs. 33.2%, p < 0.0001).

CONCLUSIONS

Non-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Temporal trends in Black-White disparities in cancer surgery and cancer-specific survival in the United States between 2007 and 2015

BACKGROUND

The American Society of Clinical Oncology (ASCO) has strived to address racial/ethnic disparities in cancer care since 2009. Surgery plays a pivotal role in cancer care; however, it is unclear whether and how racial/ethnic disparities in cancer surgery have changed over time.

METHODS

This cohort study included 1,113,256 White and Black cancer patients across 9 years (2007-2015) using patient data extracted from the Surveillance, Epidemiology, and End Results (SEER)-18 registries. Patient data were included from 2007 to adjust insurance status and by 2015 to obtain at least a 3-year survival follow-up (until 2018). The primary outcome was a surgical intervention. The secondary outcomes were the use of (neo)adjuvant chemotherapy and cancer-specific survival (CSS). Adjusted associations of the race (Black/White) with the outcomes were measured in each cancer type and year.

RESULTS

The gap between surgery rates for Black and White patients narrowed overall, from an adjusted odds ratio (aOR) of 0.621 (0.592-0.652) in 2007 to 0.734 (0.702-0.768) in 2015. However, the racial gap persisted in the surgery rates for lung, breast, prostate, esophageal, and ovarian cancers. In surgically treated patients with lymph node metastasis, Black patients with colorectal cancer (CRC) were less likely to receive (neo)adjuvant chemotherapy than White patients. Black patients undergoing surgery were more likely to have a worse CSS rate than White patients undergoing surgery. In breast cancer patients, the overall trend was narrow, but continuously present, with an adjusted hazard ratio (aHR) of 1.224 (1.278-1.173) in 2007 and 1.042 (1.132-0.96) in 2015.

CONCLUSIONS

Overall, progress has been made toward narrowing the Black-White gap in cancer surgical opportunity and survival. Future efforts should be directed toward those specific cancers for which the Black-White gap continues. Additionally, it is worth addressing the Black-White gap regarding the use of (neo)adjuvant chemotherapy for CRC treatment.

Proof of Concept for a Mindfulness-Informed Intervention for Eating Disorder Symptoms, Self-Efficacy, and Emotion Regulation among Bariatric Surgery Candidates

Up to 64% of patients seeking bariatric (weight-loss) surgery report eating disorder (ED) symptoms (addictive-like eating, binge eating, emotional eating, grazing) that can interfere with post-surgical weight loss. This prospective proof-of-concept study aimed to evaluate the impact of a pre-surgical mindfulness-informed intervention (MII) on ED symptoms and potential mechanisms-of-action to inform optimization of the intervention. Surgery-seeking adults attended four, 2-hour, MII sessions held weekly. Participants completed validated questionnaires assessing ED symptoms, eating self-efficacy, emotion regulation, and mindful eating pre-MII, post-MII, and at a 12-week follow-up. The MII consisted of mindfulness training, with cognitive, behavioral, and psychoeducational components. Fifty-six patients (M = 47.41 years old, 89.3% female) participated. Improvements in addictive-like eating, binge eating, emotional eating, and grazing were observed from pre- to post-MII. ED symptom treatment gains were either maintained or improved further at 12-week follow-up. Eating self-efficacy and emotion regulation improved from pre-MII to follow-up. Scores on the mindful eating questionnaire deteriorated from pre-MII to follow-up. In mediation analyses, there was a combined indirect effect of emotion regulation, eating self-efficacy, and mindful eating on grazing and binge eating, and an indirect effect of emotion regulation on emotional eating and addictive-like eating. Participation in the MII was associated with improvements in ED symptoms and some mechanisms-of-action, establishing proof-of-concept for the intervention. Future work to establish the MII's efficacy in a randomized controlled trial is warranted.

Factors Associated With Bariatric Surgery Referral Patterns: A Systematic Review

INTRODUCTION

Bariatric surgery (BS) has been shown to effectively treat morbid obesity and improve obesity-related comorbidities. Nonetheless, BS remains underutilized among qualified patients.

MATERIALS AND METHODS

PubMed, SCOPUS, and OVID databases were searched to identify published comparative studies examining BS referral patterns. Data on barriers to BS referrals were examined and summarized.

RESULTS

Barriers to referrals stemmed largely from a lack of familiarity with safety, efficacy, and postoperative care amongst providers. Providers with previous referrals were more likely to report higher knowledge, comfort in referring patients, and ability to provide postoperative care. Provider initiated discussion of BS was positively associated with referrals. Female and younger patients were more likely to receive referrals. Furthermore, access to appropriate peri-operative resources, local bariatric programs, and insurance eligibility were associated with referral rates. Encouragingly, providers across specialties report eagerness to gain exposure and training in BS.

CONCLUSIONS

Lack of provider familiarity with BS efficacy, safety and postoperative care likely contributes to low utilization rates of BS. Further potential barriers in access to BS are logistic factors such as insurance coverage, limited local perioperative resources, and clinic time constraints for patient counseling. Promotion of BS amongst providers and both surgical and non-surgical trainees will likely have a significant impact on referral rates and access to this life-saving procedure. Future studies should further investigate the barriers to BS and delineate the effect size of each barrier on referral rates to efficiently increase access.

Predictors of 30-day follow-up visit completion after primary bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BACKGROUND

Adherence to follow-up visits is often unsatisfactory after bariatric surgery.

OBJECTIVES

To identify predictors, including surgery type and preoperative demographics, body mass index (BMI), medical conditions, and smoking status, of 30-day follow-up visit completion.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers (2015-2018).

METHODS

Patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy were included in this analysis. Data were analyzed using weighted logistic regression. Subanalyses included stratification of the sample by sex and age (<45, 45-60, and >60 years).

RESULTS

Patients (n = 566,774) were predominantly female (79.6%), White (72.4%), non-Hispanic (77.9%), and middle-aged (44.5 ± 11.9 years), with a mean BMI of 45.3 ± 7.8 kg/m². More than 95% of patients completed the 30-day visits. In the whole-sample analysis, older age (odds ratio [OR], 1.02) and the presence of non-insulin-dependent diabetes (OR, 1.04), hypertension (OR, 1.03), hyperlipidemia (OR, 1.10), obstructive sleep apnea (OR, 1.15), and gastroesophageal reflux disease (OR, 1.16) were positive predictors of the 30-day visit completion (P_s < .01). Conversely, sleeve gastrectomy procedure (OR, .86), Black race (OR, .87), Hispanic ethnicity (OR, .94), and the presence of insulin-dependent diabetes (OR, .96) and smoking (OR, .83) were negative predictors (P_s < .01). Several differences emerged in subanalyses. For example, in sex stratification, Hispanic ethnicity lost its significance in men. In age stratification, BMI and male sex emerged as positive predictors in the age groups of <45 and 45-60 years, respectively.

CONCLUSION

Although challenged by small effect sizes, this analysis identified subgroups at a higher risk of being lost to follow-up after bariatric surgery.

Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion

Importance

There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion.

Objective

To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years.

Design Setting and Participants

This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021.

Exposure

Living in a Medicaid expansion state.

Main Outcomes and Measures

The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals.

Results

Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals.

Conclusions and Relevance

This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

Introducing a Bariatric Surgery Program at a Large Urban Safety Net Medical Center Serving a Primarily Hispanic Patient Population

Background

Few bariatric surgery programs exist at safety net hospitals which often serve patients of diverse racial and socioeconomic backgrounds. A bariatric surgery program was developed at a large urban safety net medical center serving a primarily Hispanic population. The purpose of this study was to evaluate safety, feasibility, and first-year outcomes to pave the way for other safety net bariatric programs.

Methods

The bariatric surgery program was started at a safety net hospital located in a neighborhood with over twice the national poverty rate. A retrospective review was performed for patient demographics, comorbidities, preoperative diet and exercise habits, perioperative outcomes, and 1-year outcomes including percent total weight lost (%TWL) and comorbidity reduction.

Results

A total of 153 patients underwent laparoscopic sleeve gastrectomy from May 2017 through December 2019. The average preoperative BMI was 47.9kg/m², and 54% of patients had diabetes. The 1-year follow-up rate was 94%. There were no mortalities and low complication rates. The average 1-year %TWL was 22.8%. Hypertension and diabetes medications decreased in 52% and 55% of patients, respectively. The proportion of diabetic patients with postoperative HbA1c <6.0% was 49%.

Conclusion

This is one of the first reports on the outcomes of a bariatric surgery program at a safety net hospital. This analysis demonstrates feasibility and safety, with no mortalities, low complication rates, and acceptable %TWL and comorbidity improvement. More work is needed to investigate the impacts of race, culture, and socioeconomic factors on bariatric outcomes in this population.

Graphical abstract

Metabolic and bariatric surgery is likely safe, but underutilized in adolescents aged 13-17 years

BACKGROUND

Bariatric surgery is now accepted for adolescents; however, we may need to improve access to surgery for this vulnerable age group.

OBJECTIVES

To compare the demographic characteristics and short-term safety outcomes of adolescents, college-aged individuals, and young adults who have had metabolic and bariatric surgery.

SETTING

Bariatric surgery centers.

METHODS

Patients aged 13-25 years in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2018 with a Current Procedural Terminology (CPT) code for sleeve gastrectomy (SG) or gastric bypass (GB) were included. Patients were stratified by operation and analyzed by age: adolescents (13-17 yr), college-aged (18-21 yr), and young adults (22-25 yr).

RESULTS

Of the 760,076 patients in the database, 1047 adolescents (.1%), 10,429 college-aged individuals (1.4%), and 24,841 young adults (3.8%) underwent SG or GB. The majority of patients in each group were female and white. Diabetes was most common among adolescents, hypertension among college-aged individuals. The most prevalent co-morbidity among young adults was diabetes. Preoperative BMI was 47 across all age strata. SG was performed in 27,292 patients: 879 (3.2%) adolescents, 7955 (29.2%) college-aged, and 18,447 (67.6%) young adults. Postoperative complications occurred in approximately 1% of individuals and were similar between age groups (P = .23). A total of 8292 patients underwent GB: 146 (1.8%) adolescents, 2207 (26.6%) college-aged, and 5939 (71.6%) young adults. There was no difference in 30-day complication rates between age groups (P = .32).

CONCLUSIONS

There may be a disparity in access to metabolic and bariatric surgery among adolescents, particularly for racial and ethnic minorities; however, these procedures are likely safe in adolescents as young as 13.

Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation.

Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population.

Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m², 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year (“improved”) compared with surgery at 3.5 years (“standard”). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics.

Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68–1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0- and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery.

Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.

Disparities in Access to Bariatric Surgery in Texas 2013-2017

Background

Access to bariatric care varies across regions, ethnic, and racial groups. Some of these variations may be due to insurance status or socioeconomic status. There are also regional and state variations in access to metabolic and bariatric surgery (MBS). The Texas Inpatient Public Use Data File (IPUDF) and Texas Outpatient Public Use Data File is a state-mandated database that collects information on demographics, procedures, diagnoses, and cost on almost all admissions in Texas. We used them to examine racial disparities in MBS over a 5-y period.

Methods

The IPUDF and Texas Outpatient Public Use Data File were examined from the years 2013 through, 2017. We included all patients undergoing a laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy and examined the demographics of these patients. Race and ethnicity are reported separately. We used U.S. Census Bureau statistics and the Texas Department of State Health Services statistics to determine the crude (unadjusted) and adjusted procedure rates of patients undergoing MBS.

Results

In the IUPUDF, the crude unadjusted procedure rate for blacks undergoing MBS was 7.29 per 10,000 population followed by 6.85 per 10,000 for non-Hispanic whites. Hispanics had the lowest rate at 3.20 per 10,000. When adjusted for sex, obesity, age, and race, blacks still had a higher rate of access followed by whites and then Hispanics.

Conclusions

There are disparities to access for bariatric surgery in Texas. Blacks have the greatest access followed by whites. Hispanics have the lowest procedure rate per population.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry

Background

The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients.

Methods

The MBSAQIP database was reviewed for RYGB and SG patients (2015–2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes.

Results

After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak.

Conclusion

African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.