Abstract
Background
Utilization of metabolic and bariatric surgery has increased significantly over the last two decades, yet barriers to access remain.
Objectives
This study aimed to 1) define rates of metabolic and bariatric surgery utilization for qualifying adults in Illinois and 2) describe patient characteristics associated with undergoing surgery at Illinois hospitals with low metabolic and bariatric surgery volume.
Setting
Metabolic and bariatric surgery at all non-federal Illinois hospitals was included.
Methods
Illinois hospital administrative data for 2016–2022 metabolic and bariatric surgery procedures (numerators) and Illinois Behavioral Risk Factor Surveillance System population estimates (denominators) were used to compute metabolic and bariatric surgery rates per estimated 100,000 Illinois residents ages 18–69 who qualified for metabolic and bariatric surgery based on National Institutes of Health Guidelines. Zip code median income was obtained from census data. Multivariable logistic regression was used to identify patient characteristics associated with receiving metabolic and bariatric surgery at low volume hospitals (LVH), defined as less than 50 annual bariatric procedures.
Results
The average annual metabolic and bariatric surgery rate was 702 per 100,000 qualifying Illinois adults. Rates were highest among non-Hispanic Black patients (890/100,000) and lowest for Hispanic patients (396/100,000) and patients from zip codes with median household income <$75,000. Lower median household income was the only characteristic associated with use of LVHs.
Conclusions
Metabolic and bariatric surgery procedures almost doubled over the study period in Illinois, increasing the most for non-Hispanic Black and Medicaid patients. However, Hispanic, and low-income patients still have rates well below the state average.
Keywords: weight loss, metabolic and bariatric surgery, access to care, social determinants of health
Introduction
Metabolic and bariatric surgery is the most effective, durable treatment for obesity and its associated medical comorbidities. 1,2 Yet historically there have been disparities in utilization of metabolic and bariatric surgery, often in populations heavily impacted by obesity.3,4 There is concern that these disparities may also exist for the quality of metabolic and bariatric surgical care received. Multiple studies show that undergoing metabolic and bariatric surgery at high volume hospitals (HVH) is associated with shorter length of stay and lower morbidity and mortality as compared to surgery at low volume hospitals (LVH). 1,2,5–8 This has led to centralization of most metabolic and bariatric surgeries at HVH, creating concerns about whether this results in reduced access to high quality metabolic and bariatric surgery for patients who already may have difficulty accessing metabolic and bariatric surgery. 9,10 This study aimed to 1) evaluate Illinois metabolic and bariatric surgery rate differences based on estimates of the Illinois population qualifying for metabolic and bariatric surgery and 2) analyze sociodemographic differences in access to HVH and LVH in Illinois.
Methods
Metabolic and Bariatric Surgery Patient and Hospital Characteristics
Data for all patients aged 18 to 69 who underwent metabolic and bariatric surgery between 2016 – 2022 were obtained from the Illinois Hospital Association’s COMPdata administrative hospital discharge database for non-federal Illinois hospitals (which excludes Veterans Affairs hospitals). Procedures included those eligible for coverage by Centers for Medicare Services (CMS) including laparoscopic sleeve gastrectomy (SG), Roux en-Y Gastric Bypass (RYGB), laparoscopic adjustable gastric band placement (LAGB) and duodenal switch). Non-Illinois residents undergoing surgery at Illinois hospitals (3.2% of all procedures) were excluded.
Patients were identified using International Classification of Diseases 10th Revision (ICD-10) procedure codes and Current Procedural Terminology (CPT) codes for metabolic and bariatric surgery. Patient age was categorized as 18–34, 35–44, 45–54, 55–64, or 65–69. Race/ethnicity were characterized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian, or other/unknown/Multiracial. Insurance status was characterized as private, Medicaid, Medicare (including Medicare disability) or uninsured. Illinois counties were categorized as Cook County, suburban Chicago metro area (‘Collar’) counties and all other Illinois counties (‘Downstate’).
Patient zip codes were matched to 2021 five-year American Community Survey (ACS) census estimates for zip code tabulation area (ZCTA) median yearly household income. Hospital volume was categorized based on the guidelines of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with LVH defined as less than 50 stapled metabolic and bariatric surgery procedures per year and HVH defined as greater than 125 stapled metabolic and bariatric surgery procedures per year.2
Population Denominators for Prevalence of Clinically Severe Obesity
Estimates of the prevalence of Illinois adults who qualify for metabolic and bariatric surgery were derived from population-weighted Illinois data from the Centers for Disease Control (CDC) 2021 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is an annual randomized telephone survey of US adults consisting of questions regarding health-related behaviors, chronic health conditions, and use of preventive services. 11 The 2021 BRFSS survey provided data for 2,486 Illinois respondents aged 18–69. For the 16.1% of respondents with missing height and weight and the 22.3% with missing household income data, body mass index (BMI) and income were imputed based on regression estimates using age, race/ethnicity, education, employment, and marital status. Prevalence estimates for the population qualifying for metabolic and bariatric surgery were based on the proportion of respondents 18–69 reporting a BMI ≥ 35 with an obesity related comorbidity or BMI ≥ 40.
Metabolic and bariatric surgery rates per 100,000 eligible individuals were estimated for Illinois household median income categories of ≤ $35,000, $35,000 – 49,999, $50,000 – 74,999, $75,000 – 99,999, or ≥ $100,000, and for White, Black, and Hispanic Illinois populations, excluding relatively small Asian (6.9%) and other race and ethnicity (3.3%) respondents. This study was deemed exempt from review by the author’s Institutional Review Board.
Statistical Analysis
Rates of metabolic and bariatric surgery for each population group were analyzed for significant differences by a one sample test of proportions for aggregate data. Chi-squares tests were used to compare patient and hospital characteristics by treatment at LVH versus HVH. Multivariable logistic regression was estimated to identify patient, procedure and hospital factors associated with the likelihood of receiving metabolic and bariatric surgery at a LVH. Regression coefficient standard errors were adjusted for clustering of observations within hospitals. All statistical analyses were performed using STATA Version 17 (StataCorp, College Station TX).
Results
Trends in Metabolic and Bariatric surgery Volume in Illinois
Figure 1 demonstrates changes in bariatric procedure volume from 2016–2022. Overall, bariatric surgeries increased during the study period, from 1200 in the first quarter of 2016 to 2200 in the last quarter of 2022, with small decreases during the initial COVID 19 shutdown and then during the Omicron spike. These increases were seen across all races/ethnicities.
Figure 1.
Quarterly Metabolic and bariatric surgery Volume by Race and Ethnicity N=42,922 Procedures for Illinois Residents at 105 Illinois Hospitals, January 2016-December 2022
Population-based Metabolic and Bariatric surgery Rates
A total of 42,922 metabolic and bariatric surgeries were performed between 2016 – 2022 at 105 non-federal Illinois hospitals. 33 Hospitals performing 84% of the surgeries were designated Bariatric Centers of Excellence (COE).12 An estimated 10.5% of the Illinois age 18–69 population potentially qualified for metabolic and bariatric surgery between 2016 – 2022. Table 1 shows the estimated qualifying populations and rates of metabolic and bariatric surgery in Illinois based on income and race/ethnicity. The overall annual rate of metabolic and bariatric surgery in Illinois was 702 per 100,000 residents. Rates of metabolic and bariatric surgery were highest among patients from zip codes with household incomes of $50 −74,999 and $75 – 99,999 and for Black patients. Annual rates of metabolic and bariatric surgery for the Hispanic population were significantly below the Black population rate (396 versus 890 per 100,000, p < 0.01). Similarly, patients from zip codes with household incomes less than $50,000 had rates significantly below those with incomes of $50–79,999 (p < 0.01).
Table 1.
Estimated Adult Bariatric Surgery Annual Rates per 100,000 Illinois Residents Qualified for Bariatric Surgery By Patient Zip Code Tract Area (ZCTA) Median Household Income and Race and Ethnicity * N=42922 Bariatric Surgery Procedures at 105 Illinois Hospitals, 2016–2022
| Estimates for Illinois Age 18–69 Population (1) | Estimated Population Percent Qualifying for Bariatric Surgery (2) | Estimated Population Qualifying for Bariatric Surgery | Average Annual Number of Bariatric Procedures 2016–2022 | Average Annual 2016–2022 Bariatric Surgery Rate per 100,000 Qualifying Persons | ||
|---|---|---|---|---|---|---|
| Total Population | 8,317,926 | 10.5 | 873,382 | 6131 | 702 | |
| Median ZCTA Household Income | <$35k | 1,522,923 | 11.5 | 175,136 | 278 | 159 |
| $35–49,999k | 2,372,725 | 11.6 | 275,236 | 928 | 337 | |
| $50–74,999 | 1,413,818 | 11.7 | 165,416 | 2,430 | 1469 | |
| $75–99,999 | 967,742 | 12.2 | 118,064 | 1,603 | 1357 | |
| $100k+ | 2,040,618 | 6.5 | 132,640 | 891 | 671 | |
| Race and Ethnicity (3) | NH White | 4,868,275 | 9.4 | 457,617 | 2,943 | 643 |
| NH Black | 1,092,457 | 15.5 | 169,330 | 1,507 | 890 | |
| Hispanic | 1,506,979 | 13.1 | 197,414 | 781 | 396 | |
Highest to lowest population rate comparisons p<0.01
Based on Illinois residents ages 18–69 from the 2021 Illinois Behavioral Risk Factor Surveillance System.
Based on 2021 Illinois Behavioral Risk Factor Surveillance System estimates for the proportion of each age 18–69 population reporting body mass index => 40 or body mass index =>35 and <40 and reporting hypertension, diabetes, arthritis, chronic kidney disease, stroke, myocardial infarction, or coronary artery disease.
Based on 2021 Illinois Behavioral Risk Factor Surveillance System estimates for the proportion of each age 18–69 racial and ethnic population, excludes Asian (6.9% of Illinois population) and Other or Multiracial race and ethnicity (3.3% of Illinois population).
Metabolic and Bariatric surgery Patient Characteristics
Table 2 shows characteristics of all patients who underwent metabolic and bariatric surgery during the study period. Patients were predominantly female (82%), White (48%) and privately insured (71%). Black patients accounted for 24.4% of the sample, approximately 10% higher than their state population in 2022 (14%), while Hispanic patients accounted for 12.7% of patients, lower than their 18% proportion of the state population. Only 15.5% of metabolic and bariatric surgery patients were covered by Medicaid as compared to about one third of all Illinois residents covered by Medicaid in 2022.
Table 2.
Bivariate Associations* and Logistic Regression Results for the Likelihood of Bariatric Surgery at a Low Volume (<50 Procedures Annually) Hospital Bariatric Surgery Procedures at 105 Illinois Hospitals, 2016–2022
| All Bariatric Surgeries | Bariatric Surgeries Performed at Low Volume Hospitals | Odds Ratio (95% CI) | |
|---|---|---|---|
| Total, n (%) | 42,922 (100.0) | 5517 (12.9) | |
| ** Age, n (%) | |||
| 18–34 | 9197 (21.4) | 1166 (12.7) | Ref |
| 35–44 | 13505 (31.5) | 1736 (12.9) | 0.98 [0.87, 1.10] |
| 45–54 | 12374 (28.8) | 1540 (12.5) | 0.98 [0.89, 1.09] |
| 55–64 | 6366 (14.8) | 830 (13.0) | 1.01 [0.79, 1.29] |
| 65 and older | 1480 (3.45) | 245 (16.6) | 1.31 [0.88, 1.98] |
| Sex, n (%) | |||
| Female | 35146 (81.9) | 4515 (12.9) | Ref |
| Male | 7776 (18.1) | 1002 (12.9) | 1.12 [0.91, 1.38] |
| ** Race & Ethnicity | |||
| Non-Hispanic White | 20602 (48.0) | 2391 (11.6) | Ref |
| Non-Hispanic Black | 10459 (24.4) | 939 (9.0) | 0.76 [0.48, 1.22] |
| Hispanic | 5467 (12.7) | 403 (7.4) | 0.62 [0.33, 1.16] |
| Asian | 252 (0.6) | 12 (4.8) | 0.80 [0.47, 1.36] |
| Other/Multiracial/Unknown | 6142 (14.3) | 1772 (28.9) | 1.21 [0.41, 3.55] |
| ** IL County Area, n (%) | |||
| Cook County | 16754 (39.0) | 1335 (8.0) | Ref |
| Collar Counties | 10350(24.1) | 819 (7.9) | 3.60 [0.66, 10.7] |
| Downstate | 15818 (36.9) | 1335 (21.3) | 2.77 [0.47, 1.36] |
| ** Insurance Category, n (%) | |||
| Private/Other | 30494 (71.1) | 3625 (11.9) | Ref |
| Medicare | 4260 (9.9) | 668 (15.7) | 0.85 [0.52, 1.40] |
| Medicaid | 6650 (15.5) | 949 (14.3) | 0.60 [0.23, 1.56] |
| Uninsured | 1518 (3.5) | 275 (18.1) | 0.99 [0.33, 2.94] |
| *ZCTA Median Income, n (%) | |||
| Less than $35,000 | 1949 (4.5) | 262 (13.4) | 2.27 [1.30, 4.00] |
| $35–49,999 | 6500 (15.1) | 893 (13.7) | 2.01 [1.16, 3.45] |
| $50–74,999 | 17009 (39.6) | 2759 (16.2) | 2.29 [1.51, 3.49] |
| $75–99,999 | 11221 (26.1) | 1240 (11.1) | 1.73 [1.27, 2.35] |
| $100,000+ | 6243 (14.5) | 363 (5.8) | Ref |
| ** Bariatric Surgery Procedure Performed, n (%) | |||
| Laparoscopic Sleeve Gastrectomy | 27410 (63.9) | 3511 (12.8) | Ref |
| Laparoscopic RYGB | 13017 (30.3) | 1501 (11.5) | 1.08 [0.58, 2.02] |
| Laparoscopic Gastric Band | 1233 (2.9) | 371 (30.1) | 0.55 [0.17, 1.77] |
| Duodenal Switch | 1233 (2.9) | 124 (10.1) | 0.20 [0.07, 0.55] |
| Open RYGB | 29 (0.1) | 10 (34.5) | 3.15 [1.07, 9.33] |
| ** Bariatric Center of Excellence, n (%) | |||
| Non-COE | 5891 (15.4) | 3693 (62.7) | Ref |
| COE | 32258 (84.6) | 770 (2.4) | 0.01 [0.01, 0.06] |
Bivariate p value < 0.05
Bivariate p-value < 0.01
Surgery at Low and High-Volume Hospitals
Among the included hospitals performing metabolic and bariatric surgery, 77 accounted for only 12.9% of all bariatric procedures performed over the study period, whereas the five highest annual volume (≥ 250 procedures/year) hospitals accounted for 27% of all metabolic and bariatric procedures. Of the 33 Metabolic and Bariatric COEs, 7 were considered LVH.
Table 2 shows bivariate comparisons and multivariable logistic regression analysis of the likelihood of surgery at a LVH. Patients 65 – 69 (16.6%), those from Downstate Illinois (21.3%), on Medicare (15.7%), Medicaid (14.3%) or uninsured (18.1%) and from zip codes with household incomes less than $75,000 all had higher rates of surgery at LVH (p < 0.01 for all). Logistic regression results show a higher likelihood of surgery at LVH for patients from zip codes with household incomes less than $35,000 (2.27 [1.30, 4.00]), $35,000–49,999 (2.01 [1.16, 3.45]), $50,000–74,999 (2.29 [1.51, 3.49]) and $50,000–74,999 (1.73 [1.27, 2.35]) when compared to patients from zip codes with household incomes greater than $100,000. There were no significant associations between age, sex, race, county location or insurance type and likelihood of surgery at LVH.
Discussion
Many studies have sought to characterize state and nationwide metabolic and bariatric surgery trends with reference to specific populations. A large electronic health record dataset from 2012–2021 found a greater than 40% increase in metabolic and bariatric surgery rates, peaking in 2018, with a 9.1% increase in Black/African American patients and a 5.5% increase in Hispanic patients, this was not dissimilar from our study findings.13 Similar reviews of state and national metabolic and bariatric surgery trends have found concordant results, however studies have shown that metabolic and bariatric surgery utilization has not increased to the same degree as the rate of obesity.10,13,14
In our study, we found that seven-year rates of metabolic and bariatric surgery in Illinois were highest in middle income populations and the Illinois Black population. This may be related to the large increase in Medicaid coverage of metabolic and bariatric surgery over the study period (12% to 22%). The proportion of Black patients covered by Medicaid increased from 33–37% during the study period. Figure 2 shows monthly bariatric procedures compared with the percentage of metabolic and bariatric procedures for Medicaid patients. Overall, as surgical volume increased, the percentage of patients covered by Medicaid also increased significantly. Rates of metabolic and bariatric surgery were lowest in the Hispanic, highest income and lowest-income populations. The only significant association with use of LVH for metabolic and bariatric surgery was among patients from zip codes with median income less than $75,000/year.
Figure 2.
Monthly Bariatric Procedural Volume Compared with Percentage of Medicaid Coverage for Bariatric Surgical Procedures.
While access to metabolic and bariatric surgery has improved significantly for Black patients in Illinois, these improvements may be related to the continued effects of expansion of metabolic and bariatric surgery coverage by Medicare and Medicaid as the proportion of Black patients with Medicaid who received metabolic and bariatric surgery increased during the study period, whereas those with private insurance did not. Similar improvements were not seen in the Hispanic and low-income populations who are disproportionately uninsured and lacking a usual source of primary care.15−17
Our study showed that metabolic and bariatric surgery utilization still lags significantly among qualifying Hispanic and low-income patients, groups heavily impacted by obesity.3,18,19 Studies show that barriers for Hispanic populations are multifaceted, including lower rates of referral by primary care providers often because Hispanic patients are more likely to be uninsured and deemed ineligible for metabolic and bariatric surgery. 20−22 Other studies have found that differing cultural attitudes towards obesity as well as lack of trust of the medical system contribute to lower use of metabolic and bariatric surgery. 21−23 Low-income populations may also experience lack of social and financial support for both the preoperative metabolic and bariatric surgical requirements in addition to the post-surgical support infrastructure.23
The only association with surgery at LVH was household income, with patients from lower income zip codes being significantly more likely than those from higher income zip codes to use LVH for metabolic and bariatric surgical care. Similar studies looking at the impact of centralization on care have found that often those who continue to use low-volume institutions do so based on closer proximity to the hospital and lower financial resources for travel.7,24
Our study has several limitations. Notably, our eligibility criteria are based on the 1991 NIH guidelines for metabolic and bariatric surgery. The decision to use of the 1991 NIH guidelines was to ensure our cohort was consistent across all years of the study. This was because the new recommendations for metabolic and bariatric surgery, which were published by the American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in 2022 would not have not been adopted by most hospitals or insurance companies during most of the study period as the eligibility criteria for metabolic and bariatric surgery.25,26 These new consensus guidelines recommend metabolic and bariatric surgery for all patients with BMI greater than 35 regardless of comorbidity and that it should be considered for patients with BMI 30–34.9.25 Because of this we significantly underestimate populations eligible for metabolic and bariatric surgery for 2023. However, the trends we report are unlikely to differ significantly despite being underestimated in last year of the eight-year study period. We do not explore patient outcomes in this study – our proxy for quality care is institutional volume. Our population rates are derived from self-reported weight, height and comorbidity data and thus likely underestimated. Many BRFSS respondents, may have undiagnosed conditions and self-reported BMI underestimates objectively measured BM.27 Our methods presume economic homogeneity within often large zip code areas, which may fail to represent the true diversity of different communities within these areas.
Conclusion
This study demonstrates continued increase in utilization of metabolic and bariatric surgery in Illinois as well as the improved utilization for Non-Hispanic Black and Medicaid patients. It also showed that, despite concerns regarding centralization of metabolic and bariatric surgery, there appear to be few systematic disparities in access to care at high-volume centers. This study also highlights the persistently lower utilization of metabolic and bariatric surgery by Hispanic and low-income communities. Our findings reinforce the need to educate providers at all levels regarding appropriate referral practices and suggest the need for addressing social and economic barriers to surgery early in the metabolic and bariatric surgery process.
Supplementary Material
Highlights:
The number of bariatric surgery procedures in Illinois almost doubled from 2016–2022.
Bariatric surgery for non-Hispanic Black and Medicaid populations increased from 2016 2022.
Low household income based on zip code is the only significant predictor of the use of LVH.
Hispanic and low-income patients continue to have the lowest rates of bariatric surgery.
Disclosures:
This research was supported by Northwestern University Department of Surgery as well as the National Cancer Institute, and the National Institutes of Health under the T32 training grant, award number 5T32CA247801-04.
Footnotes
Conflicts of Interests:
The authors assert they have no conflicts of interest.
ETHICS/Consent Statements:
This article does not contain any studies with human participants or animals performed by any of the authors. For this type of study formal consent is not required.
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