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Access to surgery

Number of bariatric procedures increases but access remains low

Pressing need to study and address the current impediments restricting access to this life changing and live saving surgery
the estimated number of adults possibly eligible for bariatric surgery increased from 11,775,017 (6.4%) in 1993 to 19,027,087 (9.9%) in 2004 and to 32,420,287 (14.7%)

Although the number of bariatric procedures in the US over the last 20 years has increased, access to surgery remains low despite a growing number of patients that are considered eligible for surgery, according to researchers from the Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA.

The outcomes from the paper, ‘Changes in Utilization of Bariatric Surgery in the United States From 1993 to 2016’, published in the Annals of Surgery (2020;271(2):201-209), show that despite improvements in the safety and effectiveness, types, number and cost of bariatric procedures, there is a pressing need to study and address the current impediments restricting access to this life changing and live saving surgery.

For the study, the researchers examined changes in perioperative outcomes and utilisation of bariatric surgery in the US from 1993 to 2016. Specifically, they looked at the annual trends and changes in number, types, cost, hospital setting and location, patient characteristics, and initial admission outcomes of primary inpatient bariatric surgeries) They also assessed the overall utilisation in the eligible adult population.

Outcomes

From 1993 to 2016, an estimated 1,903,273 patients underwent primary inpatient bariatric surgery in the US and the estimated number of procedures increased from 8,631 in 1993 to 162,969 in 2016. Roux-en-Y Gastric Bypass (open RYGB) has declined from 48.6% of all procedures in 1993 to 28.6% in 2016 (laparoscopic RYGB), as laparoscopic sleeve gastrectomy rose to 68.8% of all cases in 2016.

Patient characteristics also changed over the study period and the researchers reported:

  • Mean age increased from 38.9 years in 1993 to 44.4 years in 2016 (p<0.001)
  • Patients were predominantly female (1,517,156/79.9%) but the number and proportion of males who received surgery increased from 1,317 (15.3%) in 1993 to 33,155 (20.4%) in 2016
  • Proportion of patients who identified as black or Hispanic and with Medicare or Medicaid increased between 1993 and 2016 (p<0.0001 for all)
  • Over the study period, the frequencies of obesity-related comorbidities increased from 10.2% to 28.3% with T2D, 28.1% to 53% with hypertension and 8% to 44.3% for obstructive sleep apnoea (p<0.0001 for each)

The authors reported that the overall mean hospital length of stay was 2.6 days, decreasing from 6.2 to 1.9 days between 1993 and 2016 (p<0.0001). Complication and mortality rates peaked in 1998 (11.7% and 1%, respectively) and decreased reaching a low of 1.4% and 0.04%, respectively, in 2016. Gastrointestinal complications were the most frequent complication (1.5%), but significantly decreased from 4.8% in 1993 to 0.2% in 2016 (p<0.0001). Surgical complications decreased from 2.3% in 1993 to 0.5% in 2016 (p<0.0001).

The cost of bariatric surgery has decreased overtime from US$14,103 (US$10,545–$US19,144) in 2001 to US$10,953 (US$8,678–US$14,082) in 2016 (p<0.01). Laparoscopic sleeve gastrectomy was associated with a lower cost compared with laparoscopic RYGB in the study period (p<0.01).

Crucially, the estimated number of adults possibly eligible for bariatric surgery increased from 11,775,017 (6.4%) in 1993 to 19,027,087 (9.9%) in 2004 and to 32,420,287 (14.7%). The estimated utilisation of surgery in the eligible population increased from 73/100,000 (0.07%) in 1993 to 622/100,000 (0.6%) in 2004 before declining to 503/100,000 (0.5%) in 2016.

A lack of knowledge from referring practitioners about the safety and effectiveness of bariatric surgery could also be a barrier to surgery, the researchers state, and results in a fewer patients being evaluated obesity specialists. The authors recommend that improving the awareness about the safety and effectiveness of bariatric surgery is needed and may help dispel referring practitioners' fears.

The authors noted that another barrier to improve access is the variable coverage for surgery across commercial, state and federal insurance payers and programmes across geographical regions, and for some payers the lack of coverage seems to be doubts over the cost-effectiveness of bariatric surgery. However, the researchers own calculations estimate of median bariatric surgery hospitalisation cost of around US$12,900, lower than the median cost of US$17,800 reported for ventral hernia repair.

“Perioperative index admission safety of bariatric surgery has improved significantly from 1993 to 2016, alongside changes in types, number and cost of surgeries, characteristics of patients having surgery, and characteristics and location of hospitals where these surgeries are done,” the authors concluded. “Although the number of surgeries has increased, utilisation of surgery in the growing number of individuals that are considered eligible for surgery has remained low. Studying and addressing barriers to utilisation may allow for greater access to surgical therapy.”

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