Bariatric Times

MAR 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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8 The Medical Student Notebook Bariatric Times • March 2018 Equity in Bariatric Surgery: Access and Outcomes by BRYN FALAHEE, MPhil Bariatric Times. 2018;15(3):8–11. ABSTRACT Obesity and the associated health risks disproportionately affect those with low socioeconomic status. However, the sociodemographic characteristics of Americans with morbid obesity do not match the bariatric surgery recipient population in he US. It is imperative that patients of all sociodemographic groups have access to equitable bariatric care. The literature has repeatedly shown that patients who receive bariatric surgery are more likely to be white, female, and have private insurance. Yet, those eligible for bariatric surgery in the US have lower family incomes, lower education levels, less access to healthcare, and are more likely to be racial minorities. More than one-third of bariatric eligible patients are either uninsured or underinsured, and 15 percent have incomes less than the poverty level. In public systems, where all patients have government-funded insurance, patients receiving surgery are still predominantly of higher socioeconomic status. Therefore, if surgical procedure rates are to represent the affected population, additional measures must be put in place to ensure surgical treatment for those who would like the procedure but might not have geographical, financial, or educational access to bariatric surgery resources. Since identifying the social determinants impacting bariatric surgery, the community has made progress in expanding access. The proportion of non-white individuals and those in the lowest income quartile undergoing bariatric surgery has increased. Yet, the populations disproportionately affected by obesity are still under-represented. Focused public health efforts are needed to equalize and expand access to bariatric care. Initial efforts may include addressing clinicians' implicit biases, reconsidering accepted insurance policies, increasing the diversity of office staff and practitioners, providing social supports to patients, and partnering with primary care providers in community health clinics. KEYWORDS Sociodemographic, access, equity, outcomes, health disparities, Medicaid, Medicare, international systems, demographics, race, income, insurance, bariatric surgery INTRODUCTION Morbid obesity is one of the foremost public health crises in the United States. Obesity and the associated health risks disproportionately affect those with low socioeconomic status, racial minorities, and other traditionally marginalized groups. Bariatric surgery is the only treatment currently offered that results in sustained weight loss, as well as a reduction in related health risks, including diabetes, hypertension, and hyperlipidemia. 1 However, the sociodemographic characteristics of Americans with morbid obesity do not match the bariatric surgery demographics in the US. 1 It is imperative that patients of all sociodemographic groups have access to equitable bariatric care, with outcomes that match their well-off, white peers. This article assesses how the current landscape of bariatric care deals with the inequity of obesity in the population, who gets access to care, patient perceptions of bariatric surgery access, and outcomes. A LONG-STANDING PROBLEM Population-based studies have continually shown disparities in bariatric surgery procedures. A systematic review and meta-analysis published in 2015 searched various databases for retrospective cohort studies that compared at least one sociodemographic characteristic of patients who were eligible for bariatric surgery to those who actually received surgery. The literature review revealed that patients who received bariatric surgery were more likely to be white, female, and have private insurance. 2 However, this is not a recently noticed trend in the bariatric community; studies dating back more than 10 years began to ask why the demographics for bariatric surgery do not represent the population with obesity. The research initially turned to patient selection. A study published in 2007 aimed to identify predictors of patient selection in bariatric surgery by conducting a national survey of 1,343 bariatric surgeons focused on patient age, race, sex, body mass index (BMI), comorbidities, social support, functional status, and insurance. The researchers found that younger age, older age, limited functional status, lacking social support, self-pay, and public insurance decreased the likelihood that the surgeon would operate. However, race did not influence a surgeon's decision to operate. Therefore, the researchers concluded that further studies were needed to look at sociocultural perceptions of morbid obesity and corresponding racial disparities. 3 This study highlights the importance of not only equitable care once the patient gets to the office, through unbiased selection by the surgeon, but also the necessity of finding ways to reach populations who do not make it to the office for assessment in the first place. It is not enough to treat only those who walk through the door if bariatric care strives to be equitable. It is also imperative to reach out to the populations of individuals who would benefit from bariatric care but do not come looking for it due to lack of knowledge, lack of access due to location, inaccessibility of resources, perceived cost, and the "corresponding racial disparities" alluded to in the article. The MEDICAL STUDENT Notebook This column is written by medical students and is dedicated to reviewing the science behind obesity and bariatric surgery. COLUMN EDITOR Daniel B. Jones, MD, MS, FASMBS Professor of Surgery, Harvard Medical School Vice Chair, Beth Israel Deaconess Medical Center Boston, Massachusetts FEATURED STUDENT Bryn E. Falahee, MPhil Medical Student, Harvard Medical School Boston, Massachusetts

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