Rural/urban, racial/ethnic, and socioeconomic disparities in bariatric surgery for morbid obesity

Objectives: Morbid obesity is associated with serious health and social consequences, and is steadily increasing among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, socioeconomic levels, co-morbidity levels, and insurance categories.

Methods: From the 2006 Nationwide Inpatient Sample database, we extracted 159,116 records representing approximately 734,000 patients with morbid obesity diagnoses; of these, 88,605 [11.5%] patients underwent bariatric surgery. From these, we calculated odds ratios for undergoing bariatric surgery adjusting for patient characteristics described above.

Results: After adjusting for patient-level characteristics, rural residents were 23% [95% CI, 18% to 28%] less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios (all p<.001) for bariatric surgery included minority status (compared to non-Hispanic Whites, ORs: Hispanics: 0.82, Asians: 0.55, Blacks: 0.51), gender (OR 0.46 for men compared to women), income level (ORs: 0.78 for $45-59,000; 0.63 for <$6,000 compared to $60,000 plus), age (odds ratios 0.73 for 40-59 year olds, 0.23 for 60 and older compared to those under age 40), insurance status (ORs: 0.73 for self pay and less than 0.25 for Medicare and Medicaid compared to privately insured patients), and co-morbidity (ORs: 0.79 for Charlson score=1, 0.24 for Charlson score=2+ compared to Charlson score=0). Compared to a young white female with private insurance and no co-morbidities residing in a wealthy urban locale, the odds of a middle-aged black male with two or more co-morbidities who is Medicaid reliant and living in a low-income rural area accessing bariatric surgery was 0.004.

Conclusions: Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, patients with these characteristics are unlikely to access bariatric surgery. Access to long term weight loss treatment for these populations is important for several reasons. Significant weight reduction can reduce future medical morbidity and healthcare costs and weight loss in obese parents is positively associated with weight normalization of their children. Given that obesity is a leading cause of preventable morbidity and mortality in the U.S., effective treatments should be made available to all patients who might benefit. In particular, current Medicare/ Medicaid policies that restrict bariatric surgery to high volume centers may effectively deny rural residents who rely on these insurance programs for this treatment.