Nearly a Five-Fold Difference Between States in Use of Bariatric Surgery

How eligible patients utilized bariatric surgery varied between states, but there were generally less procedures performed in areas where obesity is a major health issue, a researcher reported.

The overall utilization of bariatric surgery among eligible patients was highest in New Jersey (10.4%), followed by Rhode Island (9.6%) and Delaware (9.2%), according to Scott Schimpke, MD, of Rush Medical College in Chicago.

The lowest utilization rates were recorded in Vermont (2.1%), Arkansas (2.6%), Alabama (2.8%) and West Virginia (2.8%), he said in a presentation at the American Society for Metabolic & Bariatric Surgery (ASMBS) virtual meeting.

There was "almost a five-fold difference between the states with the highest and lowest utilization," Schimpke and colleagues noted.

The CDC reports that Midwestern (33.9%) and Southern (33.3%) states have the highest prevalence of obesity, followed by states in the Northeast (29.0%) and the West (27.4%).

Schimpke noted that bariatric surgery offers significant weight loss and resolution or improvements in related symptoms -- such as diabetes, heart disease, and sleep apnea -- with a relatively low rate of adverse events.

"The best treatment for severe obesity is also, unfortunately, the most underutilized by many of the very people who can most benefit," said Schimpke. "These state disparities in utilization, and the factors contributing to it, need to be better understood and addressed to ensure equitable access to bariatric surgery, and to reduce the burden of obesity in America."

The researchers analyzed the PearlDiver Mariner insurance claims database for the state-by-state analysis, and identified 99,173 bariatric surgery patients out of >1.8 million eligible for weight loss surgery between 2010 and 2019, for a 5.5% utilization rate. They classified bariatric surgery as sleeve gastrectomy or gastric bypass surgery.

Eligible adults had a BMI of at least 35 with a comorbidity. In 2017-2018, a little over 42% of U.S. adults had obesity, according to the CDC, while another 9.2% had severe obesity.

Schimpke reported that patients who underwent bariatric surgery were more likely to be female and have commercial insurance (80% vs 70% with public insurance).

The Northeast region had the highest utilization rate (7.95%), while the Midwest had the lowest (4.47%). The proportion of bariatric surgeries that were sleeve gastrectomies also varied from <30% in Alaska, North Dakota, and Rhode Island to <80% in New Jersey, Nevada, and Mississippi.

The researchers suggested that multiple factors may contribute to these variations, including physician beliefs, the number of bariatric surgeons in certain geographic areas, financial incentives, insurance coverage and policy differences, as well as patient characteristics. About 256,000 bariatric surgeries were performed in the U.S. in 2019, which represents less than 1% of the country's currently eligible surgical population, they reported.

"Bariatric surgery remains one of the most underutilized treatments in all of medicine," said ASMBS president Matthew M. Hutter, MD, of Harvard Medical School in Boston. "Access to this life-saving and transformational treatment should not be determined by zip code but rather by medical need."

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