RESUMO
BACKGROUND: Metabolic and bariatric surgery (MBS) is under-accessed by non-White patients, who are disproportionately affected by obesity. We hypothesized that unique barriers experienced by socially vulnerable patients drive disparate MBS utilization. OBJECTIVES: To determine whether socially vulnerable patients experience greater attrition and face more insurance-mandated medical weight management (MWM) requirements. SETTING: Urban, academic center. METHODS: This retrospective cohort study included adults evaluated for MBS in 2018. Social vulnerability was determined using the 2018 Social Vulnerability Index. Outcomes included attrition, or failure to undergo surgery within 1year, and the number and duration of MWM requirements. Multivariable logistic regression and negative binomial regression tested these associations. RESULTS: In 2018, 339 patients were evaluated for MBS (83% female, 70% Black). The attrition rate was 57%. On adjusted analyses, patients in the highest social vulnerability quartile had double the odds of attrition compared to their least vulnerable counterparts (OR 2.33, 95% CI 1.11-4.92, P = .03). Highly vulnerable patients had double the number (IRR 2.29, 95% CI 1.42-3.72, P = .001) and nearly quadruple the duration (IRR 3.90, 95% CI 1.93-7.86, P < .001) of MWM requirements compared to those with low social vulnerability. Odds of attrition increased by 11% and 20% for each additional MWM visit (OR 1.11, 95% CI 1.02-1.20, P = .02) and month (OR 1.20, 95% CI 1.08-1.33, P = .001), respectively. CONCLUSIONS: Patients with high social vulnerability were less likely to undergo MBS and faced more insurance-mandated preoperative requirements, which independently predicted attrition. Insurance-mandated MWM is inequitable and may contribute to disparate care of patients with severe obesity.
RESUMO
BACKGROUND: We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery. OBJECTIVE: To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery. SETTING: University hospital. METHODS: A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements. RESULTS: A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01). CONCLUSIONS: Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.