Objective: To identify sociodemographic and clinical predictors of patient selection in bariatric surgery.
Summary Background Data: Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients’ personal preferences regarding surgical treatment.
Methods: We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities.
Results: A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14–0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07–0.11), older age (OR, 0.70; 95% CI, 0.56–0.90), limited functional status (OR, 0.66; 95% CI, 0.52–0.82), poor social support (OR, 0.37; 95% CI, 0.30–0.47), self-pay (OR, 0.72; 95% CI, 0.57–0.91), and public insurance (OR, 0.54; 95% CI, 0.43–0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects.
Conclusions: Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.
Population-based studies have shown racial, gender-based, and socioeconomic disparities among bariatric surgery patients. A national survey of U.S. bariatric surgeons using clinical vignettes reveals that age, body mass index, and social support are the chief determinants of patient selection for bariatric surgery. Comorbidities, functional status, and payment source influence surgeon decisions to a lesser extent with little or no influence from patient sex or race.
From the Departments of *Surgery, †Health Studies, and ‡Medicine, and the §Robert Wood Johnson Clinical Scholars Program, University of Chicago, Chicago, IL.
Dr. Santry undertook this research while she was a Robert Wood Johnson Clinical Scholar supported by the Robert Wood Johnson Foundation. Additional funding was provided by a pilot project grant from the Center on Aging at the University of Chicago (P30 AG-12857-08) and a research grant from the Dr. Paul Jordan Research Fund in Surgery at the University of Chicago.
Dr. Santry presented preliminary data from this paper at the Charles Huggins Research Conference at the University of Chicago in Chicago, IL on May 16, 2005 and at the Surgical Forum of the American College of Surgeons Clinical Congress in San Francisco, CA on October 19, 2005.
Reprints: Heena P. Santry, MD, Department of Surgery, University of Chicago, MC 6040, 5841 S. Maryland Avenue, Chicago, IL 60637. E-mail: firstname.lastname@example.org.