Changes in Utilization of Bariatric Surgery in the United States From 1993 to 2016

Guilherme M. Campos, MD, PhD; Jad Khoraki, MD; Matthew G. Browning, PhD; Bernardo M. Pessoa, MD; Guilherme S. Mazzini, MD, PhD; Luke Wolfe, MS

Disclosures

Annals of Surgery. 2020;271(2):201-209. 

In This Article

Abstract and Introduction

Abstract

Objective: The aim of this study was to obtain estimates of changes in perioperative outcomes and utilization of bariatric surgery in the United States from 1993 to 2016.

Background: Bariatric surgery has evolved over the past 2 decades. Nationally representative information on changes of perioperative outcomes and utilization of surgery in the growing eligible population (class III obesity or class II obesity with comorbidities) is lacking.

Methods: Adults with obesity diagnosis who underwent primary bariatric surgery in the United States from 1993 to 2016 were identified in the National Inpatient Sample database. Estimates of the yearly number, types and cost of surgeries, patients' and hospital characteristics, complications and mortality rates were obtained. Prevalence of obesity and comorbidities were obtained from the National Health and Nutrition Examination Survey and changes in utilization of surgery were estimated.

Results: An estimated 1,903,273 patients underwent bariatric surgery in the United States between 1993 and 2016. Mean age was 43.9 years (79.9% women, 70.9% white race, 70.7% commercial insurance); these and other characteristics changed over time. Surgeries were exclusively open operations in 1993 (n = 8,631; gastric bypass and vertical banded gastroplasty, 49% each) and 98% laparoscopic (n = 162,969; 69.8% sleeve gastrectomy and 27.8% gastric bypass) in 2016. Complication and mortality rates peaked in 1998 (11.7% and 1%) and progressively decreased to 1.4% and 0.04% in 2016. Utilization increased from 0.07% in 1993 to 0.62% in 2004 and remained low at 0.5% in 2016.

Conclusions: Perioperative safety of bariatric surgery improved over the last quarter-century. Despite growth in number of surgeries, utilization has only marginally increased. Addressing barriers for utilization may allow for greater access to surgical therapy.

Introduction

Bariatric surgery has evolved in the United States and worldwide over the past 2 decades, with changes in the types of surgery, the introduction and dissemination of laparoscopic techniques, refinements in patient selection and preparation processes for surgery, and improvements in perioperative and long-term outcomes.[1–6] As a testament to these important advances, evidence indicates that current bariatric surgery techniques, when performed in accredited centers, have low complication rates, and provide for sustained and meaningful weight loss in most patients and significantly improve quality of life, type 2 diabetes (T2D), and cardiovascular health while reducing risks of premature mortality.[7–11] However, nationally representative information of changes in types and number of bariatric surgeries performed, settings at which surgery is offered, patient characteristics, and overall utilization in the continuously growing eligible population with severe obesity[12,13] is lacking.

Although the estimated number of bariatric surgeries reported annually in the United States has increased over time,[1,14] it has been suggested recently that utilization of surgery in the adult population is approximately 1%.[15] However, this utilization estimate takes into account only the proportion of the population expected to qualify for surgery with a body mass index (BMI) of 40 kg/m2 or higher, and does not include the many individuals with class II obesity (BMI 35–39.9 kg/m2) and at least one related comorbidity who are also considered possible candidates.[16] As the national prevalence of class II obesity is more than twice that of class III obesity,[17] inclusion of all potential qualifying individuals is expected to yield substantially lower penetration rates of surgery. Defining details of and trends in the utilization of bariatric surgery in the estimated eligible population is needed to support studying and overcoming the barriers to access to surgical care.

This study aimed to estimate the annual trends and changes in number, types, cost, hospital setting and location, patient characteristics, and initial admission outcomes of primary inpatient bariatric surgeries, as well as overall utilization in the eligible adult population, in the United States from 1993 to 2016 using 2 nationally representative databases.

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