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

Results

An estimated 1,903,273 patients underwent primary inpatient bariatric surgery in the United States from 1993 to 2016. The estimated number of surgeries performed annually increased from 8,631 in 1993 to 162,969 in 2016 (Figure 1; Supplemental Tables 1a and 1b, http://links.lww.com/SLA/B753). Surgical techniques changed significantly, perhaps the most noteworthy of which was a dramatic shift from exclusively open procedures in 1993 to almost exclusively laparoscopic procedures in 2016. Types of bariatric surgery also changed over the years. Open VBG was once the most commonly performed bariatric surgery (49% of cases in 1993) but now is rarely used, along with laparoscopic AGB. In contrast, RYGB has withstood the test of time as one of the most popular bariatric procedures, accounting for 48.6% and 28.6% of cases in 1993 and 2016, respectively. Nevertheless, the fractional contribution of RYGB to the total annual number of bariatric surgeries recently declined due to an increased utilization of laparoscopic SG, which accounted for 68.8% of all cases in 2016, and 70.5% when accounting for the small proportion of open SG.

Figure 1.

Number and types of inpatient primary bariatric surgery procedures in the United States—1993 to 2016.

Characteristics of the patient population receiving bariatric surgery and setting at which it is offered have also changed (Table 2; Supplemental Tables 2a and 2b, http://links.lww.com/SLA/B753). Mean age at the time of operation increased steadily from 38.9 years in 1993 to 44.4 years in 2016 (P<0.001) and was 43.9 years over the entire study period. Although patients receiving surgery were predominantly female (1,517,156 or 79.9%), the number and proportion of males who received surgery increased from 1,317 (15.3%) in 1993 to 33,155 (20.4%) in 2016. Similar trends were observed for race and insurance. Although most patients who received surgery across the study period were white and had commercial insurance, the proportion of patients who identified as black or Hispanic and with Medicare or Medicaid increased between 1993 and 2016 (P < 0.0001 for all). Frequencies of obesity-related comorbidities increased among bariatric surgery patients between 1993 and 2016, from 10.2% to 28.3% with T2D, 28.1% to 53% with hypertension, and 8% to 44.3% for obstructive sleep apnea (P < 0.0001 for each). In 1993, most surgeries were performed in urban nonteaching (75.2%) and large (53.4%) hospitals (Supplemental Tables 3a and 3b, http://links.lww.com/SLA/B753). In comparison, most surgeries performed in 2016 were in urban teaching (72.5%, P < 0.0001) hospitals, whereas the proportion in large hospitals declined (47.4%, P = 0.005).

Safety Outcomes and Length of Stay

Complication and mortality rates peaked in 1998 (11.7% and 1%, respectively) and steadily decreased afterward, reaching a nadir of 1.4% and 0.04%, respectively, in 2016 (Figure 2 and Table 3; Supplemental Tables 4a and 4b, http://links.lww.com/SLA/B753). Overall, gastrointestinal complications were the most frequent type of complication observed across the 23-year study period (1.5%), but significantly decreased from 4.8% in 1993 to 0.2% in 2016 (P < 0.0001). Surgical complications were reported in 1.1% of all cases and similarly decreased over time from 2.3% in 1993 to 0.5% in 2016 (P < 0.0001).

Figure 2.

Number of inpatient primary bariatric surgery procedures and initial admission complication and mortality rates in the United States from 1993 to 2016.

The overall mean hospital LOS was 2.6 days, decreasing from 6.2 to 1.9 days between 1993 and 2016 (P < 0.0001). Similarly, LOS for individual surgery types decreased over the entire study period.

Costs

Total hospital cost of primary inpatient bariatric surgery admissions between 2001 and 2016 was $12,867 ($9,908–$16,911) (Table 4). Cost decreased overtime; from $14,103 ($10,545–$19,144) in 2001 to $10,953 ($8,678–$14,082) in 2016 (P < 0.01). Among the 2 most common bariatric procedures in recent years, laparoscopic SG was associated with a lower cost compared with laparoscopic RYGB throughout the years (P < 0.01).

Utilization

The estimated number of adults possibly eligible for bariatric surgery increased from 11,775,017 (6.4%) in 1993 to 19,027,087 (9.9%) in 2004 and to 32,420,287 (14.7%) in 2016 (Table 5; Supplemental Figure 1, http://links.lww.com/SLA/B753). The estimated utilization of surgery in the eligible population increased from 73/100,000 (0.07%) in 1993 to a peak of 622/100,000 (0.6%) in 2004 before declining to 503/100,000 (0.5%) in 2016.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....