Bariatric Surgery Safety Improved Over Time, but Utilization Is Low

By Marilynn Larkin

February 13, 2020

NEW YORK (Reuters Health) - Despite advances in the safety of bariatric surgery over the past 25 years, utilization has remained low, an observational study reveals.

When offered in accredited centers, the complication rate for bariatric surgery is lower than for a cholecystectomy, Dr. Guilherme Campos of Virginia Commonwealth University in Richmond told Reuters Health by email.

With that said, he noted, "Despite all the improvements and benefits that are well documented in the literature, only 0.5% of the population that can benefit from bariatric surgery, receives it."

"Most potential referring practitioners - from primary care physicians, to specialists such as endocrinologists, and even obesity medicine doctors - overestimate surgical risks, and do not have a clear understanding of the potential for surgery to ameliorate existing diseases, improve quality of life, remit type 2 diabetes, and improve cardiovascular health while reducing risks of cancer and premature mortality," he said. "Thus, they do not start a conversation with patients about surgery or do not refer their patients."

Further, he said, "While obesity is classified as a disease by the American Medical Association, there are still many biases and barriers that patients face as to get appropriate treatment for obesity covered. Medicare and most Medicaid products cover surgery; (however), many commercial insurance providers have limitations on coverage."

Dr. Campos and colleagues identified close to two million adults who underwent bariatric surgery in the U.S. from 1993 to 2016. At baseline, the mean age was 43.9; 79.9% were women; 70.9%, white; and 70.7% had commercial insurance. However, these and other characteristics changed over time, according to the Annals of Surgery report.

Among the findings:

- In 1993, all 8,631 procedures were performed as open surgeries, about equally distributed between gastric bypass and vertical banded gastroplasty;

- In 2016, 98% of about 163,000 procedures were done laparoscopically: 69.8% sleeve gastrectomy and 27.8% gastric bypass;

- In 1998, complication and mortality rates peaked (11% and 1%, respectively) and progressively decreased to 1.4% and 0.04%;

- Although utilization increased from 0.07% in 1993 to 0.62% in 2004, it remained low, at 0.5%, in 2016.

Dr. Campos noted that in smaller countries such as Sweden, which have universal health coverage, bariatric surgery is much more common than in the U.S. "Improved health insurance coverage for bariatric surgery (would) allow more patients to seek treatment," he said.

Further, he added, "improving education in medical schools about all the options for treatment of obesity (would) likely also improve referral patterns" and enable more individuals to benefit from bariatric surgery.

Dr. Eduardo Grunvald, Medical Director of the UCSD Weight Management Program in California, commented in an email to Reuters Health, "Although there are some limitations to this analysis, the conclusions are consistent with other analyses, clinical experience, and expert consensus regarding underutilization and benefits of bariatric surgery in general, especially in the modern era of laparoscopic surgery and metabolic procedures."

In addition to insurance barriers, Dr. Grunvald points to the following:

- Patient misinformation, fear and bias. "Many patients simply are afraid of a major abdominal surgery, may not fully understand the benefit-risk balance, and operate under the cognitive paradigm of simple willpower, discipline and self control when it comes to managing weight," he said. "The scientific evidence supports the unfortunate truth that the majority of patients with severe obesity are unable to sustain significant weight loss long-term, in part mediated by underlying biological factors outside of an individual's control."

- Confusion in the medical profession. "Aside from lack of training and education on obesity treatment, there is sometimes a lack of clarity on which patients should be referred for surgical weight loss," he noted. "Not only do patients receive different opinions from different doctors, they are recipients of conflicting messages in the popular media, from family and friends, and from the internet. It is rare that a patient receives unified guidance and support when it comes to surgical weight loss."

Further, he added, "Some patients may not think they weigh enough to qualify for bariatric surgery, even though their weight-related conditions would make them eligible."

SOURCE: Annals of Surgery, February 1, 2020.