A comprehensive 20-year analysis of bariatric surgery discussions and outcomes has unveiled significant racial disparities in surgical progression rates, with Black patients facing notably lower odds of proceeding with the procedure after initial consultations.
Researchers from Brigham and Women's Hospital, led by Alexander Turchin, MD, MS, examined data from 122,487 patients with class II obesity or higher (BMI ≥35) between 2000 and 2020. The study revealed that while 9.1% of eligible patients discussed metabolic and bariatric surgery with their healthcare providers, only 12.2% of these individuals ultimately underwent the procedure.
Racial Disparities in Surgical Progression
The analysis uncovered a striking disparity: despite similar rates of initial surgical discussions between Black and non-Black patients (9.5% vs 9%, P=0.09), Black patients were significantly less likely to proceed with surgery. Only 8.4% of Black patients progressed to surgery compared to 12.6% of non-Black patients (P<0.001), translating to 44% lower odds of proceeding with the procedure (OR 0.56, 95% CI 0.45-0.70).
These findings are particularly concerning given that Black patients in the study demonstrated higher rates of diabetes (10% vs 7.1%, P<0.001) and slightly higher average BMI (39.4 vs 39.1, P<0.001) compared to non-Black patients.
Gender Disparities and Temporal Trends
The study also identified significant gender-based disparities. Men were less likely than women to both discuss (8.1% vs 9.6%, P<0.001) and receive surgery (7.6% vs 14.6%, P<0.001). This gender gap has actually widened over the study period, with the difference in surgery progression rates between women and men increasing by 2.7% annually (P=0.037).
Improving Access and Understanding Barriers
"Our findings indicate that we need to improve these conversations and identify barriers to undergoing surgery once it has been discussed," stated Dr. Turchin. The researchers identified several potential factors contributing to lower surgical progression rates among Black patients, including:
- Implicit provider bias
- Higher rates of medical mistrust
- Lower levels of health literacy
- Cultural and social factors
Positive Developments and Future Implications
One encouraging finding was that surgical discussions became more common over the two decades, increasing from 3.2% to 10% (P<0.001). Additionally, the disparity in progression rates between Black and non-Black patients showed signs of improvement, decreasing by 4.4% annually (P=0.044).
The researchers noted that primary care physicians, who initiated most surgical discussions, should be the primary focus of interventions aimed at increasing metabolic and bariatric surgery uptake. However, they also acknowledged that the recent emergence of effective anti-obesity medications, particularly GLP-1 receptor agonists, may influence future surgical referral patterns.
Study Demographics and Limitations
The study population, drawn from Mass General Brigham-affiliated primary care practices, included patients under 65 years of age with class II obesity or higher. The cohort's median age was 45, with a median BMI of 37.3. The racial composition included 75.1% white, 10.2% Black, 5.1% Hispanic, and 1.4% Asian patients.
A notable limitation was the lack of information about discussions regarding non-surgical weight-loss alternatives, such as medication or lifestyle interventions. The researchers recommend future studies focus on identifying specific patient barriers to receiving metabolic surgery following provider recommendations.
