Factors associated with bariatric surgery utilization among eligible candidates: who drops out?

Falling short in bariatric surgery: An exploration of key barriers and motivators of attrition

BACKGROUND

In the United States, obesity-related diseases pose significant healthcare challenges, with bariatric surgery offering a potential solution. However, bariatric surgery completion rates, particularly among Black and Hispanic populations, remain low.

OBJECTIVE

This study applied the Theoretical Domains Framework (TDF) to explore behavioral factors influencing bariatric surgery program attrition among a majority Black participant population to inform interventions for improving attrition.

METHODS

We conducted semi-structured interviews with 40 surgical and non-surgical participants and conducted deductive content analysis informed by six TDF constructs to explore factors influencing bariatric surgery program attrition.

RESULTS

Participants' decision-making regarding bariatric surgery is influenced by behavioral factors, including knowledge, skills, social roles, beliefs about capabilities, optimism, and beliefs about consequences.

CONCLUSION

Understanding multifaceted factors influencing bariatric surgery attrition will inform the development of tailored interventions that address knowledge gaps, enhance skills, and consider social role conflicts to improve patient engagement and decision-making in managing obesity, especially for Black populations.

Bariatric surgery: trends in utilization, complications, conversions and revisions

BACKGROUND

Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States.

METHODS

We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis.

RESULTS

We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB.

CONCLUSIONS

The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

Factors associated with progression or non-progression to bariatric surgery in adults: A systematic review

Access to bariatric surgery is limited, and the factors related to undergoing or not undergoing the procedure are poorly understood. To this end, a systematic review of PubMed, Embase, PsycINFO, and CINAHL was conducted to deduce the factors associated with progression or non-progression to bariatric surgery. Quantitative and qualitative English-language articles ranging in date from database conception to September 2023 were included. Eligible studies employed adult participants (18 years of age or above) who had been referred for bariatric surgery. A total of 57 studies were identified. Fifteen key factors were found, alongside six less frequently studied factors: age, sex, BMI, race and ethnicity, distance to clinic, socio-economic status, insurance coverage, physical health, psychological health, eating history and habits, substance use and smoking, social influence and relationships, pre-surgery process and requirements, surgery-related concerns, choice of surgery, and others (emergency room visitation, COVID-19 virus, health literacy, appearance perceptions, time-off work, and stigma related to surgery). No factors were found to be reliably associated with progression or non-progression to bariatric surgery; however, the nature of these findings is tentative considering methodological flaws and limited research. Further studies are required to elucidate potential inequities in bariatric surgery access and educate policymakers and health professionals.

Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality?

BACKGROUND

Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes.

METHODS

Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles.

RESULTS

Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001).

CONCLUSIONS

Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.

Comparison of safety and healthcare utilization following sleeve gastrectomy or gastric bypass among medicare beneficiaries using sex as a biologic variable

BACKGROUND

Bariatric surgery is a common operation, but differences in outcomes between males and females are unknown.

OBJECTIVES

To compare the risk of mortality, complications, reintervention, and healthcare utilization after sleeve gastrectomy or gastric bypass using sex as a biologic variable.

SETTING

United States.

METHODS

Retrospective cohort study of adults undergoing sleeve gastrectomy or gastric bypass from January 1, 2012 to December 31, 2018 using Medicare claims data. We performed a heterogeneity of treatment effect analysis to determine the impact of sleeve gastrectomy versus gastric bypass comparing males to females. The primary outcome was safety (mortality, complications, and reinterventions) up to 5 years after surgery. The secondary outcome was healthcare utilization (hospitalization and emergency department use).

RESULTS

Among 95,405 patients the majority (n = 71,348; 74.8%) were female and most (n = 57,008; 59.8%) underwent sleeve gastrectomy. For all patients, compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of complications and reintervention but a higher risk of revision. Compared to gastric bypass, sleeve gastrectomy was associated with a lower risk of mortality for females (adjusted hazard ratio .86, 95% CI .75-.96) but not males. We found no difference in procedure treatment effect by sex for mortality, hospitalization, emergency department use, or overall reintervention when comparing sleeve to gastric bypass.

CONCLUSIONS

Females and males have similar outcomes following bariatric surgery. Females have a lower risk of complications but a higher risk of reintervention. Decisions surrounding treatment for this common procedure should be tailored to include a discussion of sex-specific differences in treatment outcome.

Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery

PURPOSE

Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care.

MATERIALS AND METHODS

This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers.

RESULTS

This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers.

CONCLUSION

Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Preoperative Follow-up in Bariatric Surgery: Why They Give Up? Rate, Causes, and Economic Impact of Dropout

BACKGROUND

Preoperative attrition is highly prevalent in patients referred for bariatric surgery. Little information is available neither on reasons reported by patients for attrition in knowledge nor costs of attrition in a publicly funded health system.

OBJECTIVES

To assess the reasons for the attrition of bariatric candidates and calculate its economic impact on a population with obesity in a public hospital in France.

METHODS

This is a retrospective study including all bariatric surgery candidates between 2014 and 2018 in our Center of Excellence in Obesity Care. Data were extracted from the hospital information system, and patient-related outcomes were collected via a standardized questionnaire. Economic analysis was performed. Primary outcome was to analyze the rate of preoperative attrition. Secondary outcome was reasons for discontinuation and their economic impact.

RESULTS

In total, 1360 patients were referred for bariatric surgery at our hospital, and 1225 were included in the study. Attrition rate in preoperative phase was 46.8%. Three factors were significantly associated with follow-up fragmentation risk: unemployment (OR 0.52, 95% CI 0.29-0.7, p < 0.001), active smoking (OR 2.24, 95% CI 1.53-5.15, p < 0.001), and body mass index (OR 0.98, 95% CI 0.97-1.00, p = 0.036). Average cost to the healthcare system was €792 for each patient who dropped out.

CONCLUSIONS

We identified predictors and patient-reported factors that seem to be beyond the possibility of removal by health professionals. We should consider and address preventable factors, through the development of care pathways tailored to the individual profile of a patient.

A qualitative analysis describing attrition from bariatric surgery to identify strategies for improving retention in patients who desire treatment

BACKGROUND

Among patients who express interest in bariatric surgery, dropout rates from bariatric surgery programs are reported as high as 60%. There is a lack of understanding how we can better support patients to obtain treatment of this serious chronic disease.

METHODS

Semi-structured interviews with individuals who dropped out of bariatric surgery programs from three clinical sites were conducted. Transcripts were iteratively analyzed to understand patterns clustering around codes. We mapped these codes to domains of the Theoretical Domains Framework (TDF) which will serve as the basis of future theory-based interventions.

RESULTS

Twenty patients who self-identified as 60% female and 85% as non-Hispanic White were included. The results clustered around codes of "perceptions of bariatric surgery," "reasons for not undergoing surgery," and "factors for re-considering surgery." Major drivers of attrition were burden of pre-operative workup requirements, stigma against bariatric surgery, fear of surgery, and anticipated regret. The number and time for requirements led patients to lose their initial optimism about improving health. Perceptions regarding being seen as weak for choosing bariatric surgery, fear of surgery itself, and possible regret over surgery grew as time passed. These drivers mapped to four TDF domains: environmental context and resources, social role and identity, emotion, and beliefs about consequences, respectively.

CONCLUSIONS

This study uses the TDF to identify areas of greatest concern for patients to be used for intervention design. This is the first step in understanding how we best support patients who express interest in bariatric surgery achieve their goals and live healthier lives.

The role of preoperative toxicology screening in patients undergoing bariatric surgery

BACKGROUND

Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes.

OBJECTIVES

To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes.

METHODS

We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis.

RESULTS

Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X² = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m² [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)].

CONCLUSIONS

Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times.

Racial variation in baseline characteristics and wait times among patients undergoing bariatric surgery

BACKGROUND

Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients.

METHODS

Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups.

RESULTS

A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0 years vs. 46.6 years, p < 0.0001), disabled (16% vs. 11.4%, p < 0.0001) and have Medicaid (8.4% vs. 3.8%, p < 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p < 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157 days vs. 127 days, p < 0.0001), despite having higher rates of patients with a body mass index above 50 kg/m2 (39.0% vs. 33.2%, p < 0.0001).

CONCLUSIONS

Non-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Variation in pre-operative insurance requirements for bariatric surgery

BACKGROUND

For patients who wish to undergo bariatric surgery, variation in pre-operative insurance requirements may represent inequity across insurance plan types. We conducted a cross-sectional assessment of the variation in pre-operative insurance requirements.

METHODS

Original insurance policy documents for pre-operative requirements were obtained from bariatric surgery programs across the entire USA and online insurance portals. Insurance programs analyzed include commercial, Medicaid, and Medicare/TriCare plans. Poisson regression adjusting for U.S. Census region was used to evaluate variation in pre-operative requirements. Analyses were done at the insurance plan level. Our primary outcome was number of requirements required by each plan by insurance type. Our secondary outcome was number of months required to participate in medically supervised weight loss (MSWL).

RESULTS

Among 43 insurance plans reviewed, representing commercial (60.5%), Medicaid (25.6%), and Medicare/TriCare (14.0%) plans, the number of pre-operative requirements ranged from 1 to 8. Adjusted Poisson regression showed significant variation in pre-operative requirements across plan types with Medicaid-insured patients required to fulfill the greatest number (4.1, 95%CI 2.7 to 5.4) compared to 2.7 (95%CI 2.2 to 3.2, P = 0.028) for commercially insured patients and 2.1 (95%CI 1.1 to 3.1, P = 0.047) for Medicare/TriCare-insured patients. Medicaid-insured patients were also required to complete a greater number of months in MSWL (6.6, 95%CI 5.5 to 7.6) compared to commercially (3.8, 95%CI 2.9 to 4.8, P < .001) and Medicare/TriCare-insured patients (1.7, 95%CI 0.3 to 3.0, P = .001).

CONCLUSION

The greater frequency of pre-operative requirements in Medicaid plans compared to Medicare/TriCare and commercial plans demonstrates inequity across insurance types which may negatively impact access to bariatric surgery. Pre-operative insurance requirements must be reevaluated and standardized using established evidence to ensure all individuals have access to this life-saving intervention.

Association between insurance-mandated precertification criteria and inpatient healthcare utilization during 1 year after bariatric surgery

BACKGROUND

Insurance-mandated precertification requirements are barriers to bariatric surgery. The value of their prescription, based on insurance type rather that the clinical necessity, is unclear.

OBJECTIVES

To determine whether there is an association between insurance-mandated precertification criteria for bariatric surgery and short-term inpatient healthcare utilization.

SETTING

Pennsylvania Health Care Cost Containment Council's inpatient care databases for the years 2016-2017.

METHODS

The study included 2717 adults who underwent bariatric surgery in Southeastern Pennsylvania in 2016. Postoperative length of stay and rehospitalizations for these individuals were followed using clinical and claims data during the first year after bariatric surgery.

RESULTS

The requirements for 3- to 6-month preoperative medical weight management, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, number of all-cause rehospitalizations, or number of all-cause rehospitalization days after adjusting for patient age, sex, race, ethnicity, the Elixhauser comorbidity score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. Among commercially insured individuals (n = 1499), the mean number of all-cause rehospitalizations during the study period was lower in patients with no medical weight management requirement by a factor of .57 (lower by 43.1%; 95% confidence interval, .35-.94, P = .03) and higher in patients with no requirement for preoperative cardiology and pulmonology evaluations by a factor of 2.09 (95% confidence interval 1.09-4.02, P = .03).

CONCLUSION

The findings suggest that the precertification requirement for preoperative medical weight management is not associated with a reduction in inpatient healthcare utilization in the first postoperative year.

Convergent Mixed Methods Exploration of Telehealth in Bariatric Surgery: Maximizing Provider Resources and Access

BACKGROUND

Telehealth may be an important care delivery modality in reducing dropout from bariatric surgery programs which is reported globally at approximately 50%.

METHODS

In this convergent mixed methods case study of a large, US healthcare system, we examine the impact of telehealth implementation in 2020 on pre-operative bariatric surgery visits and provider perspectives of telehealth use.

RESULTS

We find that telehealth was significantly associated with a 38% reduction in no-show rate compared with the prior year. Additionally, providers had positive experiences with regard to the appropriateness and feasibility of using telehealth in the pre-operative bariatric surgery process.

CONCLUSIONS

Telehealth use in the pre-operative bariatric surgery process may lead to greater efficiency in healthcare resource utilization. Insurance providers and bariatric accreditation bodies globally should consider accepting telehealth visits and self-reported weights when determining coverage decisions to ensure access for patients.

Effect of bolus enteral tube feeding on body weight in ambulatory adults with obesity and type 2 diabetes: a feasibility pilot randomized trial

Background/objectives

To ascertain the effect on body weight of 14 days of bolus enteral feeding with mixed meal (MM) and electrolyte solution (ES) in ambulatory adults with type 2 diabetes and obesity, and also the safety and feasibility of using a modified, intraorally anchored enteral feeding tube for this purpose.

Subjects/methods

We conducted a randomized, crossover pilot trial with 16 participants. A 140 cm, 8-French feeding tube was placed in the jejunum under electromagnetic guidance and anchored intraorally. Participants were randomized to self-administer 120 mL 523 kJ (125 kcal) MM, or 50 kJ (12 kcal) ES four times/day for 14 days. After ≥14 days without the tube, participants crossed over to the other treatment. The primary outcome compared weight change between treatments. Thereafter, participants could elect to undergo additional MM cycles. Participants were encouraged to continue with all usual activities including eating ad lib throughout the study.

Results

Ten participants withdrew prior to completing two randomized 14-day cycles (4 social, 3 intolerant of anchor, and 3 intolerant of tube). Six participants were assessed for the primary outcome and showed no significant difference in weight loss between MM and ES (p = 0.082). For the secondary outcome of within-group weight loss, average weight loss from baseline was significant for MM but not for ES: −2.40 kg (95% CI: −3.78, −1.02; p = 0.008) vs. −0.64 kg (95% CI: −2.01, 0.74; p = 0.27). A total of 23 2-week cycles were completed (12 paired, 2 unpaired, and 9 additional), with no significant adverse events for 334 days of tube use.

Conclusions

Repeated bolus nutrient administration via enteral feeding tube is associated with weight loss in adults with obesity and type 2 diabetes, with no significant difference seen between MM and ES feeds. The prototype device was safe, but requires development for further investigation into the effect of bolus jejunal feeding on weight and to improve acceptability.

Impact of Statewide Essential Health Benefits on Utilization of Bariatric Surgery

BACKGROUND

In response to concerns about inadequate insurance coverage, bariatric surgery was included in the Affordable Care Act's essential health benefits program-requiring individual and small-group insurance plans in 23 states to cover bariatric surgery. We evaluated the impact of this policy on bariatric surgery utilization.

METHODS

Multiple-group interrupted time series analyses of IBM MarketScan commercial claims data from 2009 to 2016.

RESULTS

Bariatric surgery utilization increased in all states after ACA implementation, but this increase was no greater in states with a bariatric surgery essential health benefit.

CONCLUSIONS

Our findings suggest that the essential health benefits program may have been too narrow in scope to meaningfully increase bariatric surgery utilization at the population level.

Impact of insurance plan design on bariatric surgery utilization

BACKGROUND

Bariatric surgery is underused in the United States.

OBJECTIVES

This study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders.

SETTING

The study used Pennsylvania Health Care Cost Containment Council's data in 5 counties of Pennsylvania from 2014 to 2016.

METHODS

Bariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery.

RESULTS

The odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23-5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005-.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83-3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32-2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39-2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans.

CONCLUSIONS

Specific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.