The Inequity of Bariatric Surgery: Publicly Insured Patients Undergo Lower Rates of Bariatric Surgery with Worse Outcomes.

OBJECTIVE: Bariatric surgery has been shown to be the most effective method of achieving weight loss and alleviating obesity-related comorbidities. Yet, it is not being used equitably. This study seeks to identify if there is a disparity in payer status of patients undergoing bariatric surgery and what factors are associated with this disparity. METHODS: We performed a case-control analysis of National Inpatient Sample. We identified adults with body mass index (BMI) greater than or equal to 25 kg/m2 who underwent bariatric surgery and matched them with overweight inpatient adult controls not undergoing surgery. The sample was analyzed using multivariate logistic regression. RESULTS: We identified 132,342 cases, in which the majority had private insurance (72.8%). Bariatric patients were significantly more likely to be privately insured than any other payer status; Medicare- and Medicaid-covered patients accounted for a low percentage of cases (Medicare 5.1%, OR 0.33, 95% CI 0.29-0.37, p < 0.001; Medicaid 8.7%, OR 0.21, 95% CI 0.18-0.25, p < 0.001). Medicare (OR 1.54, 95% CI 1.33-1.78, p < 0.001) and Medicaid (OR 1.31, 95% CI 1.08-1.60, p = 0.007) patients undergoing bariatric surgery had an increased risk of complications compared to privately insured patients. CONCLUSIONS: Publicly insured patients are significantly less likely to undergo bariatric surgery. As a group, these patients experience higher rates of obesity and related complications and thus are most in need of bariatric surgery.

Buckle of the bariatric surgery belt: an analysis of regional disparities in bariatric surgery.

BACKGROUND: Surgical options have emerged as effective treatments to mitigate obesity-associated co-morbidities leading to reduced mortality risk. Despite the benefits of bariatric surgery, a low portion of the eligible population undergoes weight loss procedures. OBJECTIVES: To determine if regional disparities exist among bariatric patients in the United States and potential effects of any difference SETTING: National Inpatient Sample (NIS). METHODS: We performed a retrospective, cross-sectional analysis of the NIS database from 2003-2010. We identified 4 regions of the United States; Northeast, Midwest, West, and South. Endpoints included race, payor status, co-morbidities, urban/rural areas, institutional academic status, surgeon, and institutional volume. The sample was analyzed using χ2 tests, linear regression, and multivariate logistical regression analysis. RESULTS: A total of 132,342 cases and 636,320 controls were studied. A majority of the study population was female (62.5%) and white (70.0%) with private insurance (42.0%). The highest prevalence of obesity was identified in the South (39.7%) and the lowest in the Midwest (17.1%). The greatest numbers of bariatric procedures are performed in the Northeast (24.4%) compared with the South (13.9%) and Midwest (13%). After controlling for demographic characteristics, the proportion of procedures performed in the Northeast compared with the South (odds ratio .52, confidence interval .40-.66; P<.001) and Midwest (odds ratio .50, confidence interval .33-.75; P<.005) was significant. CONCLUSION: Significant disparities in bariatric procedures performed were identified in the South and Midwest regions compared with the Northeast. Although the South has a higher prevalence of obesity, thus it could be suggested by outreach programs.

No more broken hearts: weight loss after bariatric surgery returns patients' postoperative risk to baseline following coronary surgery.

BACKGROUND: The obesity epidemic is associated with a rise in coronary surgeries because obesity is a risk factor for coronary artery disease. Bariatric surgery is linked to improvement in cardiovascular co-morbidities and left ventricular function. No studies have investigated survival advantage in postoperative bariatric patients after coronary surgery. OBJECTIVES: To determine if there is a benefit after coronary surgery in patients who have previously undergone bariatric surgery. SETTING: National Inpatient Sample. METHODS: We performed a retrospective, cross-sectional analysis of the National Inpatient Sample database from 2003 to 2010. We selected bariatric surgical patients who later underwent coronary surgery (n = 257). A comparison of postoperative complications and mortality after coronary surgery were compared with controls (n = 1442) using χ2 tests, linear regression analysis, and multivariate logistical regression models. RESULTS: A subset population was identified as having undergone coronary surgery (n = 1699); of this population, 257 patients had previously undergone bariatric surgery. They were compared with 1442 controls. The majority was male (67.2%), white (82.6%), and treated in an urban environment (96.8%). Patients with bariatric surgery assumed the risk of postoperative complications after coronary surgery that was associated with their new body mass index (BMI) (BMI<25 kg/m2: odds ratio (OR) 1.01, 95% CI .76-1.34, P = .94; BMI 25 to<35 kg/m2: OR .20, 95% CI .02-2.16, P = .19; BMI≥35 kg/m2: OR>999.9, 95% CI .18 to>999.9, P = .07). Length of stay was significantly longer in postbariatric patients (BMI<25, OR 1.62, 95% CI 1.14-2.30, P = .007). CONCLUSIONS: Postoperative bariatric patients have a return to baseline risk of morbidity and mortality after coronary surgery.

Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation.

BACKGROUND: Whether high-ratio resuscitation (HRR) provides patients with survival advantage remains controversial. We hypothesized a direct correlation between HRR infusion rates in the first 180 minutes of resuscitation and survival. STUDY DESIGN: This was a retrospective analysis of massively transfused trauma patients surviving more than 30 minutes and undergoing surgery at a level 1 trauma center. Mean infusion rates (MIR) of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (Plt) were calculated for length of intervention (emergency department [ED] time + operating room [OR] time). Patients were categorized as HRR (FFP:PRBC > 0.7, and/or Plts: PRBC > 0.7) vs low-ratio resuscitation (LRR). Student's t-tests and chi-square tests were used to compare survivors with nonsurvivors. Cox proportional hazards regression models and Kaplan-Meier curves were generated to evaluate the association between MIR for FFP:PRBC and Plt:PRBC and 180-minute survival. RESULTS: There were 151 patients who met criteria: 121 (80.1%) patients survived 180 minutes (MIR:PRBC 71.9 mL/min, FFP 92.0 mL/min, Plt 3.5 mL/min) vs 30 (19.9%) who did not survive (MIR:PRBC 47.3 mL/min, FFP 33.7 mL/min, Plt 1.1 mL/min), p = 0.43, p < 0.0001 and p < 0.011, respectively. A Cox regression model evaluated PRBC rate, FFP rate, and Plt rate (mL/min) as mortality predictors within 180 minutes to assess if they significantly affected survival (hazard ratios 1.01 [p = 0.054], 0.97 [p < 0.0001], and 0.75 [p = 0.01], respectively). Another model used stepwise Cox regression including PRBC rate, FFP rate, and Plt rate (hazard ratios 1.00 [p = 0.85], 0.97 [p < 0.0001], and 0.88 [p = 0.24], respectively), as well as possible confounding variables. CONCLUSIONS: This is the first study to examine effects of MIRs on survival. Further studies on the effects of narrow time-interval analysis for blood product resuscitation are warranted.