Does Lower Income Reduce Your Chance of Bariatric Surgery?

In Canada, demand for bariatric surgery outstrips access by around 600-fold (and that is probably a conservative estimate).

Of course, if you have the money, you can always go to one of the rapidly increasing number of Canadian private centres for an adjustable gastric band. You can perhaps also grab your check book and hop on a plane for surgery in the US or Mexico.

However, if there is no way you can come up with the cash, then it’s pretty much a waiting game in the public system with reported waiting times exceeding several years in most provinces.

But here is an interesting observation we just published in Obesity Surgery showing that even in a publicly funded clinic, folks with lower income are less likely to get surgery than people with higher socioeconomic status.

For this study Kieran Halloran, Raj Padwal, Carlene Johnson-Stoklossa, Daniel Birch and I performed a retrospective analysis of 419 patients who were seen in the Edmonton Weight Wise obesity clinic between 2005-2006 (which, admittedly, was long before I moved to Edmonton).

For this study, we arbitrarily defined all patients who were unemployed, on long-term disability or receiving social assistance as having a “low income” status. The remaining patients were categorized as “regular income” status.

Thirty-three (7%) patients were found ineligible for surgery or excluded because of missing income status data.

Of the remaining 386 patients, 72 (19%) were of low income status and 89 (23%) were approved for surgery, however, compared to patients of regular income status, those with low income status were 55% less likely to be approved for surgery (15.3% versus 24.8%).

Although, this may be suspected, we did not find that premature program termination or difference in attrition rates (60% at 6 months!) were significantly different between patients of low and regular income status as a possible explanation for our findings.

Notably, low income patients were older, heavier, and had greater comorbidity, but this was also not a major determinant of reduced chances of getting surgery. In fact, the inverse association between low income status and approval for surgery was actually stronger after adjustment for comorbidities.

Although mental illness was more common in patients of lower income status, it was also not predictive of approval for surgery. This is perhaps not surprising because of the emphasis placed on the management and stabilization of mental illness prior to proceeding with surgery in the Weight Wise program.

Thus, while our observations show that even within a publicly funded and universally accessible regional obesity program “lower income” status patients were substantially less likely to be approved for bariatric surgery than “normal income” patients.

The reasons for this remain unclear and certainly deserve further study.

Sensitivity to this apparent disparity and the exploration of program modifications to ensure equity across all socioeconomic strata is essential to ensure that all Canadians have timely access to appropriate bariatric care.

AMS
Edmonton, Alberta

p.s. Whether or not recent changes to the Edmonton Bariatric program have changed the impact of socioeconomic status on approval for bariatric surgery is currently being explored in the CIHR-funded APPLES study.

Halloran K, Padwal RS, Johnson-Stoklossa C, Sharma AM, & Birch DW (2010). Income Status and Approval for Bariatric Surgery in a Publicly Funded Regional Obesity Program. Obesity surgery PMID: 20401743