title: Variation in the use of minimally invasive bariatric surgery.
abstract: BACKGROUND
  Obesity is a significant public health problem in the United States. Despite the known benefits of bariatric surgery, most patients eligible for bariatric surgery do not receive it. Access to minimally invasive bariatric surgery (MIS), the surgical gold standard, may be a limitation.
  
  
  OBJECTIVE
  We investigated geographic variation in the utilization of laparoscopy for bariatric surgical procedures.
  
  
  METHODS
  We utilized a unique 3-state inpatient database. Adult patients receiving initial bariatric surgery were included. Patients were divided into hospital service areas (HSAs). Rates of MIS utilization in each HSA were calculated. HSAs were divided into quintiles of utilization. Patient and hospital characteristics were compared across quintiles.
  
  
  RESULTS
  Over the 5-year study period, 127,008 patients received bariatric surgery. MIS technology was available in all HSAs. MIS was performed in 88.4% of procedures and was performed in 70.6% of patients in the lowest quintile compared with 97.0% in the highest (P<.01). The use of laparoscopy across quintiles varied significantly by rural hospital status: All 7 rural hospitals were located in the lowest quintile of utilization.
  
  
  CONCLUSIONS
  Variation in the performance of MIS bariatric surgical procedures exists. These differences can likely be attributed to physician preference or patient population. Obesity rates are elevated in rural areas. The implementation of MIS bariatric surgery programs in rural areas may improve the treatment of obesity and downstream co-morbidities in these populations.
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: Lindsay.Kuo@uphs.upenn.edu.
authors.forename: Lindsay E
authors.initials: LE
authors.lastname: Kuo
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kristina D
authors.initials: KD
authors.lastname: Simmons
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Noel N
authors.initials: NN
authors.lastname: Williams
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rachel R
authors.initials: RR
authors.lastname: Kelz
mesh_terms: D000328:Adult; D050110:Bariatric Surgery / Q000379:methods* / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000592:standards / Q000706:statistics & numerical data*; D009765:Obesity / Q000601:surgery*; D013997:Time Factors
keywords: Bariatric surgery; Geographic variation; Laparoscopy