Importance Bariatric surgery is a proven treatment for severe obesity, yet disparities in its utilization persist, particularly among socioeconomically disadvantaged populations.

Objective To evaluate the association between neighborhood socioeconomic status (nSES) and bariatric surgery utilization in Maryland and assess whether this relationship varies by race and ethnicity.

Design, Setting, and Participants A cross-sectional, population-based study using the Maryland State Inpatient Database (2018–2020), linked with the Distressed Communities Index (DCI). The study included adults aged ≥18 years with body mass index (BMI) ≥35 kg/m² who were eligible for bariatric surgery. Race/ethnicity was self-reported and categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.

Main Outcomes and Measures The primary outcome was receipt of bariatric surgery. The primary exposure was nSES, measured using DCI quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). Multivariable logistic regression models estimated the adjusted odds of undergoing surgery, accounting for age, sex, race/ethnicity, insurance, comorbidities, obesity class, and urbanicity. Interaction terms tested effect modification by race.

Results Of 169,026 eligible individuals, 11,963 (7.1%) received bariatric surgery. Most recipients were female (82.6%), with nearly equal representation of Black (46.9%) and White (46.1%) patients. A socioeconomic gradient in utilization was evident: individuals from distressed neighborhoods had 30% lower odds of receiving surgery (OR, 0.70; 95% CI, 0.64– 0.76) compared to those in prosperous areas. Odds were similarly reduced for mid-tier (OR, 0.74; 95% CI, 0.70–0.79), at-risk (OR, 0.89; 95% CI, 0.83–0.96), and comfortable (OR, 0.89; 95% CI, 0.84–0.95) neighborhoods. Race moderated this association: across all DCI quintiles, Black individuals were more likely than White individuals to undergo surgery, with marginal effects increasing from 0.90% in prosperous to 2.10% in distressed areas.

Conclusions and Relevance Bariatric surgery remains underutilized among eligible patients, especially those in socioeconomically disadvantaged neighborhoods. However, utilization patterns differ by race, with higher odds among Black individuals across all neighborhood strata. These findings highlight the need for targeted interventions to improve equity in obesity treatment access.

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study used publicly available, de-identified administrative data and was exempt from Institutional Review Board (IRB) oversight by the University of Maryland IRB [Protocol #2284677-1]. Because the analysis involved secondary use of de-identified data, no direct interaction with human subjects occurred, and informed consent was not required.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

The data underlying the results presented in the study are available from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), maintained by the Agency for Healthcare Research and Quality (AHRQ). Access to these data requires a formal data use agreement and can be obtained via the HCUP Central Distributor at: https://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp. Researchers must meet the criteria for access to confidential data as outlined by AHRQ.

https://hcup-us.ahrq.gov/db/state/siddbdocumentation.jsp