Severe Obesity Management in a Large Academic Health System: A Retrospective Evaluation of Metabolic Bariatric Surgery Counselling Practices

Metabolic and bariatric surgery (MBS) is an effective treatment for severe obesity but remains substantially underutilized. Limited data exist on outpatient counselling patterns preceding surgical uptake. Using electronic health record data, we conducted a 10-year retrospective cohort study of adults with body mass index ≥ 40 kg/m². The primary outcome was documentation of the MBS discussion. Secondary outcomes included MBS receipt and demographic factors associated with documented discussion. Among 60 574 eligible patients, only 7.6% had documented MBS discussion. Overall, 1.2% underwent MBS. Surgery occurred in 12.1% of patients with documented discussion compared with 0.3% without discussion. Patients with documented discussion were younger (median, 42 vs. 47 years), had higher BMI (median, 46.8 vs. 42.0 kg/m²), and were more often female. Eligible women were more likely than men to have documented discussion (8.7% vs. 5.5%). Black patients had higher discussion rates than White patients, despite known downstream disparities in MBS utilization. Documented MBS discussion is rare but represents a critical inflection point in surgical uptake. Demographic differences in counselling suggest clinician- and system-level factors influence access before referral, highlighting outpatient counselling as a key target to improve equitable MBS utilization.