Impact of the COVID-19 pandemic on racial disparities in adolescent bariatric surgery: an MBSAQIP analysis

BACKGROUND: Metabolic and bariatric surgery (MBS) is the most effective intervention for severe adolescent obesity, yet persistent disparities exist in surgical access. The COVID-19 pandemic disrupted elective surgery and may have altered access for historically underserved populations. METHODS: Using MBSAQIP, we identified adolescents aged 19 years or younger who underwent MBS from 2015 to 2023, stratified into three phases: pre-COVID (2015-2019), acute COVID (2020-2021), and recovery (2022-2023). Race/ethnicity was classified using Hispanic-priority methodology. Racial and ethnic composition, comorbidity burden, and 30-day outcomes were compared using Fisher's exact and Kruskal-Wallis tests. Firth penalized logistic regression was used for sensitivity analysis of rare outcomes. RESULTS: Overall, 5432 adolescents underwent MBS from 2015 to 2023. White representation declined from 49% pre-COVID to 32% during recovery (- 17%; 95% CI - 19%, - 14.7%), while Hispanic representation increased from 25 to 36% (+ 11%; 95% CI + 9.1%, + 13.2%) and Black representation from 17 to 21% (+ 4%; 95% CI + 2.6%, + 6.2%); cohort composition differed significantly across phases (p < 0.001). Comorbidity burden was stable. Overall, 30-day complication rates were low (1.0%). Among Black patients, complication rates declined from 3.9% pre-COVID to 0.8% during recovery (- 3.1%; 95% CI - 5.7%, - 2.1%; p = 0.004). In sensitivity analysis, Black patients had higher odds of complications compared with White patients (OR 3.21; 95% CI 1.55, 6.71; p = 0.002). No individual complication type differed significantly after Benjamini-Hochberg correction. Readmission and reoperation rates did not differ significantly across phases. CONCLUSIONS: The racial and ethnic composition of adolescents undergoing MBS shifted substantially across the COVID-19 pandemic, with increased representation of historically underserved racial and ethnic groups. Complication disparities observed among Black patients pre-COVID were not statistically significant in later phases, though sparse event counts limit interpretation. Prospective studies are needed to clarify the mechanisms driving pandemic-era changes in equity of access to adolescent MBS.