Variation of metabolic and bariatric surgery utilization by neighborhood socioeconomic status in Maryland

Oluwasegun Akinyemi; Terrence Fullum; Mojisola Fasokun; Kakra Hughes; Dahai Yue; Craig Scott Fryer; Jie Chen; Kellee White-Whilby

doi:10.1371/journal.pone.0330318

Peer Review History

Original SubmissionJuly 29, 2025
19 Sep 2025 Decision Letter - Athanasios Pantelis, Editor Dear Dr. Akinyemi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 01 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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Kind regards, Athanasios G. Pantelis Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please note that your Data Availability Statement is currently missing [the repository name and/or the DOI/accession number of each dataset OR a direct link to access each database]. If your manuscript is accepted for publication, you will be asked to provide these details on a very short timeline. We therefore suggest that you provide this information now, though we will not hold up the peer review process if you are unable. 3. 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[Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Dear Authors, I read your manuscript carefully and found it timely, policy-relevant, that focused on a health equity issue. However, several areas could be strengthened in terms of clarity, framing, methodological detail, and interpretation of race-specific findings. 1- Please use "Metabolic and Bariatric surgery (MBS)" instead of bariatric surgery, alone. 2- I suggest expanding the discussion about other important factors such as referral bias, racism, hospital distance from referral points. 3- Discuss more how insurance can have effect on nSES. Could insurance status be a mediator rather than a confounder factor? 4- Please add a brief description of Figure 1 in the results or discussion to make it easier to understand. Reviewer #2: I commend the authors for a very thorough work and interesting findings that could help healthcare directed to certain populations regarding Bariatric Surgery in particular. My only points regarding the results and possible confounding factors are age and insurance coverage across neighborhood socioeconomic status which are not analysed per DCI category. This of course could influence the results either way since in more distressed neighborhoods there is less likelihood of private insurance but probably younger population so it would be complex to say which way the influence would be more profound. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Mohammad Kermansaravi Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0330318.r001
Revision 1
24 Oct 2025 Author Response Dear Editor and Reviewers, Thank you for your thoughtful evaluation of our manuscript and for the opportunity to revise it. We appreciate the insightful comments from the Academic Editor and both reviewers, and we have carefully addressed each point. Below, we provide a point‑by‑point response and a summary of changes made to the revised manuscript. Editor’s Comments 1. Use of IFSO‑compliant nomenclature. We have replaced the term “bariatric surgery” with “metabolic and bariatric surgery (MBS)” throughout the manuscript, including in the title, abstract, tables, and narrative text. The abbreviation MBS is now defined at first use and used consistently thereafter. 2. STROBE checklist. A completed STROBE checklist is provided as a separate file. In it, we indicate the page and section in the manuscript where each reporting item is addressed. 3. Causal language. We revised the manuscript to avoid causal or policy‑prescriptive wording, reflecting the observational and cross‑sectional nature of our study. Statements that previously implied causality (for example, “effect of nSES on MBS use”) now describe associations (e.g., “association between nSES and MBS utilization”), and we emphasized that causal inferences cannot be drawn from these data. 4. Limitations. The limitations section has been expanded and now more clearly articulates how unmeasured confounding, selection bias, measurement limitations, and the cross‑sectional design may influence interpretation of our findings. We explicitly note that age and insurance distributions vary across socioeconomic strata and may confound the observed associations, and that our reliance on administrative data may lead to misclassification of comorbidities and procedures (Page 16-17, Lines 332-360). In addition, we have updated the Data Availability Statement and checked the reference list for completeness and currency, replacing any outdated citations. Reviewer #1 1. Use “Metabolic and Bariatric Surgery (MBS)” instead of “bariatric surgery”. As noted above, the nomenclature has been updated throughout the manuscript, including the title and table captions. 2. Expand discussion of referral bias, racism, and hospital distance. The Discussion now includes a paragraph addressing potential referral bias and structural racism in access to surgical care, citing relevant literature. We also discuss how geographical distance to MBS‑capable hospitals may reduce utilization among individuals in distressed neighborhoods (Discussion, Page 15, Lines 293-306). 3. Insurance as mediator or confounder. We added text to the Discussion noting that insurance coverage may function as both a mediator and a confounder in the relationship between neighborhood socioeconomic status and MBS utilization. We caution that Medicaid and uninsured status can both reflect socioeconomic disadvantage and limit access to surgery, and we note that further causal mediation analyses are beyond the scope of our cross‑sectional study (Page 15, Lines 307-323). 4. Description of Figure 1. The Results section now briefly describes Figure 1, highlighting the geographic distribution of neighborhood distress across Maryland and the corresponding variation in MBS utilization (Page 13, Lines 257-259). Reviewer #2 We appreciate the reviewer’s observation that age and insurance coverage may confound our results. To address this, we conducted additional analyses of age, insurance and other study variables distributions across DCI quintiles and present these results in a new Table 2 (Pages 10-11, Lines 193-209, Page 26-27). The table shows that distressed neighborhoods have a higher proportion of younger adults (27.0 % aged 18–44 years vs. 20.9 % in prosperous areas) and a higher prevalence of Medicaid coverage (31.6 % vs. 11.9 %), whereas private insurance is more common in prosperous communities (41.1 % vs. 20.6 %). These differences are summarized in the Results (Page 10, Lines 193-209) and discussed in the context of potential confounding in the Discussion (Page 15, Lines 307-324). We thank the reviewers again for their constructive feedback. We believe that these revisions have strengthened the manuscript and clarified the interpretation of our findings. We hope the revised submission meets the standards of PLOS ONE and look forward to your decision. Sincerely, Oluwasegun Akinyemi, MD, MSc., PhD (on behalf of all authors) Attachments Attachment Submitted filename: Response to Reviewers_10202025.docx https://doi.org/10.1371/journal.pone.0330318.r002
28 Oct 2025 Decision Letter - Athanasios Pantelis, Editor Variation of Metabolic and Bariatric Surgery Utilization by Neighborhood Socioeconomic Status in Maryland PONE-D-25-41261R1 Dear Dr. Akinyemi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Athanasios G. Pantelis Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0330318.r003
Formally Accepted
Acceptance Letter - Athanasios Pantelis, Editor PONE-D-25-41261R1 PLOS ONE Dear Dr. Akinyemi, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Athanasios G. Pantelis Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0330318.r004

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