Bariatric Volume and Outcomes / Surgery for Obesity and Related Diseases 11 (2015) 343–350
[10]
[11]
[12]
[13]
[14] [15] [16]
[17]
[18]
[19]
[20]
[21] [22]
banding procedures for the treatment of morbid obesity. Ann Surg 2013;257:791–7. Jafari MD, Jafari F, Young MT, Smith BR, Phalen MJ, Nguyen NT. Volume and outcome relationship in bariatric surgery in the laparoscopic era. Surg Endosc 2013;27:4539–46. Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903–8. Dimick JB, Osborne NH, Nicholas L, Birkmeyer JD. Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg 2009;209:702–6 Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014: MBSAQIP Standards and Pathways. Available from: https://www.facs.org/quality-programs/mbsaqip/standards. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909–17. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36:8–27. Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361. (445–4). Weller WE, Hannan EL. Relationship between provider volume and postoperative complications for bariatric procedures in New York State. J Am Coll Surg 2006;202:753–61. Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, Warshaw AL. Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 2006;243:657–62. (discussion 662). Jones KBJ, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006;16:721–7. Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149–55. (discussion 155). Nguyen NT, Wolfe BM. Laparoscopic versus open gastric bypass. Semin Laparosc Surg 2002;9:86–93. Weller WE, Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery. Ann Surg 2008;248:10–5.
349
[23] Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076–81. [24] Reames BN, Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and operative mortality in the modern era. Ann Surg. Epub 2013 Dec 23. [25] Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc 2010;24:138–44. [26] Kohn GP, Galanko JA, Overby DW, Farrell TM. High case volumes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training. J Am Coll Surg 2010;210:909–18. [27] Kothari SN, Boyd WC, Larson CA, Gustafson HL, Lambert PJ, Mathiason MA. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg 2005;15:323–9 [28] Iezzoni LI. Using administrative diagnostic data to assess the quality of hospital care. Pitfalls and potential of ICD-9-CM. Int J Technol Assess Health Care 1990;6:272–81. [29] Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997;127:666–74. [30] Weingart SN, Iezzoni LI, Davis RB, et al. Use of administrative data to find substandard care: validation of the complications screening program. Med Care 2000;38:796–806. [31] Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369: 1434–42. [32] Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9. [33] Pratt GM, McLees B, Pories WJ. The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. Surg Obes Relat Dis 2006;2:497–503. (discussion 503). [34] Schirmer B, Jones DB. The American College of Surgeons Bariatric Surgery Center Network: establishing standards. Bull Am Coll Surg 2007;92:21–7. [35] Livingston EH. Bariatric surgery outcomes at designated centers of excellence vs nondesignated programs. Arch Surg 2009;144: 319–25. (discussion 325).
Editorial comment
Comment on: Hospital volume and outcomes for laparoscopic gastric bypass and adjustable gastric banding in the modern era This is an important and timely paper revisiting the relationship between hospital volume and outcome after bariatric surgery in the modern era. Hospital volume has long been considered an important criterion in accreditation for bariatric surgery. In 2004, a minimum hospital volume of 125 cases was imposed for hospitals seeking level 1 Center of Excellence (COE) accreditation. As the authors stated in the article, this case volume cutoff was based on literature not reflecting the current age of laparoscopy and improved perioperative care. Reconsideration of this policy under the new accreditation system initiated by the ASMBS
and ACS in 2012 has changed the requirement for comprehensive accreditation to 50 stapled cases. What Varban et al. report in their study is outcomes improvement over time in all hospitals, regardless of volume, as well as the persistence of a volume–outcome relationship between the lowest (o50 cases) and highest (4125 cases) volume hospitals. Interestingly, when evaluating their data but not discussed explicitly within the article, no difference was found in the volume–outcome relationship between medium volume (50–125 cases) and higher volume (4125 cases) hospitals. This study supports
350
O. A. Varban et al. / Surgery for Obesity and Related Diseases 11 (2015) 343–350
the change in volume criteria under the new Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) program and supports accreditation. As referred to in the article, accreditation had come under scrutiny after a study by Birkmeyer et al. [1] failed to find outcomes benefit to Centers for Medicaid and Medicare (CMS) patients undergoing bariatric surgery at COEcertified hospitals. This led to an overall policy change, and as of 2013, COE is no longer required for CMS-insured patients. Unfortunately, this also left accreditation in a state of flux. Governing bodies and societies invested in treating obesity continue to believe that accreditation is a valuable process that ensures resources for new and developing programs and provides a method for outcomes accountability. The volume outcomes relationship established in this paper, as well as recent data from Morton et al. showing that hospital accreditation status is associated with safer outcomes, shorter hospital length of stay, and lower total charges after bariatric surgery continue to support the utility of accreditation [2].
Based on this study, continued support should be given for comprehensive accreditation at 50 stapled cases. In addition, other process measures should be evaluated and considered, such as individual surgeon volume. Process analysis to improve lower volume hospitals should also be addressed, because volume alone likely does not reflect the only source of difference in patient outcome. Dana A. Telem, MD and Aurora D. Pryor, MD Division of Advanced Gastrointestinal, Bariatric, Foregut and General Surgery Department of Surgery Stony Brook University Medical Center Stony Brook, NY
References [1] Birkmeyer NJ, Dimick JB, Share D, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010;28(304):435–42. [2] Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg 2014;260:504–8
[10]
[11]
[12]
[13]
[14] [15] [16]
[17]
[18]
[19]
[20]
[21] [22]
banding procedures for the treatment of morbid obesity. Ann Surg 2013;257:791–7. Jafari MD, Jafari F, Young MT, Smith BR, Phalen MJ, Nguyen NT. Volume and outcome relationship in bariatric surgery in the laparoscopic era. Surg Endosc 2013;27:4539–46. Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903–8. Dimick JB, Osborne NH, Nicholas L, Birkmeyer JD. Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg 2009;209:702–6 Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014: MBSAQIP Standards and Pathways. Available from: https://www.facs.org/quality-programs/mbsaqip/standards. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909–17. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36:8–27. Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361. (445–4). Weller WE, Hannan EL. Relationship between provider volume and postoperative complications for bariatric procedures in New York State. J Am Coll Surg 2006;202:753–61. Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, Warshaw AL. Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 2006;243:657–62. (discussion 662). Jones KBJ, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006;16:721–7. Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg 2000;191:149–55. (discussion 155). Nguyen NT, Wolfe BM. Laparoscopic versus open gastric bypass. Semin Laparosc Surg 2002;9:86–93. Weller WE, Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery. Ann Surg 2008;248:10–5.
349
[23] Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076–81. [24] Reames BN, Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and operative mortality in the modern era. Ann Surg. Epub 2013 Dec 23. [25] Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc 2010;24:138–44. [26] Kohn GP, Galanko JA, Overby DW, Farrell TM. High case volumes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training. J Am Coll Surg 2010;210:909–18. [27] Kothari SN, Boyd WC, Larson CA, Gustafson HL, Lambert PJ, Mathiason MA. Training of a minimally invasive bariatric surgeon: are laparoscopic fellowships the answer? Obes Surg 2005;15:323–9 [28] Iezzoni LI. Using administrative diagnostic data to assess the quality of hospital care. Pitfalls and potential of ICD-9-CM. Int J Technol Assess Health Care 1990;6:272–81. [29] Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997;127:666–74. [30] Weingart SN, Iezzoni LI, Davis RB, et al. Use of administrative data to find substandard care: validation of the complications screening program. Med Care 2000;38:796–806. [31] Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369: 1434–42. [32] Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9. [33] Pratt GM, McLees B, Pories WJ. The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. Surg Obes Relat Dis 2006;2:497–503. (discussion 503). [34] Schirmer B, Jones DB. The American College of Surgeons Bariatric Surgery Center Network: establishing standards. Bull Am Coll Surg 2007;92:21–7. [35] Livingston EH. Bariatric surgery outcomes at designated centers of excellence vs nondesignated programs. Arch Surg 2009;144: 319–25. (discussion 325).
Editorial comment
Comment on: Hospital volume and outcomes for laparoscopic gastric bypass and adjustable gastric banding in the modern era This is an important and timely paper revisiting the relationship between hospital volume and outcome after bariatric surgery in the modern era. Hospital volume has long been considered an important criterion in accreditation for bariatric surgery. In 2004, a minimum hospital volume of 125 cases was imposed for hospitals seeking level 1 Center of Excellence (COE) accreditation. As the authors stated in the article, this case volume cutoff was based on literature not reflecting the current age of laparoscopy and improved perioperative care. Reconsideration of this policy under the new accreditation system initiated by the ASMBS
and ACS in 2012 has changed the requirement for comprehensive accreditation to 50 stapled cases. What Varban et al. report in their study is outcomes improvement over time in all hospitals, regardless of volume, as well as the persistence of a volume–outcome relationship between the lowest (o50 cases) and highest (4125 cases) volume hospitals. Interestingly, when evaluating their data but not discussed explicitly within the article, no difference was found in the volume–outcome relationship between medium volume (50–125 cases) and higher volume (4125 cases) hospitals. This study supports
350
O. A. Varban et al. / Surgery for Obesity and Related Diseases 11 (2015) 343–350
the change in volume criteria under the new Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) program and supports accreditation. As referred to in the article, accreditation had come under scrutiny after a study by Birkmeyer et al. [1] failed to find outcomes benefit to Centers for Medicaid and Medicare (CMS) patients undergoing bariatric surgery at COEcertified hospitals. This led to an overall policy change, and as of 2013, COE is no longer required for CMS-insured patients. Unfortunately, this also left accreditation in a state of flux. Governing bodies and societies invested in treating obesity continue to believe that accreditation is a valuable process that ensures resources for new and developing programs and provides a method for outcomes accountability. The volume outcomes relationship established in this paper, as well as recent data from Morton et al. showing that hospital accreditation status is associated with safer outcomes, shorter hospital length of stay, and lower total charges after bariatric surgery continue to support the utility of accreditation [2].
Based on this study, continued support should be given for comprehensive accreditation at 50 stapled cases. In addition, other process measures should be evaluated and considered, such as individual surgeon volume. Process analysis to improve lower volume hospitals should also be addressed, because volume alone likely does not reflect the only source of difference in patient outcome. Dana A. Telem, MD and Aurora D. Pryor, MD Division of Advanced Gastrointestinal, Bariatric, Foregut and General Surgery Department of Surgery Stony Brook University Medical Center Stony Brook, NY
References [1] Birkmeyer NJ, Dimick JB, Share D, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010;28(304):435–42. [2] Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg 2014;260:504–8
