CE: ; ANNSURG-D-15-00237; Total nos of Pages: 2;
ANNSURG-D-15-00237
LETTER TO Commentary on: ‘‘Ensuring Excellence in Centers of Excellence Programs’’ Reply: e read with interest the article by Mehrotra and Dimick titled ‘‘Ensuring Excellence in Centers of Excellence Programs.’’1 We disagree with several statements made in this Surgical Perspective. Fundamentally, we believe that accreditation has resulted in better outcomes and lower mortality without restricting access and that, when the entire body of literature on this issue is reviewed, the data support these claims. Additionally, an accreditation system provides a platform for uniform methods of patient selection, clinical pathways and processes of care, and a data collection system, providing a report card of risk-adjusted data, and most importantly, local and regional quality improvement efforts. Without accreditation, none of the above will take place. Specifically, the authors state, ‘‘several recent empirical evaluations of such programs have found that designated hospitals are, at best, only modestly better than nondesignated hospitals.’’ To date, there are numerous studies that have compared outcomes of accredited versus nonaccredited centers.2–6 The vast majority have reported significantly lower mortality rates at accredited centers. We believe that any and all reductions in operative mortality, however modest, are of clinical significance. With regards to surgical volume, the authors conclude that ‘‘Although volumeoutcome relationships are strong for rare, high-risk surgical conditions, they are much weaker for the common conditions that are often the focus of programs (eg, bariatric surgery).’’ The American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons have established the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) with data-driven standards regarding volume and substantial feedback from the membership to ensure that appropriate volumes are maintained without restricting participation in the program.7 Compared with the previous ASMBS Center of Excellence program that required 125 cases per year, MBSAQIP has lowered the
W
Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001274
THE
EDITOR
volume requirements based on the best available evidence to 50 bariatric stapling cases per year for comprehensive centers and to 25 cases per year for low acuity centers. Of note, Jafari and colleagues have reported a higher operative mortality at high-volume, nonaccredited centers compared with high-volume, accredited centers, indicating that the crucial component to improve outcomes is not volume but accreditation.8 In addition, this implies that there is lower rate of ‘‘failure to rescue’’ in patients who develop complications at accredited centers, reinforcing the utility of specific structure and process measures in place to recognize and expeditiously treat complications.6 We also disagree with the authors’ statement that ‘‘The goal of these programs is to encourage patients to change hospitals.’’ The goal of accreditation has never been to regionalize bariatric surgical care, but, instead, to improve care. The MBSAQIP standards were established with the goal of being inclusive of surgeons and health systems performing bariatric surgery in a wide variety of safe settings and regions. By taking into account the broad perspectives of the ASMBS membership and by lowering the volume requirements, the MBSAQIP program is designed to make high-quality bariatric surgery available in more hospitals, not fewer. The authors also noted potential disadvantages in designating bariatric accreditation centers including a negative impact on access for racial minorities and the need for patients to travel to obtain care. At the current time, there are 732 MBSAQIP designated centers nationwide with center representation in all 50 states. Therefore, it is unlikely for patients to have to travel a meaningful distance to obtain quality bariatric care. Another study has shown that the number of Medicare beneficiaries and the rate of ethnic minorities receiving bariatric surgery actually increased (rather than decreased as stated by the authors) after the Medicare Bariatric National Coverage Determination confirming that there are no unintended consequences of disparity in the treatment of ethnic minorities related to the development of bariatric surgery accreditation.9 Despite our difference in opinions, we are agreeable with the authors on 1 point: the need to examine outcomes within the context of designating accredited centers. The MBSAQIP recently began releasing riskadjusted data to each designated center on a quarterly basis. The risk-adjusted data can be of use for quality improvement efforts but may potentially be used as criteria for accreditation designation. There are merits to accreditation that go well beyond participation in various insurer-initiated Center of Excellence programs. Ultimately, it is about improving
Annals of Surgery Volume XX, Number X, Month 2015
patient care. Any improvement, no matter how small, is important and can only be accomplished by collecting data, measuring outcomes, and providing centers with riskadjusted data. Currently, 602 hospitals worldwide participate in the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP1), which provides risk-adjusted clinical data that are far superior to administrative datasets. There are 732 bariatric surgery centers in the United States participating in MBSAQIP. The rapid adoption of this new program by the ASMBS membership, the launch of a national quality improvement project for MBSAQIP members to decrease readmissions,10 the requirement to maintain the essential program, personnel and infrastructure to care for the bariatric patient in fiscally demanding times, and the continued excellent outcomes reported by accredited sites all speak to the value of accreditation in bariatric surgery. Although opponents to accreditation have been vocal, the data are clear and present. The bariatric surgery community and patients have spoken: accreditation improves care for patients and is here to stay. John M. Morton, MD, MPH Department of Surgery Stanford University Palo Alto, CA Shanu N. Kothari, MD Department of General Surgery Gundersen Health System La Crosse, WI Stacy A. Brethauer, MD Bariatric and Metabolic Institute Cleveland Clinic Cleveland, OH Raul J. Rosenthal, MD Bariatric and Metabolic Institute Cleveland Clinic Weston, FL Ninh T. Nguyen, MD Department of Surgery University of California Irvine Medical Center Orange, CA [email protected]
REFERENCES 1. Mehrotra A, Dimick JB. Ensuring excellence in centers of excellence programs. Ann Surg. 2015;261:237–239. 2. Nguyen NT, Nguyen B, Nguyen VQ, et al. Outcomes of bariatric surgery performed at accredited vs nonaccredited centers. J Am Coll Surg. 2012;215:467–474.
www.annalsofsurgery.com | 1
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; ANNSURG-D-15-00237; Total nos of Pages: 2;
ANNSURG-D-15-00237
Letter to the Editor
3. Kwon S, Wang B, Wong E, et al. The impact of accreditation on safety and cost of bariatric surgery. Surg Obes Relat Dis. 2013;9:617–622. 4. Telem DA, Talamini M, Altieri M, et al. The effect of national hospital accreditation in bariatric surgery on perioperative outcomes and longterm mortality. Surg Obes Relat Dis. 2015;11: 749–757. 5. Gebhart A, Young M, Phelan M, et al. Impact of accreditation in bariatric surgery. Surg Obes Relat Dis. 2014;10:767–773.
2 | www.annalsofsurgery.com
Annals of Surgery Volume XX, Number X, Month 2015
6. Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260:504–508. 7. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014. Available at http://www.mbsaqip.org/?page_id ¼ 54. Accessed January 14, 2015. 8. Jafari MD, Jafari F, Young MT, et al. Volume and outcome relationship in bariatric surgery in the
ß
laparoscopic era. Surg Endosc. 2013;27:4539– 4546. 9. Nguyen NT, Hohmann S, Slone J, et al. Improved bariatric surgery outcomes for Medicare beneficiaries after implementation of the Medicare national coverage determination. Arch Surg. 2010;145:72–78. 10. Morton J. The first metabolic and bariatric surgery accreditation and quality improvement program quality initiative: decreasing readmissions through opportunities provided. Surg Obes Relat Dis. 2014;10:377–378.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANNSURG-D-15-00237
LETTER TO Commentary on: ‘‘Ensuring Excellence in Centers of Excellence Programs’’ Reply: e read with interest the article by Mehrotra and Dimick titled ‘‘Ensuring Excellence in Centers of Excellence Programs.’’1 We disagree with several statements made in this Surgical Perspective. Fundamentally, we believe that accreditation has resulted in better outcomes and lower mortality without restricting access and that, when the entire body of literature on this issue is reviewed, the data support these claims. Additionally, an accreditation system provides a platform for uniform methods of patient selection, clinical pathways and processes of care, and a data collection system, providing a report card of risk-adjusted data, and most importantly, local and regional quality improvement efforts. Without accreditation, none of the above will take place. Specifically, the authors state, ‘‘several recent empirical evaluations of such programs have found that designated hospitals are, at best, only modestly better than nondesignated hospitals.’’ To date, there are numerous studies that have compared outcomes of accredited versus nonaccredited centers.2–6 The vast majority have reported significantly lower mortality rates at accredited centers. We believe that any and all reductions in operative mortality, however modest, are of clinical significance. With regards to surgical volume, the authors conclude that ‘‘Although volumeoutcome relationships are strong for rare, high-risk surgical conditions, they are much weaker for the common conditions that are often the focus of programs (eg, bariatric surgery).’’ The American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons have established the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) with data-driven standards regarding volume and substantial feedback from the membership to ensure that appropriate volumes are maintained without restricting participation in the program.7 Compared with the previous ASMBS Center of Excellence program that required 125 cases per year, MBSAQIP has lowered the
W
Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001274
THE
EDITOR
volume requirements based on the best available evidence to 50 bariatric stapling cases per year for comprehensive centers and to 25 cases per year for low acuity centers. Of note, Jafari and colleagues have reported a higher operative mortality at high-volume, nonaccredited centers compared with high-volume, accredited centers, indicating that the crucial component to improve outcomes is not volume but accreditation.8 In addition, this implies that there is lower rate of ‘‘failure to rescue’’ in patients who develop complications at accredited centers, reinforcing the utility of specific structure and process measures in place to recognize and expeditiously treat complications.6 We also disagree with the authors’ statement that ‘‘The goal of these programs is to encourage patients to change hospitals.’’ The goal of accreditation has never been to regionalize bariatric surgical care, but, instead, to improve care. The MBSAQIP standards were established with the goal of being inclusive of surgeons and health systems performing bariatric surgery in a wide variety of safe settings and regions. By taking into account the broad perspectives of the ASMBS membership and by lowering the volume requirements, the MBSAQIP program is designed to make high-quality bariatric surgery available in more hospitals, not fewer. The authors also noted potential disadvantages in designating bariatric accreditation centers including a negative impact on access for racial minorities and the need for patients to travel to obtain care. At the current time, there are 732 MBSAQIP designated centers nationwide with center representation in all 50 states. Therefore, it is unlikely for patients to have to travel a meaningful distance to obtain quality bariatric care. Another study has shown that the number of Medicare beneficiaries and the rate of ethnic minorities receiving bariatric surgery actually increased (rather than decreased as stated by the authors) after the Medicare Bariatric National Coverage Determination confirming that there are no unintended consequences of disparity in the treatment of ethnic minorities related to the development of bariatric surgery accreditation.9 Despite our difference in opinions, we are agreeable with the authors on 1 point: the need to examine outcomes within the context of designating accredited centers. The MBSAQIP recently began releasing riskadjusted data to each designated center on a quarterly basis. The risk-adjusted data can be of use for quality improvement efforts but may potentially be used as criteria for accreditation designation. There are merits to accreditation that go well beyond participation in various insurer-initiated Center of Excellence programs. Ultimately, it is about improving
Annals of Surgery Volume XX, Number X, Month 2015
patient care. Any improvement, no matter how small, is important and can only be accomplished by collecting data, measuring outcomes, and providing centers with riskadjusted data. Currently, 602 hospitals worldwide participate in the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP1), which provides risk-adjusted clinical data that are far superior to administrative datasets. There are 732 bariatric surgery centers in the United States participating in MBSAQIP. The rapid adoption of this new program by the ASMBS membership, the launch of a national quality improvement project for MBSAQIP members to decrease readmissions,10 the requirement to maintain the essential program, personnel and infrastructure to care for the bariatric patient in fiscally demanding times, and the continued excellent outcomes reported by accredited sites all speak to the value of accreditation in bariatric surgery. Although opponents to accreditation have been vocal, the data are clear and present. The bariatric surgery community and patients have spoken: accreditation improves care for patients and is here to stay. John M. Morton, MD, MPH Department of Surgery Stanford University Palo Alto, CA Shanu N. Kothari, MD Department of General Surgery Gundersen Health System La Crosse, WI Stacy A. Brethauer, MD Bariatric and Metabolic Institute Cleveland Clinic Cleveland, OH Raul J. Rosenthal, MD Bariatric and Metabolic Institute Cleveland Clinic Weston, FL Ninh T. Nguyen, MD Department of Surgery University of California Irvine Medical Center Orange, CA [email protected]
REFERENCES 1. Mehrotra A, Dimick JB. Ensuring excellence in centers of excellence programs. Ann Surg. 2015;261:237–239. 2. Nguyen NT, Nguyen B, Nguyen VQ, et al. Outcomes of bariatric surgery performed at accredited vs nonaccredited centers. J Am Coll Surg. 2012;215:467–474.
www.annalsofsurgery.com | 1
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; ANNSURG-D-15-00237; Total nos of Pages: 2;
ANNSURG-D-15-00237
Letter to the Editor
3. Kwon S, Wang B, Wong E, et al. The impact of accreditation on safety and cost of bariatric surgery. Surg Obes Relat Dis. 2013;9:617–622. 4. Telem DA, Talamini M, Altieri M, et al. The effect of national hospital accreditation in bariatric surgery on perioperative outcomes and longterm mortality. Surg Obes Relat Dis. 2015;11: 749–757. 5. Gebhart A, Young M, Phelan M, et al. Impact of accreditation in bariatric surgery. Surg Obes Relat Dis. 2014;10:767–773.
2 | www.annalsofsurgery.com
Annals of Surgery Volume XX, Number X, Month 2015
6. Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260:504–508. 7. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014. Available at http://www.mbsaqip.org/?page_id ¼ 54. Accessed January 14, 2015. 8. Jafari MD, Jafari F, Young MT, et al. Volume and outcome relationship in bariatric surgery in the
ß
laparoscopic era. Surg Endosc. 2013;27:4539– 4546. 9. Nguyen NT, Hohmann S, Slone J, et al. Improved bariatric surgery outcomes for Medicare beneficiaries after implementation of the Medicare national coverage determination. Arch Surg. 2010;145:72–78. 10. Morton J. The first metabolic and bariatric surgery accreditation and quality improvement program quality initiative: decreasing readmissions through opportunities provided. Surg Obes Relat Dis. 2014;10:377–378.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
