This article appears in the February 2012 issue of HealthLeaders magazine.
While widely regarded as the best medical weapon to combat obesity and a lucrative venture for providers, bariatric surgery is still in its infancy in terms of quality measures.
To date, more than 109,000 procedures, costing about $26,000 a piece, are performed each year, but surgeons have had no easy way of comparing their quality metrics to those of their peers, making it difficult to identify and improve any unfavorable nationwide trends.
Now, the American Society for Metabolic and Bariatric Surgery is trying to change that by creating a national database of quality measures so that all bariatric surgeons in the United States can see where they fall.
Key quality measures
The most important quality measurements are structure, process, and outcome, says Robin Blackstone, MD, president of the ASMBS and medical director of the Scottsdale (AZ) Healthcare Bariatric Center.
Structural elements, such as volume, have traditionally been a measurement used as a quality indicator, but Blackstone says it’s actually a proxy because it doesn’t give real quality data.
"In procedures with high mortality rates and major complication rates, it’s very useful to use volume, but over the last seven or eight years, the whole issue of using volume has come into question as people have evolved more to use a composite outcome measure," she says.
Measuring process elements, such as giving patients medication to prevent blood clots prior to surgery, is critical, but it is also difficult to discern the impact it has on the quality of care because the data isn’t clear which elements of process are most important yet, Blackstone says.
For now, using risk-adjusted and reliability-adjusted composite measures is the most effective quality metric.
"To measure outcome well you have to do what’s called risk adjustment," Blackstone says. "That means you actually have to know what are the factors about the population that make them higher risk or lower risk. Traditionally over the years a number of risk adjustments have been done and the procedure itself is a major risk factor."
Other risk factors include male gender, tobacco use, renal failure, and heart disease, she says.
The Raleigh (NC) Center for Weight Loss Surgery, which performs surgeries at Rex Healthcare, focuses on outcomes as a quality measure.
"The top quality metrics we’re most focused on are mortality rates, readmission rates, reoperation rates—those are the biggest ones," says Joseph Moran, MD, founder of the weight-loss center, which is a recognized Center of Excellence by the ASMBS and accredited by the Surgical Review Corporation.
"Once you get past that, then people look at things like excess body weight loss and percent body weight loss and comorbidity resolution. These are the most important metrics that we as an institution and program look at to make sure we’re exceeding the standards published in the U.S."
Provost Bariatrics, too, recognizes the importance of tracking quality outcomes, focusing on readmissions, reoperations, wound infection rates, and venous thromboembolism incidents.
"Some of these metrics are tracked through the hospital and some are through the practice, and we look at them on a regular basis," says David Provost, MD, founder and surgeon at the Denton, TX, practice, also certified as a Center of Excellence by the ASMBS. "Some incidents are infrequent enough to where we haven’t had to act on them. The nice thing is when you track outcomes, you can recognize clusters of adverse events—if you don’t follow it or don’t track it, you’ll never know."
Corrective action
The Raleigh Center for Weight Loss Surgery and Provost Bariatrics both have taken corrective measures after noticing irregularities in their outcome quality tracking reports.
Recently, Moran noticed a high number of patients requiring the use of total parenteral nutrition, given by way of IV by providers after the patient has been discharged.
"We investigated the situation and found it was ordered by a physician extender but for the wrong reasons," he says. "We educated the provider and saw our TPN numbers drop back down to a normal level."
It’s incidents like this that have taught Moran that one of the most important steps a bariatric surgeon can do to improve quality is to fully educate the patient and any follow-up care providers.
"You have to give appropriate education, whether it be accomplished with materials provided by surgeons’ offices, dietitians, providers, support groups, or even online programs; that can increase the knowledge base of the patient going into surgery," he says. "This is something bariatric surgeons didn’t do a very good job of 10 or 20 years ago."
Provost had a similar experience when he was conducting a regular review of quality measures and noticed an abnormally high blip in wound infection rates.
Upon further analysis of the data, Provost realized that the infection rate was consistent among all patient groups, indicating that the problem was systemic.
"We looked at other things that have been done to reduce infection rates, and preop cleansing before the patient even comes to hospital has been shown to be effective in cardiac surgeries," Provost says.
He and his team began providing patients with chlorhexidine scrubs to wash their abdomens before coming in for surgery. "And by doing that, we soon saw infection rates decrease," he says.
Comparing national quality data
The next step to improving quality in bariatric surgery is to go beyond the case-by-case correction process by enabling surgeons and hospitals to view and compare quality statistics nationwide.
That is what the ASMBS is hoping to accomplish with its Bariatric Outcomes Longitudinal Database, its latest attempt to improve quality in bariatric surgery. In 2004 the ASMBS began accrediting bariatric surgery programs.
The society has accredited 458 programs to date, based on a number of requirements, such as performing at least 125 surgeries per year. Another 52 bariatric programs have applied for certification in the past six months.
When Rex Healthcare began its bariatric surgery pilot program in 2007, Moran had already decided he would eventually apply for ASMBS Center of Excellence certification. The weight-loss center became an established program in mid-2008 and received its COE designation in 2010.
"The COE designation was a top goal of the healthcare facility and our practice," Moran says. "COEs tend to perform higher volumes per year and have demonstrated better outcomes in comparison to lower volume, non-COE facilities. The COE was also becoming a requirement of many of the third-party payers in order to perform cases and receive reimbursement for services."
The ASMBS is now creating a quality composite measure through the BOLD database, which has data for 400,000 patients who have been followed over at least four years. The data will be predictive of center performance and allow each bariatric program to judge how it compares with its peers.
In 2012, the society will give programs actual targets for process improvements based on their BOLD scores.
"The way this whole field has evolved is to use composite measures, which are things you take signals of quality from a number of different places and combine them to make an overall measure you can use," Blackstone says.
Blackstone and the ASMBS are working with the University of Michigan bariatric surgery collaborative and the American College of Surgeons to improve BOLD.
"We’re combining all three quality programs to come up with a single standard for quality that we will use for all of our programs in the United States," she says. "What is really exciting about this project is that it’s taking the roots of what we’ve been doing and evolving us to the next level so that surgeons will get high-level, scientifically derived data to engage them in continuous quality improvement."
Looking to the future
The ASMBS has set a goal to decrease the bariatric surgery major complication rate by half by 2017.
"If we are successful in doing that we will not only have the most effective treatment for obesity, but we’ll deliver that for patients more safely than we’re doing now, and that’s a tremendous value for the healthcare system," says Blackstone. "By striving to have this high-quality program, everyone wins: Patients have a better experience and get the weight off with less complications, and the hospital service line offers true value and they also contribute to the ability of the hospital to provide other service line care that might not be so lucrative."
Having access to the BOLD data is going to be critical moving forward because of the direction the healthcare industry is heading, Moran says.
"It’s ultimately going to come down to a pay-for-performance-type model where you’re going to be evaluated based upon your outcomes compared to those of your peers," he says. "It’s probably going to be a preferential push to move folks toward institutions that can provide quality care with really low cost and low complication rates. Ultimately that’s what it’s coming down to and that’s the truth for the majority of medicine and surgery anyway."
And most important, quality metrics will improve outcomes for patients and the health of communities.
"Obesity is the biggest epidemic in the country, and bariatric surgery is the most effective treatment," Blackstone says. "It will make an impact in your community to have an obesity-focused program. If done correctly and within good safety limits, that program can be very cost-effective for the hospital."
This article appears in the February 2012 issue of HealthLeaders magazine.
Marianne Aiello is a contributing writer at HealthLeaders Media.