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Better Bariatric Surgery Outcomes Depend on Data, Accreditation

 |  By cclark@healthleadersmedia.com  
   February 06, 2014

A surgeon's success in reducing readmissions among gastric bypass surgery patients underscores the importance of collecting data through a system of accreditation.

Three years ago, bariatric surgeon John Morton, MD, thought the 8.5% readmission rate for gastric bypass patients at his hospital, Stanford University, was something to boast about, because it compared favorably to national readmission rates of about 20%.

But then he saw the data.

Nationally, readmission rates for bariatric surgery patients hovered lower, around 6%. Stanford no longer looked so good. What's more, data showed that 60% of its gastric bypass readmissions were occurring because patients just weren't drinking enough water. They were simply dehydrated.

"We saw that our patients didn't always understand their diet despite the best efforts of our education," says Morton, who directs Stanford's Bariatric Surgery and Surgical Quality programs. But "until I saw the data, I wasn't moved to action."

Morton's experience illustrates the importance of collecting data through a system of accreditation, which by the way, 175 of 900 hospitals that perform bariatric surgical services do not have, he says. More on that shocking statistic later.

After seeing its readmission statistics, Stanford instituted a quality improvement program "that decreased our readmission rate by approximately 70%," so that 18 months later it had dropped to 2.5%, Morton says. "We wouldn't have done that if we didn't have the data."

How They Did It
Stanford's bariatric teams launched a "readmission bundle" that included common sense care coordination, like good preoperative education, giving prescriptions in advance so patients could fill them before surgery, and explaining expectations for their stay in the hospital. Other actions included assuring same-day physician appointments, coordination with patients' families, and explaining what patients should eat and drink and what specific number they should call if they need help.

Morton relates Stanford's experience to show the benefits of quality measurement under the new Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program or MBSAQIP (don't try to pronounce it), which launched a year ago.

This week, MBSAQIP issued its first requirements for accreditation in a 60-page document. Morton was one of the writing committee's co-chairs.

Two Accreditation Programs Merge
The MBSAQIP melds two accreditation programs that had been operated separately, one by the American College of Surgeons (which accredited about 550 hospitals, and the other by the American Society for Metabolic and Bariatric Surgery, which accredited 150 hospitals. Under the new combined program, hospitals will all have a specially trained nurse reviewer, "a person outside the direct medical practice" to independently and accurately collect 100 or more patient variables abstracted manually from charts.

Lab values that give a sense of a patient's severity of illness include, comorbidities, complications, reoperations, time in the operating room during surgery, amount of blood loss, and who assisted the procedure.

These are the kinds of statistics that help hospitals compare themselves with other organizations, and ultimately recognize problems.

Accreditation also requires bariatric programs to conduct periodic patient follow-ups out at least one year, and eventually to five, to determine how the patient did, whether they lost weight, how much, and whether they gained it back. It tracks complications such as bowel obstruction, deep vein thrombosis, bleeding, or surgical site infections, some of which may not appear until after discharge.

Astonishingly Accreditation-Free
The fact that 20% of the nation's 900 bariatric surgery programs operate without any accreditation is astonishing, especially because without careful checks, gastric bypass is a dangerous and potentially fatal procedure, requiring proper training and technical skill. I even called back Morton to double check this statistic, and he did.

Accreditation, Morton says, has greatly reduced mortality rates, which were 1% 10 years ago.

He attributes the drop in mortality to three specific changes in the way surgeons perform these procedures:

  • Research showing that the more bariatric procedures a surgeon performed, the lower the rates of mortality and other complications, which led to minimum center and surgeon volume requirements as part of accreditation.
  • Better training and certification requirements, also a requirement for accreditation.
  • The development of less invasive laparoscopic techniques instead of open gastric bypass surgeries, which yielded fewer complications.

What an Accredited Bariatric Program Must Have
MBSAQIP's new guidelines require hospitals to put in place program components the average referring physician or patient might not really think about. But just imagine a program that doesn't have these elements. At minimum a program must have:

  • A program director who actively practices bariatric surgery, chairs a specifically defined program committee, and other responsibilities filling two pages; a coordinator who is a registered dietician, and a clinical reviewer who does not supervise patient care to enter data.
  • Surgeons whose licenses are in good standing, who have formal bariatric surgery training, who can document performing at least 25 stapling cases a year at a single center, and who operate in a program with adequate surgical backup in case patients develop complications.
  • A designated area with a consistent and knowledgeable nursing team where bariatric procedures are performed.
  • Registered nurses, advanced practice nurses, psychologists, psychiatrists, social workers, and exercise therapists specifically trained for bariatric patient care.
  • Furniture, physical space, and equipment sized to handle large patients.
  • Long-term follow-up plans on a 30-day, six month and one-year and annually thereafter schedule, patient education protocols, and support groups with regularly scheduled and supervised programs.
  • Process improvement initiatives and safety culture monitoring.

If anyone thinks all this goes without saying, they should stop to consider that there are 175 hospitals that can't demonstrate that they have these standards in place.

Synchronizing Payer Contract Criteria
In time, Morton says, the MBSAQIP hopes to eliminate a major headache for any hospital that takes private health insurance, because the four big insurers—Aetna, Cigna, United and Blue Cross Blue Shield—that are the biggest payers of bariatric surgical procedures (the bills for 70% of all bariatric procedures are reimbursed by private health plans) all have very different minimal requirements for contracting.

"At my institution, we complete about a dozen different accreditation processes for different insurers," Morton says. "What we want to see happen through MBSAQIP is that there would be a single standard that people can rally around, trust, and believe in, and do away with all the redundancy and duplicity that's involved with all these applications." One single accreditation process would be easier on everyone, he says.

Sounds like a good idea.

Bariatric surgery is a growth business in more ways than one, Morton says. It's not just a lucrative profit center for hospitals at an average facility payment of between $15,000 and $35,000. There is also what Morton calls "the echo" effect:

There are physicians' fees, and additional testing for patients with obesity-related conditions like sleep apnea, cardiology evaluation, endoscopic procedures, plastic surgery reconstruction just to name a few. "There's quite a bit of benefit to the bottom line for hospitals that do bariatric surgery," he says.

So why not get accredited?

View a list of hospitals accredited to perform bariatric procedures.


See Also:

Bariatrics Gets its Own Quality Measures

Peer Review of Surgeons' Skills Carries 'Threatening Undertones'

CA Details Bariatric Surgery Trends by Hospital

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