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Centers of Excellence outcomes

Widespread variation in bariatric outcomes in Centers of Excellence

Both centres and payers looking to improve care for the bariatric population, should concentrate on reducing variation where most procedures are performed by regional collaboration and selective referral
The findings could help inform how continued progress in quality improvement for bariatric surgery can be achieved

There is widespread variation in post-operative outcomes among bariatric centres of excellence in the US, according to a study published by researchers from the University of Michigan. The researchers conclude that both centres and payers looking to improve care for the bariatric population, should concentrate on reducing variation where most procedures are performed by regional collaboration and selective referral.

The paper, ‘Variation in Outcomes at Bariatric Surgery Centers of Excellence’, published in JAMA Surgery, sought to describe the variation in surgical outcomes across bariatric centres of excellence and the geographic availability of high-quality centres. The researchers performed a retrospective review of patients who underwent bariatric surgery at accredited centres to identify the variations in postoperative complications across these centres. They write that their findings, based on data obtained prior to the implementation of MBSAQIP, could help inform how continued progress in quality improvement for bariatric surgery can be achieved.

Study

They gathered data from the Healthcare Cost and Utilization Project’s State Inpatient Database, which was created by the Agency for Healthcare Research and Quality. Data were available from 165 bariatric centres of excellence in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin). The other 38 states either did not participate in the Healthcare Cost and Utilization Project or did not have 3 consecutive years of data available during the study period, between January 1, 2010, and December 31, 2013.

In the study, the primary outcome of interest was the rate of serious complications (anastomotic leak, cardiac, genitourinary, haemorrhagic, neurologic, obstruction, postoperative shock, pulmonary, splenic injury, thromboembolic, wound infection, and reoperation). They also identified the geographic proximity between high-quality and low-quality centres of excellence, and the extent of variation that exists across different operative volumes. Therefore, hospitals were divided into terciles on the basis of their annual volume of bariatric procedures and were labeled ‘low volume’, ‘medium volume’ or ‘high volume.’

In total, 145, 527 patients were included in the study and laparoscopic Roux-en-Y gastric bypass (78 193 [53.7%]) was the most common procedure, followed by laparoscopic sleeve gastrectomy (44 887 [30.8%]). The most common comorbidity conditions were hypertension (80 807 [55.5%]) and diabetes (44 190 [30.4%]).

Nearly all of the 165 accredited bariatric centres in the study (99.4%) were located in an urban setting and most of which (117 [70.9%]) were within a teaching hospital. The centres were also geographically diverse, with 78 (47.3%) located in the Northeast and 52 (31.5%) in the South.

Of the 145,527 patients, 6,970 (4.8%) had a complication and 2,367 (1.6%) had a serious complication. The most common complication was postoperative bleeding (2796 [1.9%]) and the in-hospital mortality rate was 0.05% (n=72).

The reported a wide variation in rates of complications at individual centres of excellence, ranging from 0.6% to 10.3% (Figure 1) and a similar variation was seen at the state level ranging from 2.1-fold variation (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold variation (Nebraska decile range, 1.0%-10.3%).

Variation in Rates of Serious Complications Across Bariatric Centers of Excellence in 12 States. Risk-adjusted and reliability-adjusted outcomes in 165 centres across 12 states (Data from Healthcare Cost and Utilization Project’s State Inpatient Database)

The paper also reported a variation in rates of complications at centres with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Mean (SD) complication rates were 1.9% (0.9%) at low-volume centres, 2.0% (1.0%) at medium-volume centres and 1.5% (0.3%) at high-volume centres (p=0.31).

The geographic availability of a higher-quality centre was assessed at the state and hospital service area levels, and the authors report that all states in the study had both low-quality hospitals and high-quality hospitals. Of the 132 hospitals in the lowest four quartiles, 38 hospitals (28.8%) had a bariatric centre in a higher quintile of quality located within the same hospital service area.

“Whether bariatric centers of excellence have improved safety for bariatric procedures has been a matter of debate…This study helps us move past the debate by identifying an important opportunity for improvement across accredited centers, where nearly all bariatric procedures are performed,” the authors note.

The researchers said that the study results in three important findings that have multiple implications for both practice and policy to improve the safety of bariatric surgery:

  • Hospital accreditation alone does not ensure uniform high-quality care, because most bariatric procedures are now performed at accredited centres, patients and payers can no longer use this designation to identify the highest-performing hospitals.
  • All the resources and infrastructure are already in place to identify true centers of excellence and the MBSAQIP collects data on outcomes, therefore the programme could readily stratify nearly all bariatric centres into low-quality, medium-quality, and high-quality performers (information that could be valuable for patients who are choosing a centre for bariatric surgery, for surgeons who are identifying quality improvement targets, and for administrators of large hospital systems who are optimizing their network service lines).
  • The MBSAQIP programme can be used as a platform for widespread quality improvement.

“As centres and payers look toward improving care for the bariatric population, focus should be aimed at reducing variation where most procedures are performed,” the authors conclude. “Given that a large proportion of low-quality centres are geographically located near higher performing centres, opportunities for improvement through selective referral or regional collaboration should be considered.”

To access this paper, please click here

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