Primary Bariatric Surgery Outcomes at MBSAQIP Accredited Ambulatory Surgery Centers vs. Comprehensive Bariatric Surgery Centers

Transcription

1 Primary Bariatric Surgery Outcomes at MBSAQIP Accredited Ambulatory Surgery Centers vs. Comprehensive Bariatric Surgery Centers Wayne J English, MD, FACS, FASMBS MBSAQIP Standards/Verification Committee Co-Chair Associate Professor of Surgery Vanderbilt University Medical Center

2 Co-Authors Kristopher Huffman David Provost, MD Teresa Fraker, MS, CBN Amy Robinson-Gerace, BM Matt Hutter, MD, MPH Anthony Petrick, MD John Morton, MD

3 Disclosures CMBS Member Co-Chair Standards/Verification CMBS Subcommittee MBSAQIP Adjudication Committee Member Clinical Investigator Allurion Obalon BAROnova

4 Standards: Two Versions

5 Background 1st version of standards Ambulatory Surgery Centers (ASC) could apply for accreditation as Comprehensive Center Outcry regarding public deception Payors had plan in progress to designate ASC other than Comprehensive Center 2 nd version of standards Separate ASC standard developed using best evidence available

6 Ambulatory Centers in MBSAQIP July 2013 June 2014 Ambulatory Surgery Centers Comprehensive Centers

7 Low Acuity Standards at ASCs 1) Age 18 and < 65 years 2) Males with a BMI < 55 and females with a BMI < 60 By implementing low-acuity definition, ASCs would still be able to operate on: Age criteria: 95% of their patients Sex and BMI criteria: approximately 98% of their patients nearly all females 84% males

8 Low Acuity Standards at ASCs 1) Age 18 and < 65 years 2) Males with a BMI < 55 and females with a BMI < 60 By implementing low-acuity definition, ASCs would still be able to operate on: Age criteria: 95% of their patients Sex and BMI criteria: approximately 98% of their patients nearly all females 84% males Conclusion: Designated as comprehensive centers, ASCs were already selecting low risk patients in vast majority of patients

9 Studies showing ASCs self selected low risk patients Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center Garofalo, et al. Obesity Surgery 2016 Outpatient laparoscopic sleeve gastrectomy: first 100 cases Badaoui, et al. J Clin Anesth 2016

10 Is Ambulatory Laparoscopic Roux-en-Y Gastric Bypass Associated With Higher Adverse Events? Demonstrated higher 30-day mortality and trend towards increasing serious complications Morton, et al. Ann Surg 2014

11 Selection of Obese Patients Undergoing Ambulatory Surgery: A Systematic Review of the Literature 23 studies (13 prospective and 10 retrospective), and 1 systematic review assessing laparoscopic bariatric surgery 106,119 patients 62,476 prospective trials 43,643 retrospective trials BMI >50 kg/m2 higher risk of developing complications Conclusion: The literature lacks sufficient information to make strong recommendations regarding appropriate selection of the obese patients scheduled for ambulatory surgery Joshi, et al. Anesthesia & Analgesia 2013

12 Primary Bariatric Surgery Outcomes at MBSAQIP-Accredited Ambulatory Surgery Centers vs. Comprehensive Bariatric Surgery Centers

13 Data: Case Selection

14 Site Characteristics Ambulatory Comprehensive N = 7 N = 39 Number of Cases Mean Volume Over Analysis Time Period AMA Medical School Affiliation 14.3% 35.9% Accreditation Council for Graduate Medical Education Residency 14.3% 41.0% Approved Cancer Program 28.6% 43.6% Bed Size Code % 2.6% % 0.0% % 53.9% % 18.0% % 10.3% % 7.7% >= % 7.7% CBSA Code % 84.6% % 15.4% CBSA Type Metro 100.0% 100.0% Community Hospital Designation 100.0% 100.0% Council of Teaching Hospitals of the AAMC 0.0% 12.8% Critical Access Hospital 0.0% 0.0% Medicare Certified 100.0% 100.0% Separate Long-Term Nursing Home 0.0% 7.7% Sole Community Provider 0.0% 0.0%

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16 After adjusting for clustering of patients within hospitals and differences in patient risk factors, the matched cohort showed no statistically significant (p < 0.05) differences in 30-day outcomes between the two center populations.

17 Conclusion Ambulatory Centers deliver similar care with respect to surgical quality as Comprehensive Centers This conclusion may not hold for a certain segment of ambulatory center patients Patients are most likely to be low-acuity patients These data help support the utility of the low acuity standards

18 Future for ASCs in MBSAQIP Standards/Verification Committee Continue to monitor outcomes data at ASCs Adapt standards as more definitive data becomes available ASCs are encouraged to Publish data Participate in MBSAQIP

19 Thank you!