Michigan Bariatric Surgery Collaborative Impact of Collaborative Outcomes-Based Quality Improvement in Bariatric Surgery Wayne J. English, M.D., F.A.C.S. Clinical Assistant Professor Michigan State University College of Human Medicine Medical Director of Bariatric Surgery Bariatric and Metabolic Institute Marquette General Hospital A Duke LifePoint Hospital Marquette, MI
ReShape Medical Disclosures
Regional Collaborative Quality Improvement Accelerates improvement by having ability to rapidly identify and broadly implement best practice Reduces variation in practice and improves overall quality
What is the Michigan Bariatric Surgery Collaborative? Payer-funded (BCBS MI) Clinical outcomes registry Quality improvement program Basic elements High quality data collection Data belongs to all MBSC participants (not BCBS Michigan)
Types of data collected Component Data Sources/Timing Content Peri-operative care and outcomes Chart review for all patients at 30 days post-op Risk factors, treatment details, complications Late outcomes Structure and process of care Survey at baseline and mailed annually to all consenting patients Annual survey of surgeons and other bariatric program staff Late complications, weight loss, comorbidity resolution, quality of life Specifics of bariatric practice, OR environment, patient safety culture Technical quality Videotaped operative procedures Peer skill ratings Subjective aspects of quality Site visit Observed structure and process specifics Cost BCBSM claims Payments for facility, professional, ancillary care
Primary focus: CQI Program Registry data Look at variation in practice Evidence Risk stratification Defining best practices Collaborative meets three times a year to: Examine data Design and implement changes
Participants Current Status of MBSC 39 sites 84 surgeons >6,000 patients annually Approximately 45,000 patients in database
MBSC Track Record Decreased use of IVC Filters and rates of serious complications Decreased readmission and ED visit rates VTE risk calculator Outcomes risk/benefit calculator Surgeon Skill Assessment Surgeon Mentorship Program
Financial Impact Decreasing readmissions, reoperations and ED visit rates Overall annual savings for BCBS MI $4.7 million Overall savings for statewide plans $14.6 million
QI Priorities Complications Pulmonary embolism Infection Leak Bleeding Cardiac Respiratory Wound complication Long-term Outcomes Weight loss Patient satisfaction Quality of life Comorbidity resolution Resource use ED visits Readmissions
Pulmonary Embolism Accounts for almost half of all deaths after bariatric surgery Standard approaches to prophylaxis Early ambulation Compression stockings / devices Anticoagulation ( blood thinners )
Variation in Medical Prophylaxis Pre-operative Post-operative Post-discharge N LMW LMW None 2,594 UF UF None 873 UF None LMW 610 UF LMW LMW 510 None UF None 382 None LMW None 223 UF None None 221 UF LMW None 175 Other Combinations 788
What MBSC Did Developed prediction rule for stratifying baseline risk of VTE by patient factors Implemented Statewide practice guidelines for VTE prophylaxis according to patient risk Based on both empirical analysis and group consensus
VTE Risk Predictor Patient Example: Risk Factor Points RYGBP 3 Age 62 5 BMI 53 3 Male 2 Ex-smoker 2 Total 15
MBSC Practice Guidelines
Trends in VTE Rates QI intervention
IVC Filter Utilization inferior vena cava (IVC) trap blood clots Value as prophylaxis in surgical patients unclear Utilization growing rapidly (200K per year) since availability of removable filters
Outcomes in patients with and without IVC filters
Outcomes after gastric bypass
Decreased Use of IVC Filters Initial data feedback
Total BCBSM payments with gastric bypass (2006) $32,008 $45,559
Net annual savings on this one QI project $2.6 million (all Michigan payers) $1.3 million (BCBSM) Enough to cover costs of the entire program
QI Projects Doesn t take much for collaborative QI programs to demonstrate return on investment IVC filter use was an incidental finding - not a primary QI target Feedback alone regarding outcomes and practice often sufficient in achieving dramatic improvements
Objectives Identify risk factors for serious complications after bariatric surgery Develop a preoperative risk calculator based on significant risk factors
Patients Primary (non-revisional) bariatric procedures between June, 2006 and December, 2010 25,469 patients 78% women Mean age 46 years Mean BMI 48 kg/m 2
Procedures Laparoscopic 92% Conversions to open 1% Procedure type Laparoscopic gastric bypass 13,758 (54%) Open gastric bypass 1,092 (4%) Adjustable gastric band 8,015 (31%) Sleeve gastrectomy 2,279 (9%) Duodenal switch 325 (1%)
Complications Minor complications: 1,245 (4.9%) Serious Complications: 644 (2.5%) Range 0.9% for Lap Band to 8% for Duodenal Switch Decreased from 5% from when MBSC first formed Mortality 0.1% Range 0.04% for Lap Band to 0.5% for open gastric bypass
Conclusions Overall rate of VTE is low likely related to near universal use of perioperative anticoagulants. Patients with 3 or more risk factors may require more aggressive VTE prophylaxis use of extended post-discharge anticoagulant Further studies to determine risk-based strategies for VTE prophylaxis in bariatric surgery are warranted
Conclusions MBSC has developed a validated populationbased risk scoring system for serious complications following bariatric surgery The risk scoring system/calculator tool will: improve informed consent process facilitate selection of procedures for high risk patients allow for better risk stratification across studies of bariatric surgery
Average of Six Ratings of Technical Skill Bottom Middle Top Video # = N Raters = Note: represents the mean; bars extend from mean ± standard error.
Next for MBSC Surgeon video assessment for sleeve gastrectomy Surgeon coaching to improve technical skills in bariatric surgery and decrease complications
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