Thursday, August 05, 2004

From the Boston Globe: Panel urges standards for obesity surgery
Responding to a sixfold jump in the number of patients undergoing obesity surgery, a state public health panel yesterday recommended that Massachusetts hospitals and doctors adopt strict standards to reduce deaths and complications.

The report includes recommendations that hospitals and surgeons perform a high number of surgeries in order to stay in practice, which ultimately could force some smaller programs at community hospitals to close. Based on their review of medical studies, panel members said hospitals that do more than 100 surgeries a year, and surgeons who do 50 to 100 cases a year, have lower complication rates.
The report from the panel, which may be found here is quite detailed. Over 100 recommendations are put forth, from insuring that hospitals offering bariatirc surgery have special operating tables, longer instruments, wider wheelchairs, and so forth. There are also recommendations about both hospital and surgical volume:
One guideline recommends surgery only at hospitals that perform 100 or more cases annually. Only 14 of the state's 24 hospitals that do obesity surgery perform that many, said Dr. George Blackburn, vice chairman of the panel and a physician at Beth Israel Deaconess Medical Center. The panel also recommended that hospitals adopt strict standards for doctors before allowing them to perform obesity surgery.

For traditional weight-loss surgery, during which doctors make a long incision, hospitals should have an experienced surgeon monitor a new surgeon for 10 cases. The hospital should then review the next 15 cases of the new surgeon, to make sure standards are met, before granting full privileges to the surgeon.
So over half of the hospitals in Massachusetts providing bariatric surgery do not meet the goals set forth in the report. Lets look at the details of the suggested volume requirements (page 17 of the PDF file):

1. Establishment of Provisional Privileges (open WLS procedures)
• Completion of the (ASBS) American Society for Bariatric Surgeons essentials courses or equivalent
• Successful completion of 10 open cases proctored by a surgeon with full privileges for open WLS.

1a. Establishment of Provisional Privileges (laparoscopic WLS procedures other than
• Meets requirements for provisional open privileges
• Successful completion of 25 laparoscopic cases proctored by a surgeon with full
privileges for laparoscopic WLS (Category B).

So before a surgeon could even perform the procedure unsupervised they would have to undergo training, perform 10 proctored open procedures and 25 proctored laparoscopic procedures. Some allowance would have to be provided for surgeons who performed bariatric surgery in residency. It seems to me that it would be hard to find ten patients willing to undergo open bariatric surgery nowadays with the popularity of laparoscopic surgery. Continuing:
2. Establishment of Full Privileges (open or laparoscopic WLS procedures)
• Review of first 15 independently performed cases by a committee that includes the chief of surgery at the surgeon’s institution and an experienced (>100 cases) weight loss surgeon; this committee may also include members of the institution’s Quality Assurance and Credentialing programs
• No substantial deviation in risk-adjusted outcomes from accepted norms and
2a. Recredentialing of Full Privileges (open or laparoscopic WLS procedures)
• Maintenance of board certification or board eligibility. Credentialed gastrointestinal surgeons who are active staff member with full admitting privilege at facility obtaining bariatric privilege are eligible
• 100 primary or revisional WLS procedures within the previous 2 years (Categories B and D)
• Presence of a second weight loss surgeon on staff with either full or provisional privileges within the same program
So even after the 35 cases required above, an additional fifteen would have to be reviewed. The surgeon would then be required to perform at least fifty a year.
A very good effort to assure quality control concerning a very risky procedure. It will be interesting to see how they work out, especially the volume requirements. Some "grandfathering" of these regulations are likely. This could still dissuade a surgeon from going off to a weekend course and proclaiming themselves a bariatric surgeon. The hospitals that are not currently meeting those goals will be very reluctant to let potentially very lucrative bariatric surgery business leave. Another problem is that if all of the procedures are shunted to a few centers in the state the desire to take care of the complications by other surgeons not working at the "Bariatric center of Excellence" will fall, for reasons explained in this post. Stay tuned.
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