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Centers of Excellence for bariatric surgery – the only locations where the procedures are covered by Medicare – do not yield fewer complications or better outcomes for patients.
The Centers for Medicare and Medicaid Services established the Centers of Excellence in 2006 with an eye on increasing safety and decreasing negative outcomes.
Dr. Justin B. Dimick of the University of Michigan, Ann Arbor, and his colleagues, reviewed bariatric surgeries performed before and after that policy went into effect and found that there were no statistically significant improvement in complications, serious complications, or reoperations. Their findings were published Feb. 26 in JAMA.
The overall safety of bariatric surgery has increased over the years, Dr. Dimick noted, as surgeons have increasingly chosen less-invasive, lower-risk procedures such as laparoscopic gastric banding, rather than higher-risk, open procedures. Surgeons’ experience has increased and technology has improved as well; both trends have made the operations easier and less dangerous.
"Our study found large improvements in bariatric surgery outcomes over time even after adjusting for changes in procedure use," he wrote.
Taking into account patient factors such as age and comorbidities, procedure type, and year of operation, 5.5% of patients at a COE hospital had any complication, compared with 6% for those at a nondesignated facility. For serious complications, the rate was 2.2% at COEs vs. 2.5% at non-COEs. The reoperation rate was 0.83% for patients in COE hospitals, compared with 0.96% at nondesignated facilities (JAMA 2013;309:792-9).
The results were drawn from comparisons of discharge data from 2004-2009 in 12 states, chosen for geographic diversity. The discharges were for Medicare and non-Medicare patients, and the researchers examined outcomes for the 2 years before the CMS policy change and about 3 years after. Overall, there were 6,723 Medicare patients who had bariatric surgery before 2006, and 15,684 who had it afterward. For non-Medicare patients, the data covered 95,558 procedures before the change, and 155,117 afterward.
Facilities can gain the Centers of Excellence designation if they meet three primary criteria: provide accommodations for obese patients, and other structural elements; perform a minimum volume of 125 cases per year; and, submit data to either the American College of Surgeons or the American Society of Metabolic and Bariatric Surgery registry. Facilities are certified by the ACS or the ASMBS. Since 2006, the CMS has designated almost 600 facilities as a Bariatric Center of Excellence.
The structural resources required by the CMS do not differ much from what the Joint Commission requires, Dr. Dimick wrote, and volume standards don’t necessarily correlate with quality. He added that the registry data are not used in any kind of continuous quality improvement process, and thus probably do not have much of an impact.
The ACS and the ASMBS have been developing new outcomes measures and standards for that registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Public comment closed on Jan. 15. The organizations said they expected to incorporate any comments into a final draft.
The CMS policy restricting coverage to Centers of Excellence should be revisited, Dr. Dimick advised. The policy does not appear to improve outcomes and may even have the unintended consequence of "sacrificing long-term effectiveness for improved short-term safety."
The study was supported by grants from the National Institute on Aging and the Agency for Healthcare Research and Quality. The authors had no relevant disclosures.
On Twitter @aliciaault
Since the Medicare policy decision 7 years ago, the Centers of Excellence have contributed to notable improvements in bariatric surgery, primarily by increasing awareness of variation between centers and focusing the attention of physicians, hospital health care personnel and administrators, and payers on the need to improve quality and safety. However, the limitations of COEs are now recognized by the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons, which have joined forces and have an initiative underway to develop new standards, with an increased focus on more robust outcome measures.
As the CMS and the surgical societies reexamine the COE policy in bariatric surgery, there is an opportunity for them to be creative; to catapult surgical outcomes science forward through scalable approaches to data sharing, measurement, collaborative networks and comparative effectiveness research; and to design a program that can not only identify high-quality hospitals, but also provide a sustained mechanism for quality improvement.
Dr. Caprice C. Greenberg is associate professor of surgery at the University of Wisconsin, Madison, and director of the Wisconsin Surgical Outcomes Research Program. Her remarks were made in an editorial accompanying Dr. Dimick’s report (JAMA 2013;309:827-8).
The Centers for Medicare and Medicaid Services,
Dr. Justin B. Dimick
Since the Medicare policy decision 7 years ago, the Centers of Excellence have contributed to notable improvements in bariatric surgery, primarily by increasing awareness of variation between centers and focusing the attention of physicians, hospital health care personnel and administrators, and payers on the need to improve quality and safety. However, the limitations of COEs are now recognized by the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons, which have joined forces and have an initiative underway to develop new standards, with an increased focus on more robust outcome measures.
As the CMS and the surgical societies reexamine the COE policy in bariatric surgery, there is an opportunity for them to be creative; to catapult surgical outcomes science forward through scalable approaches to data sharing, measurement, collaborative networks and comparative effectiveness research; and to design a program that can not only identify high-quality hospitals, but also provide a sustained mechanism for quality improvement.
Dr. Caprice C. Greenberg is associate professor of surgery at the University of Wisconsin, Madison, and director of the Wisconsin Surgical Outcomes Research Program. Her remarks were made in an editorial accompanying Dr. Dimick’s report (JAMA 2013;309:827-8).
Since the Medicare policy decision 7 years ago, the Centers of Excellence have contributed to notable improvements in bariatric surgery, primarily by increasing awareness of variation between centers and focusing the attention of physicians, hospital health care personnel and administrators, and payers on the need to improve quality and safety. However, the limitations of COEs are now recognized by the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons, which have joined forces and have an initiative underway to develop new standards, with an increased focus on more robust outcome measures.
As the CMS and the surgical societies reexamine the COE policy in bariatric surgery, there is an opportunity for them to be creative; to catapult surgical outcomes science forward through scalable approaches to data sharing, measurement, collaborative networks and comparative effectiveness research; and to design a program that can not only identify high-quality hospitals, but also provide a sustained mechanism for quality improvement.
Dr. Caprice C. Greenberg is associate professor of surgery at the University of Wisconsin, Madison, and director of the Wisconsin Surgical Outcomes Research Program. Her remarks were made in an editorial accompanying Dr. Dimick’s report (JAMA 2013;309:827-8).
Centers of Excellence for bariatric surgery – the only locations where the procedures are covered by Medicare – do not yield fewer complications or better outcomes for patients.
The Centers for Medicare and Medicaid Services established the Centers of Excellence in 2006 with an eye on increasing safety and decreasing negative outcomes.
Dr. Justin B. Dimick of the University of Michigan, Ann Arbor, and his colleagues, reviewed bariatric surgeries performed before and after that policy went into effect and found that there were no statistically significant improvement in complications, serious complications, or reoperations. Their findings were published Feb. 26 in JAMA.
The overall safety of bariatric surgery has increased over the years, Dr. Dimick noted, as surgeons have increasingly chosen less-invasive, lower-risk procedures such as laparoscopic gastric banding, rather than higher-risk, open procedures. Surgeons’ experience has increased and technology has improved as well; both trends have made the operations easier and less dangerous.
"Our study found large improvements in bariatric surgery outcomes over time even after adjusting for changes in procedure use," he wrote.
Taking into account patient factors such as age and comorbidities, procedure type, and year of operation, 5.5% of patients at a COE hospital had any complication, compared with 6% for those at a nondesignated facility. For serious complications, the rate was 2.2% at COEs vs. 2.5% at non-COEs. The reoperation rate was 0.83% for patients in COE hospitals, compared with 0.96% at nondesignated facilities (JAMA 2013;309:792-9).
The results were drawn from comparisons of discharge data from 2004-2009 in 12 states, chosen for geographic diversity. The discharges were for Medicare and non-Medicare patients, and the researchers examined outcomes for the 2 years before the CMS policy change and about 3 years after. Overall, there were 6,723 Medicare patients who had bariatric surgery before 2006, and 15,684 who had it afterward. For non-Medicare patients, the data covered 95,558 procedures before the change, and 155,117 afterward.
Facilities can gain the Centers of Excellence designation if they meet three primary criteria: provide accommodations for obese patients, and other structural elements; perform a minimum volume of 125 cases per year; and, submit data to either the American College of Surgeons or the American Society of Metabolic and Bariatric Surgery registry. Facilities are certified by the ACS or the ASMBS. Since 2006, the CMS has designated almost 600 facilities as a Bariatric Center of Excellence.
The structural resources required by the CMS do not differ much from what the Joint Commission requires, Dr. Dimick wrote, and volume standards don’t necessarily correlate with quality. He added that the registry data are not used in any kind of continuous quality improvement process, and thus probably do not have much of an impact.
The ACS and the ASMBS have been developing new outcomes measures and standards for that registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Public comment closed on Jan. 15. The organizations said they expected to incorporate any comments into a final draft.
The CMS policy restricting coverage to Centers of Excellence should be revisited, Dr. Dimick advised. The policy does not appear to improve outcomes and may even have the unintended consequence of "sacrificing long-term effectiveness for improved short-term safety."
The study was supported by grants from the National Institute on Aging and the Agency for Healthcare Research and Quality. The authors had no relevant disclosures.
On Twitter @aliciaault
Centers of Excellence for bariatric surgery – the only locations where the procedures are covered by Medicare – do not yield fewer complications or better outcomes for patients.
The Centers for Medicare and Medicaid Services established the Centers of Excellence in 2006 with an eye on increasing safety and decreasing negative outcomes.
Dr. Justin B. Dimick of the University of Michigan, Ann Arbor, and his colleagues, reviewed bariatric surgeries performed before and after that policy went into effect and found that there were no statistically significant improvement in complications, serious complications, or reoperations. Their findings were published Feb. 26 in JAMA.
The overall safety of bariatric surgery has increased over the years, Dr. Dimick noted, as surgeons have increasingly chosen less-invasive, lower-risk procedures such as laparoscopic gastric banding, rather than higher-risk, open procedures. Surgeons’ experience has increased and technology has improved as well; both trends have made the operations easier and less dangerous.
"Our study found large improvements in bariatric surgery outcomes over time even after adjusting for changes in procedure use," he wrote.
Taking into account patient factors such as age and comorbidities, procedure type, and year of operation, 5.5% of patients at a COE hospital had any complication, compared with 6% for those at a nondesignated facility. For serious complications, the rate was 2.2% at COEs vs. 2.5% at non-COEs. The reoperation rate was 0.83% for patients in COE hospitals, compared with 0.96% at nondesignated facilities (JAMA 2013;309:792-9).
The results were drawn from comparisons of discharge data from 2004-2009 in 12 states, chosen for geographic diversity. The discharges were for Medicare and non-Medicare patients, and the researchers examined outcomes for the 2 years before the CMS policy change and about 3 years after. Overall, there were 6,723 Medicare patients who had bariatric surgery before 2006, and 15,684 who had it afterward. For non-Medicare patients, the data covered 95,558 procedures before the change, and 155,117 afterward.
Facilities can gain the Centers of Excellence designation if they meet three primary criteria: provide accommodations for obese patients, and other structural elements; perform a minimum volume of 125 cases per year; and, submit data to either the American College of Surgeons or the American Society of Metabolic and Bariatric Surgery registry. Facilities are certified by the ACS or the ASMBS. Since 2006, the CMS has designated almost 600 facilities as a Bariatric Center of Excellence.
The structural resources required by the CMS do not differ much from what the Joint Commission requires, Dr. Dimick wrote, and volume standards don’t necessarily correlate with quality. He added that the registry data are not used in any kind of continuous quality improvement process, and thus probably do not have much of an impact.
The ACS and the ASMBS have been developing new outcomes measures and standards for that registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Public comment closed on Jan. 15. The organizations said they expected to incorporate any comments into a final draft.
The CMS policy restricting coverage to Centers of Excellence should be revisited, Dr. Dimick advised. The policy does not appear to improve outcomes and may even have the unintended consequence of "sacrificing long-term effectiveness for improved short-term safety."
The study was supported by grants from the National Institute on Aging and the Agency for Healthcare Research and Quality. The authors had no relevant disclosures.
On Twitter @aliciaault
The Centers for Medicare and Medicaid Services,
Dr. Justin B. Dimick
The Centers for Medicare and Medicaid Services,
Dr. Justin B. Dimick
FROM JAMA
Major finding: Complication rates were 5.5% at Centers of Excellence, compared with 6% at nondesignated facilities. Reoperation rates were 0.83% for COEs, compared with 0.96% at nondesignated facilities.
Data source: A retrospective, longitudinal study using Medicare and non-Medicare hospital discharge data for 321,464 patients from 12 states for 2004-2009.
Disclosures: The study was supported by grants from the National Institute on Aging and the Agency for Healthcare Research and Quality. The authors had no relevant disclosures.
