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Michigan Bariatric Surgical Society November 13, 2009

Michigan Bariatric Surgical Society November 13, 2009. Why Bariatric Surgery? Why ASMBS BSCOE?. Disclosures. Chairman Board of Directors SRC Board Member NOVUS RRG Board Member Surgical Excellence LLC Cook Biotec Wound Healing Research Grant

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Michigan Bariatric Surgical Society November 13, 2009

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  1. Michigan Bariatric Surgical SocietyNovember 13, 2009 Why Bariatric Surgery? Why ASMBS BSCOE?

  2. Disclosures • Chairman Board of Directors SRC • Board Member NOVUS RRG • Board Member Surgical Excellence LLC • Cook Biotec Wound Healing Research Grant • Bariatric Surgery Director Bon Secours St. Mary’s • Ethicon Surgery Advisory Group

  3. Bring me a solution; not a problem

  4. What is the Problem • Obesity and its resultant diseases are the drivers of chronic illness • Chronic illness consumes 80-90% of our entire health care budget • 80-90% of chronic illness and its costs are preventable by lifestyle change • Type 2 diabetes alone consumes almost 20% of all healthcare costs and increasing daily • Obesity and its associated illness are the number one health problem in the work place • Bariatric Surgery has proven that chronic illness can be reversed

  5. What is the Solution? Comprehensive wellness program that includes bariatric surgery

  6. Role of the Bariatric Surgeon • Bariatric Surgery is the missing link that has shown the value of significant, sustained weight loss • 60% reduction in overall mortality • 56% reduction in cardiac mortality • 92% reduction in diabetes mortality • 60% reduction in cancer mortality • Pays for itself in 29-48 months • Safe enough to offer a warranty Adams, etal, New England Journal of Medicine2007:357 (8): 753-761

  7. Bariatric Surgery is: • Most rehabilitative procedure done in modern medicine • Safest intra-abdominal operation (major) • Bariatric surgery CAN’T operate away obesity

  8. Bariatric Surgeons must be part of a comprehensive wellness program • Screening of large populations for risk stratification • Design of programs and incentives to engage people at risk to change behavior leading to risk • Offer surgery to those at enough risk • Capture operated patients into system to assure long term follow up

  9. Bariatric Surgeons must: • Socially responsible in the war on obesity/war on the metabolic syndrome, concentrate on children • Continue/refine/spread the “Center of Excellence” concept • Continue to refine surgical skills and procedures • Advance appropriate non surgical approaches • Educate: public, medical colleagues, government, and media • Eliminate obesity discrimination

  10. Key Factors for Bariatric Surgery • Safety • Effectiveness • Return on investment

  11. Safety • Buchwald meta-475 studies, 85K patients (1990-2006) • 30 day mortality – 0.4%, lower in later years-graded by risk and complexity • 30 days to 2 years – 0.8% Surgery. 2007:142 (4): 621-632

  12. Data from Independent Sources • Health Grades (website) 2002-2004; 30 day 0.19% • AHRQ statistical brief 23 – 2004; 30 day 0.2% • Zigmond, et al. JAMA. 2005; 294: 1909-1917, 66,000 surgery, 30 day 0.33% • Pratt, et al. Surgery of Obesity Related Diseases. 2006; 2:497-503, SRC application Data 66190 pts. 30 day 0.29% 90 day 0.34% • Williams, et al. Int. J Qual Healthcare. 2008 Jan. 3 pub. 30 Day non bariatric gastric surgery Fellowship trained 2.8% General Surgeon 4.8%

  13. Relative 90 day mortality Demick, et al. JAMA. 2004; 292:847-851 • AAA: 3.9% • CABG: 3.5% • Esophagectomy: 9.1% • Total Hip: 0.3%

  14. Effectiveness (Let me count the ways) Adams, et al. New England Journal of Medicine. 2007:357 (8) 753-761 Overall Reduction of Mortality Mortality: 60% Diabetes: 92% Heart Disease: 56% Cancer: 60%

  15. Comorbidity Reduction Buchwald, et al. JAMA.2004;202 (14):1724-1732 • Type 2 DM: Resolved 76.8%, Improved 86% • HBP: Resolved 61.7%, Improved 78.5% • Hyperlipidemia: Improved over 70% • OSA: Resolved 85.7%

  16. Christou, et al. Annals of Surgery. 2004; 240:416-424 • Mortality 6.17% → 0.68% • Cancer 8.49% → 2.03% All comorbid conditions except anemia and intestinal disorders lower costs decreased 45%

  17. Costs of Obesity and Related Diseases • BMI > 35 increases costs 44% Quisenberry, et al. Arch Intern Med. 1998:158:466 • Total Health costs; 1/3 due to obesity (Rand Corp) • 2010 – 48% of children overweight or obese (CDC) • 2025 – 200,000,000 Type 2DM - $687 Billion Amer. College of Endo. Consensus Statement, July 23, 2008 • 2050 – 29% GNP Obesity (Peter Orszag-Head of Congressional Budget Office)

  18. Cost of Type 2 DM • 15-20% total health budget • $11,300/year – Economic cost of DM in US 2007 – ADA www.diabetes.org • $33,495/year – www.unum.com • 10 year mortality – 51% Zhou, et al. Diabetes care.2005;28:2856-2863 • Leg amputation – every 30 seconds

  19. Cost of Bariatric Surgery • QALY - $50,000 → $129,000 Lee, et al. J. Amer. Soc. Nephrol.2008; 19: 1792-1797 • Cost excluding physician fees 2004: $10,300 AHRQ statistical brief # 23:Jan 07

  20. Return on Investment Cremieux, et. Al, Amer. Journ. Managed Care. 2008;14 (9):51-58 • Assuming Surgery $17,000 pays 29-48 months Finkelstein, et al. Amer. Journ. Managed Care. 2005; 11 (10): 641-646 • Depending on Copays – pays 5-9 years “We shouldn’t even have to consider this as no other treatment ever has been held to this standard”

  21. Discrimination Discrimination against the obese is stronger than that against race and gender overt Puhl, et al. Intern Journal of Obesity.2008;32:992-1000

  22. Summary • Chronic illness is mostly life style • Cost of chronic illness is unsustainable • Bariatric surgery reverses chronic disease • Bariatric surgery reduces morbidity, mortaility, and cost • Bariatric Surgeons must be socially responsible • Bariatric surgery must be part of a multi-dimensional program aimed at prevention, effective medical interventions, and surgery

  23. Summary • Bariatric surgery is the safest major surgery done • Bariatric surgery is the most rehabilitative treatment in modern medicine • Results of bariatric surgery proves the worth of prevention and reversal of the “metabolic syndrome”

  24. Why ASMBS BSCOE?

  25. Why COE? 2003: A year of crisis Disbelief in bariatric surgical outcomes Reports of high complication rates Increased malpractice litigation Surgeons did not have data to respond, and Many health plans were terminating coverage, while Others began their own centers of excellence program 25

  26. The requirements were not justified The requirements were not fair Access was restricted or denied Scientific research was hampered Furthermore, bariatric surgeons felt that: Surgery must be performed by qualified teams in well-equipped hospitals Each center must select and standardize its best care Every patient must be reported into a uniform database Results must becompared and appliedto create continuous quality improvement In 2003,Other “COE” programs had problems Solution: Establish a completely independent corporation, involving industry stakeholders, to administer an international, evidence-based program for health care quality and patient safety ― a credible central outcomes database serving as the cornerstone. 26

  27. ASMBS Created Partnership with Surgical Review Corporation A completely independent, nonprofit organization – shields Society from restraint of trade The Board of Directors oversees the organization and is comprised of industry stakeholdersrepresenting surgeons, third-party payors, professional liability carriers, allied health, and consumers The International Bariatric Surgery Review Committee (IBSRC) reviews applications to the ICE program and recommends changes to standards. The IBSRC is headed by Raul Rosenthal, MD and comprised of three regional committees: Latin America, Europe and Asian-Pacific. 27

  28. Program Statistics Program Statistics Total Applicants: 1,110 Hospitals 1,922 Surgeons Centers of Excellence: 384 Hospitals 660 Surgeons ICE Centers located in United Kingdom and Taiwan. Brazilian Centers announced at next week’s conference. BOLD Database: 182,301+ Patients Entered 925 surgeons and 685 facilities using BOLD 28

  29. Performance of First 176 BSCOE Centers Application Data Verified by Site Inspection Pratt, G.M., McLees, B., W.J. Pories. The ASMBS Bariatric Surgery Centers of Excellence Program: A Blueprint for Quality Improvement. Surgery for Obesity and Related Diseases, 2, 2006. pp. 497-503. 29

  30. New Mortality Data from BOLD DeMaria, EJ.  Baseline data from ASMBS-designated bariatric surgery centers of excellence using the Bariatric Outcomes Longitudinal Database.  Paper presented at:  26th Annual Meeting of the American Society for Metabolic and Bariatric Surgery; June 24, 2009; Grapevine, TX. 30

  31. And for these common abdominal procedures: “Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (P = 0.10).” Williams SC, Koss RG, Morton DJ, Schmaltz SP, Loeb JM. Case Volume and Hospital Compliance with Evidence-based Processes of Care. Int J Qual Health Care. 2008 Jan 3 Epub ahead of print 31

  32. Quality IndicatorsSt. Mary’s Hospital, Richmond, VA 32

  33. Demographics 2003-2005 (Range)2006-2008 (Range) Age 43 + 1.1 (14-73) 43 + 0.69 (15-73) BMI 48.8 + 1.7 (36.2-91.5) 47 + 0.45 (32.6-91.3) Weight 293 + 5.18 (164-670) 292 + 3.66 (168-602) % Female 82.6% 83%

  34. Potential Factors for Improvement • Concurrent review of enhanced data collection. • Collaborative committee became actual team. • Pathway development and adherence to pathways • Leverage with administration (Bariatric Unit). • Reduction in overall obesity discrimination. • Patient Selection Committee.

  35. Pre-operatively, the following profiles will need review by the Multidisciplinary Care Team. Once convened, the Care Team will put forth a treatment plan for the candidate that serves to maximize the outcome for this individual. • Age over 70 • BMI over 65 • Decreased mobility (requiring assistive device or person to ambulate). • Cardiovascular insufficiency (EF less than 30), prior cardiac event within 6 weeks of surgery. • Uncontrolled diabetes (hemoglobin A1C less than 7 or fasting blood glucose less than 150). • Severe or untreated depression or other mental illness. • Previous, failed obesity surgery. • Renal disease (creatinine greater than 2.4) acute vs. chronic. • Severe sleep apnea with pulmonary hypertension. • Mental retardation. • Steroid dependency (maintenance therapy 2 months or greater). • Liver Reduction Diet. • Avoid Ventilators. • Reviewed 114: Surgery performed 43-all due to patient behavior.

  36. Goals for Immediate Future • Clinical transformation; Reduction in costs while continued quality improvement. • Decrease length of stay. • Reduce costs by $2,000/case.

  37. SummaryOutcomes Improved by ASMBSDesignation as BSCOE® • Formation of energized Bariatric Surgery Team. • Enhanced administration support. • Improved data collection and review. • Reduction of 30 day adverse events. • Overall complications • Reoperations • Readmissions • *Mortality*

  38. Bariatric Outcomes Longitudinal Database 38

  39. BOLD Data Dissemination Facts Data Dissemination Policies and Procedures governed by Data Dissemination and Access Committees based upon these principles: Surgeons will always have access to their own information at no charge No surgeon-specific data will be released without the surgeon’s permission Very Important 39

  40. Result:A Rigorous Compliance Program+Data for Best Practices =Excellence SRC’s Strategic Alliances tells the story:Full-time Advocacy for Bariatric Surgeons 40

  41. Value for Excellence (VforE) SRC’s new VforE program offered exclusively for fully approved BSCOE providers. • SRC actively pursues special benefits just for BSCOE centers and surgeons (this includes reimbursement and coverage) • A current catalogue of benefits is shown on SRC’s Web site • This program also benefits those providing products and services for BSCOEs • The VforE program will eventually be used to attract patients to BSCOE and ICE centers • Benefits more than exceed participant cost in the BSCOE program • No other organization devotes this effort or offers such a program 41

  42. International COE (ICE) • Centers certified in UK, Taiwan, and Brazil • Brazilian Society contracted with SRC • Mexican Centers soon to be certified. • IBSRC committees for Europe, Latin America, and Asia-Pacific.

  43. Excellence does not consist of levels ― the opposite of excellent is good There is no easy path to excellence! 43

  44. Thank you! Neil E. Hutcher, M.D. Commonwealth Surgeons, Bon Secours Medical Group 5855 Bremo Road, Suite 506 Richmond, VA 23226 (804) 285-3225 1-866-720-8446

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