SCOAP Community Speaks Up: Bariatric Surgery

Clinicians at Evergreen Hospital asked us recently, “Can you update us on SCOAP’s data on quality and safety trends for bariatric surgery?”

We are frequently asked about the impact of SCOAP benchmarking on surgical quality and safety. SCOAP has been collecting data on bariatric procedures since its beginning in 2006. Recently, we reviewed trends for operative reinterventions, in-hospital mortality and 30-day mortality for gastric bypass, sleeve gastrectomy, and lap band procedures. Paralleling nationwide trends, bariatric surgery at SCOAP hospitals has gotten much safer in the last 5 years. Rates of operative reinterventions (mostly for leaks) for patients having gastric bypass have decreased from 5% to 2% from 2006-2010 (figure 1). Lap band reinterventions are expected to be infrequent, and to date, their rate has fluctuated between 0% and 1%. There was significant growth in the use of sleeve gastrectomies, with almost none being done in 2006, to and over 100 per quarter in 2010. In the last 2 years when the numbers have been more robust, we have seen reintervention rates of 1-2%, and in 2009 (when we started to get robust post-index hospitalization data), the rate of 30-day death and/or reintervention after sleeve was 2.68% (3 out of 112).

Of course, these improvements in leak rates are temporal trends, and it is almost impossible to attribute them to SCOAP alone. However, SCOAP continues to engage clinicians in changing practice patterns around important components of surgical site infection and leaks that should be expected to reduce the rates of these serious adverse events. Through newsletters, regional and annual meetings, and sharing actionable data and benchmarks about everything from glycemic control to leak testing, we are hoping to drive these rates even lower.

The SCOAP Advisory Board and metrics committees engage in a quarterly and annual process of review of all metrics to ensure that they remain useful, relevant, and a good use of abstracting resources. After reviewing data trends over the last five years, a few trends emerged related to bariatric surgery. As expected, short term lap band outcomes have remained stable with little variability, and the number of known process of care measures around adjustable banding have always been limited and have not expanded. The SCOAP Advisory Board determined that adjustable band procedures should be removed from the registry as a SCOAP-eligible procedure in order to increase the focus on gastric bypass, sleeve gastrectomy, and other newly added optional gastric procedures for ulcer or cancer. These procedures are higher risk, are increasingly utilized, and though 30-day mortality rates in Washington have declined considerably in the last decade (figure 2), there is still much opportunity for improvement. SCOAP will continue to shine the spotlight on aspects of these procedures that can contribute to better outcomes (e.g., by studying the use of sealing devices to decrease the rate of anastomotic leaks). Despite this change to SCOAP data collection, most adjustable banding centers in Washington are involved in a longer-term outcome tracking activity through the University of Washington’s Bariatric Outcomes and Obesity Modeling (BOOM) project. This survey-based data gathering activity is evaluating weight change, band adjustment patterns, and quality of life 2-5 years after banding and is providing benchmarked data to the centers. For more information about this project contact Brad Kramer, BOOM Project Manager at cbkramer@uw.edu) and expect an update in a future newsletter.

We still have opportunity to work together to make bariatric surgery safer. SCOAP is trying to focus the surgical community on achieving better glycemic control during and after bariatric surgery as a way to decrease infectious complications. There is still substantial variability between hospitals (figures 3 and 4) in how basic metrics of glycemic control and disturbing variation in even the checking of perioperative blood sugars, the use of insulin in diabetic patients with blood sugars of >200, and the effectiveness of glycemic control in the 2 days after surgery. While on average 90% of SCOAP bariatric patients with diabetes have a blood sugar checked (up from 45% when we started) there are still many hospitals where this is less common. As disturbingly, while on average 80% of patients with a very high blood sugar get started on insulin, that means that 1 in 5 do not, and there is even more variation in this metric. Where we all perform inconsistently is in how often we keep our patients’ blood sugar less than 200 during the 48-hour post op period. In keeping blood sugars less than 200 during the 48 hours post-op, the SCOAP average is even worse (40%), and only a few hospitals are considered high performing in this more complex metric. In SCOAP, 37% patients undergoing bariatric surgery are diabetic, so we have lots of opportunity to do a better job. Glycemic control may be one of our more effective strategies to improve outcome. A set of recent studies including one using NSQIP outcomes [1] found that for every 40 mg/dL increase in post-operative glucose above 140, there was a 30% increased risk of postoperative infection. SCOAP is conducting a series of regional meetings and workshops to learn more about best practices in perioperative glycemic control. This will also be a focus of part of the annual meeting in Chelan on June 17th. We hope to see you there and continue the hard work of driving quality improvement for our patients. Working together, the SCOAP community is aiming to get all of our patients the best possible outcomes.

Thanks for the question and all that you do to make SCOAP a success!

Reference

[1] Ramos M, Khalpey Z, Lipsitz, S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery. Ann Surg 248 (4); Oct 2008.

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