Raising the Standard: Bariatric Surgery Targeting Opioids (BSTOP): The Third MBSAQIP National Quality Improvement Project

| July 1, 2019

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is the Quality Director at Geisinger Surgical Institute and Director of Bariatric and Foregut Surgery for Geisinger Health System in Danville, Pennsylvania.  Dr. Gadaleta is Chair of the Department of Surgery at Southside Hospital and Director of Metabolic and Bariatric Surgery at North Shore University Hospital, Northwell Health in Manhasset, New York; and Associate Professor of Surgery at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2019;16(7):12.


In the past 50 years, healthcare policy in the United States (US) has focused on several population-based efforts to eliminate preventable “epidemics” that have disproportionately contributed to death and disease in large segments of the US population. Cigarette smoking and obesity are two of the most well-known. It has become clear over the past several years that opioid dependency is now similarly responsible for devastating preventable healthcare problems in the US population.

Opioid-overdose deaths have increased every year for the past two decades, driving a drug-overdose epidemic that killed more than 72,000 Americans in 2017.1 Until recently, many surgeons considered this a societal and political problem beyond the means of most providers to influence. However, it has become increasingly clear that many patients suffering from opioid dependence and addiction are first exposed to opioids through postoperative prescriptions. A population-based study of 36,000 surgical patients published in JAMA Surgery found the incidence of new, persistent opioid use after surgical procedures to be 5.9 to 6.5 percent, with no difference between major and minor surgical procedures.2 Patients undergoing bariatric surgery could be particularly vulnerable to opioid dependence. The Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) cohort prospectively evaluated opioid prescribing before and after bariatric surgery. In patients with no reported preoperative opioid prescriptions, rates of regular prescribed opioid use (daily, weekly, or “as needed”) increased to 5.8 percent at six months postoperatively and 14.2 percent by Year 7 postoperatively.3 Bariatric surgeons undoubtedly have an opportunity to help quell the US opioid epidemic.

In 2015, the National Institutes on Drug Abuse (NIDA) reported an estimated two million people in the US suffered from substance use disorders related to prescription opioid pain relievers with a mortality of 1.3 to 1.6 percent.4 That same year, the one-year mortality for all initial bariatric surgical procedures in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry was 0.39 percent, and mortality decreased to 0.11 percent in 2018. An assessment of quality improvement opportunities determined that complete elimination of venous thromboembolism (VTE), anastomotic leak, pneumonia, and bleeding complications in bariatric surgery would prevent about 48 deaths annually.5 If only six percent of postoperative bariatric patients suffer from new opioid dependence with a 1.3 percent mortality, then about twice as many (n=105) patient deaths could be prevented annually with the complete elimination of new opioid dependence. Ironically, the best way to save lives in bariatric surgery might have less to do with our technical skills and more to do with our prescribing practices.

Congress addressed the opioid crisis with passage of legislation in October 2018. The Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act was signed into law, providing treatment for patients suffering from opioid dependence but also guidelines for providers. Some of the key measures within this legislation affecting surgeons include:

  1. Opioids must be prescribed electronically for all Medicare patients.
  2. Opioid prescription patterns will be analyzed annually for hospitals and providers.
  3. The legislation prohibits the ongoing use of pain questions on health system questionnaires tied to performance and reimbursement.6

The last measure is particularly important to surgeons because it eliminates the patient satisfaction liabilities associated with postoperative pain control that profoundly influenced opioid prescribing patterns.

Both the scope of the opioid crisis and the opportunity to improve the care of our bariatric patients has led the Data and Quality Subcommittee of MBSAQIP to focus the third national quality improvement project on opioid reduction. Invitations to participate in Bariatric Surgery Targeting Opioids (BSTOP) were sent to all MBSAQIP-accredited bariatric centers in the last week of June 2019.

The purpose of this project is to support MBSAQIP-accredited centers interested in reducing opioid prescriptions while improving postoperative pain control. The timeline for the project is July 2019 through December 2020. The initial phase includes invitations and onboarding of centers. Centers must commit to participation by signing the stakeholder’s agreement by August 5, 2019. Training of centers will continue through September 2019. The pre-implementation data collection phase is scheduled for October and November 2019. This phase focuses on baseline data collection. Centers are asked not to change their current practices during this phase but to optimize their collection and population of the custom fields. The pilot phase will run through December 2019 and January 2020. Centers will receive the protocol and begin implementation. Centers should have 100 percent compliance with data collection and greater than 80 percent compliance with the protocol by the end of this phase. The implementation phase runs from February through November 2020. The protocol is designed to:

  1. Educate patients and providers about the risks of opioid use after bariatric surgery
  2. Implement routine opioid-reducing multimodal pain strategies
  3. Implement routine use of regional analgesia
  4. Minimize perioperative opioid use
  5. Comply with the SUPPORT Act as well as state opioid reduction laws

We encourage all centers to participate regardless of their current pain management strategies. This project represents a landmark opportunity to influence the management of perioperative surgical pain for generations to come. Please email any questions to mbsaqipquality@facs.org.

References

  1. National Center for Health Statistics. Vital statistics rapid release: provisional drug overdose death counts. Vital statistics rapid release. October 2018 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed July 3, 2019.
  2. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery. 2017;152(6):e170504.
  3. Raebel MA, Newcomer SR, Reifler LM, et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013;310(13):1369–1376.
  4. Center for Behavioral Health Statistics and Quality (CBHSQ). 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.
  5. Daigle CR, Brethauer SA, Tu C, et al. Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes. Surg Obes Relat Dis. 2018;14(4):652–657.
  6. Davis CS. The SUPPORT for Patients and Communities Act—what will it mean for the opioid-overdose crisis? N Engl J Med. 2019; 380(1):3–5.

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