One Year Later: Reflections on the 2013 ASMBS Presidential Address

| November 2, 2014

An Interview with Dr. Jaime Ponce including insights from other members of ASMBS Leadership

Bariatric Times. 2014;11(11):10–13.

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

This Month’s Interview with:

Jaime Ponce, MD
Medical Director for the Bariatric Surgery program at Hamilton Medical Center, Dalton, Georgia and Memorial Hospital, Chattanooga, Tennessee; Past-President, American Society for Metabolic and Bariatric Surgery.

Ninh T. Nguyen, MD
Professor of Surgery, Chief, Division of Gastrointestinal Surgery University of California, Irvine Medical Center; President, American Society for Metabolic and Bariatric Surgery.

John M. Morton, MD, MPH, FACS, FASMBS
Chief of the Section of Bariatric and Minimally Invasive Surgery,
Stanford University, Stanford, California, Presient-Elect, American Society for Metabolic and Bariatric Surgery.

Wayne English, MD, FACS
Clinical Assistant Professor, Department of Surgery, Michigan State University College of Human Medicine; Medical Director, Bariatric & Metabolic Institute, Marquette General Hospital—A Duke LifePoint Hospital, Marquette, Michigan; Chair of the American Society for Metabolic and Bariatric Surgery Access to Care Committee.

Ranjan Sudan, MD
Vice Chair of Education, Associate Professor of Surgery, Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; Chair of the American Society for Metabolic and Bariatric Surgery Research Committee.

Aurora D. Pryor, MD
Professor of Surgery and Vice Chair for Clinical Affairs; Chief, General Surgery Division;  Director, Bariatric and Metabolic Weight Loss Center, Stony Brook University Medical Center, Stony Brook, New York; Chair of the American Society for Metabolic and Bariatric Surgery Emerging Technology and Procedure Committee.

Shanu N. Kothari, MD, FACS
Director of Minimally Invasive Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin; Chair of the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee.

Funding: No funding was provided in the preparation of this manuscript.
Financial disclosures: The authors report no conflicts of interest relevant to the content of this article.

Dr. Rosenthal: Dr. Ponce, last year during the first annual ObesityWeek, you gave the ASMBS Presidential address.1 In that address, you gave the follwowing recommendations, suggestions, and statements to the Society for the future. Can you provide an evaluation on how we have done as a Society in fulfilling each of these recommendations in one year’s time?

1.) The ASMBS needs to fully embrace training and education of metabolic and bariatric surgery at all levels.

Dr. Ponce: This past year we have put together exceptional educational events with the Spring Event meeting in Miami, Florida, and now Obesity Week 2014 in Boston, Massachusetts. In addition, we have re-evaluated the Bariatric Surgery fellowship training and certification and now the American Board of Surgery (ABS) is considering the development of a process for Board Certification in Bariatric Surgery. Dr. Ninh Nguyen can provide more information.

Dr. Nguyen: We are still in the early phase of discussion to establish a certificate of added qualification in bariatric surgery in conjunction with the ABS. This means that trainees who complete an ASMBS approved fellowship training may eventually qualify to take a validated examination and receive a certificate of added training. Advantages for such a certificate include ensuring the public trust, improving knowledge of our trainees, and enhancing the legitimacy of our field.

We need to continually enhance educational efforts for our members and trainees to keep them updated on the latest innovation and technologies in bariatric surgery. One of the most important avenues to keep up with the latest research is to attend the ASMBS annual meeting. This year, we are introducing a new bariatric educational offering, The ASMBS Textbook of Bariatric Surgery.2,3 This is a 2 volumes textbook with the 1st volume devoted to bariatric surgery and the 2nd volume devoted to bariatric medicine, psychosocial and nutritional aspects of bariatric surgery.

Dr. Ponce: Finally, the new ASMBS Textbook of Bariatric Surgery will be released during the Obesity Week meeting. This textbook is a new accomplishment in educational tools provided for all levels (students, residents, surgeons, multidisciplinary team staff, etc.).

2.) The ASMBS needs to continue to be in the leadership for accreditation standards.

Dr. Ponce: The new standards are already in place, many payors are following the new standards and some are re-evaluating the needed changes in their policies. Surveyors are trained and have started site visits to enable new hospitals to become accredited. Finally, for the first time, each center got their risk adjusted outcomes report per procedure performed. This will enable us to establish the quality improvement initiatives that have become a new item in the accreditation process. Dr. John Morton, ASMBS President-Elect, can speak more about these new initiatives.

Dr. Morton: Since its implementation, the MBSAQIP has been very successful with about 750 centers now participating. This makes it the second largest accreditation program in the American College of Surgeons (ACS). This year, we have been working on a new intiative called Decreasing Readmissions through Opportunities Provided or DROP. Through a recent study,[4] we have concluded that although complications at accredited centers are rare, readmissions are still high.  A main driver in this initiative is a study conducted at Stanford Hospital and Clinic.[4,5] Stanford reduced hospital readmissions by 75 percent after implementing changes in patient education, discharge, planning, and pre-operative procedures. The DROP program aims to mimick Stanford’s success in decreasing 30-day readmissions by providing more evidence-based resources, including best practice toolkits. Modules will include best practice information on important areas in bariatric surgery that may directly impact re-admissions (e.g., surgical site infections, types of antibiotics used, and dietary recommendations). The letters have gone out to accredited centers inviting them to participate in the DROP program. We estimate this program will have a lot of success.

3.) The ASMBS needs to use the data for quality improvement.

Dr. Ponce: For the first time in June 2014, each MBSAQIP accredited center received their semi-annual, risk-adjusted report per procedure, allowing each center to compare how they are doing in complications and overall outcomes with all the other centers. This report will help them to identify opportunities for quality improvement. Data now will be used to improve quality and it is a new feature of the database. Dr. Morton can explain this new feature.

Dr. Morton: In June 2014, the ASMBS began comparing results from hospitals accross the United States. We feel this is important because different hospitals may operate on different patient and with different procedures. These risk-adjusted assessments allow us to capture a fair comparison of centers, taking patient and procedure into account.

4.) The ASMBS needs to continue to collaborate at all levels.

Dr. Ponce: Besides partnering with the Obesity Society (TOS) to organize Obesity Week and partnering with the American College of Surgeons (ACS) to establish the MBSAQIP, we also held the first annual Obesity Summit in September 2014. The Obesity Summit was a meeting that included 20 professional societies with the mission of providing a network and developing cross-community relationships to aid in the provision and coordination of care for the obese population. Dr. John Morton, who led the summit, can provide more information.

Dr. Morton: The first annual Obesity Summit this past September proved to be a great success greeted by much enthusiasm to repeat the event in 2015. The ASMBS along with over 20 medical societies discussed how to help every member of the medical community that treats a patient with obesity. We discussed putting together a consensus for joint guidelines on the care of patients with obesity and also conducted a needs assessment among the other disciplines. We received 100 percent support from all societies to move forward with the joint guidelines. We will be continuing discussion with medical specialties about these guidelines and also examining the needs assessment.

5.) The ASMBS needs to use technology to the fullest extent.

Dr. Ponce: The ASMBS is in discussion with The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to examine the utility of telementoring for the laparoscopic sleeve gastrectomy. This technology will allow new procedures or difficult cases to be done under the direct mentoring by an experienced surgeon at a distance. This pilot program will hopefully be available to all surgeons, including surgeons from overseas. Dr. Nguyen can ellaborate.

Dr. Nguyen: Training in the technical aspects of bariatric surgery is not new. This can be commonly done at our annual meeting, attending weekend courses, or through a mentoring process whereby the trainee surgeon travels to the mentor institution and watches live surgical cases. Then, at a later date, the mentor travels to the trainee surgeon’s institution to proctor the trainee surgeon. The latter option is an attractive one for training but can be cumbersome, time-intensive, and very costly. A telementoring program will streamline this important aspect of learning and may allow many more surgeons to participate in this type of training.

6.) The ASMBS needs to pursue universal access to care.

Dr. Ponce: The Essential Health Benefits have a deficient access for bariatric surgery in 28 states. The Access to Care Committee has worked hard to put together an access tool kit with all the necessary information per state that can be used to fight and establish local access in each of the 28 states that currently do not offer coverage. The goal is to have universal access at some point. The committee is continuing their hard work. Dr. Morton and Dr. Wayne English, Chair of the Access Committee can elaborate on this work.

Dr. Morton: The ASMBS has done a good job in pursuing universal access to care. We have proved that bariatric surgery is both safe and effective. Recently, The Centers for Medicare and Medicaid Services (CMS) made the decision to cover some bariatric procedures for Medicare recipients who meet criteria and The American Medical Association (AMA) recognized obesity as a disease. While these were great strides, there is still much that we need to accomplish. One big push is for the Essential Health Benefit by state. Currently, 22 states cover bariatric surgery and 28 do not. we want to extend coverage to the 28 states without coverage. The ASMBS State Chapters will be providing a toolkit to each of these states that includes the following: fact sheets, list of key opinion leaders in their state, Power Point presentations on types of surgery, and cost analyses. We aim to describe to elected officials that bariatric surgery is safe, effective and won’t break the bank. The data are on our side and bariatric surgery is here to stay.

Dr. English: The ASMBS Access to Care Committee has been working hard to obtain universal access to care with uniform coverage for both medical and surgical treatment of obesity. Unfortunately, the Essential Health Benefits does not include obesity treatment, which means each state is faced with a decision to determine if they will include obesity treatment coverage in the State Health Insurance Exchange.  Sadly, only 22 states decided to include bariatric surgery coverage. The AMA’s recent recognition of obesity as a disease, and CMS decision to cover some bariatric procedures for Medicare recipients who meet specific criteria has been extremely helpful for our cause.

However, 28 states in the country do not have bariatric surgery coverage. The Essential Health Benefit Tool Kit was created to make it easier for ASMBS State Chapters to educate elected state officials about the safety, effectiveness and cost saving measures associated with bariatric surgery. The Tool Kit includes fact sheets on obesity and bariatric surgery, list of key opinion leaders in each state, sample introduction letters and call to action summaries, PowerPoint presentations, and cost analyses data.

In addition, we have recently submitted Local Care Determination (LCD) Reconsideration requests to three Medicare Administrator Contractors (MACs) in an effort to open access to care, requesting to change of comorbidity definitions felt to be too restrictive, and to two MACs requesting to change age restriction criteria for sleeve gastrectomy coverage.  Responses are currently pending and we will inform the ASMBS membership when information becomes available.

7.) The world is getting smaller, and ASMBS must reach every place.

Dr. Ponce: During this year, I acted as the president of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) North America chapter. In this position, I helped to establish better communication among the leadership of IFSO and the ASMBS to expand in different areas and explore potential opportuites to reach all countries. We are planning to offer some post-graduate courses from Obesity Week online for surgeons that live far away and cannot travel to the United States for the meeting. We are also going to work with IFSO to develop more educational projects, including the telementoring technology, to reach more places around the world.

8.) The ASMBS needs to embrace research that explains the therapy, and I do think that we are trying to do that.

Dr. Ponce: Support for innovative research continues. Dr. Ranjan Sudan, Chair of the Research Committee, can provide an update on their work.

Dr. Sudan: Research through discovery and innovation helps the needle move forward for our specialty in many different ways. The ASMBS has supported this conviction by promoting research and has offered research grants worth nearly one million dollars to its members over the last several years. Many young scientists have used this funding to launch their academic careers. The grants have funded basic science research in areas such as diabetes and the gut-brain axis as well as clinical areas of interest such as sexual dysfunction. Awardees are recognized at the annual meeting and have an opportunity to present their findings to the membership.

The society also recognizes the importance of outcomes research as this has the potential to impact public and payor policy and increase access to care. The research committee has been actively working to make the Bariatric Outcomes Longitudinal Database (BOLD data available to its membership through the availability of the participant use file. This data set has been interrogated by the society to address issues of importance, including the following: 1) readmission rates, 2) outcomes of revision bariatric surgery, and 3) data pertaining to access, such as ethnicity resulting in four national presentations at ASMBS, TOS, and Society for Surgery of the Alimentary Tract (SSAT); two published manuscripts6,7 and three other manuscripts in preparation. Data queried from BOLD was instrumental in obtaining coverage from CMS for coverage for sleeve gastrectomy. Also, Blue Cross and Blue Shield of North Carolina has recently revised its policies and made it easier for patients to obtain revisions following publication of outcomes for reoperative bariatric surgery.6 The data are also used to determine volume of bariatric cases performed, their trends, distribution, and outcomes as well answer key questions pertaining to quality, safety, and efficacy. Over the last few years, the volume of bariatric operations performed annually in the United States has remained relatively stable despite the well-known effects on resolution of comorbid conditions based on several recent short-term randomized studies. The society has recognized the need for large multi-institutional studies to address these questions and is in the process of planning such studies. The MBSAQIP has a new data registry that has integrated the ASMBS and ACS data registries and is rapidly accumulating data that will continue to be very relevant to address such issues.

9.) The ASMBS needs to continue to work with the industry to complement the progress and innovation in bariatric surgery.

Dr. Ponce: New technologies are being evaluated by the FDA and the ASMBS is following the studies carefully. Additionally, we have been able to comment in FDA panels. Next year, more devices may be formally evaluated and will continue to complement with our expertise. Dr. Aurora Pryor, Chair of the Emerging Technologies Committee, can provide more insight.

Dr. Pryor: I think it is very exciting that many new technologies are potentially coming to the United States in the next few years. New technologies allow us to potentially improve patient care and expand interest in bariatric surgery. The ASMBS is closely involved in this process. We have provided feedback to the FDA device panels on both study design and specific product recommendations. As each potential new technology is developed, we are keeping the membership abreast on our webpage. For any new device approval, we have also started a new technology update as part of ASMBS Connect, a monthly newsletter available to ASMBS members. We plan to make recommendations for device application and utility as these new technologies come to the US market.

10.) The ASMBS needs to continue to be the leader in position statements and guidelines that are now based on better data.

Dr. Ponce: More position statements and documents are waiting to be finalized. A systematic review of the literature on reoperative surgery has been published8 and many more collaborative statements may be coming out of the Obesity Summit. Dr. Shanu Kothari, Chair of Clinical Issues Committee, can provide more information.

Dr. Kothari: The ASMBS has a strong history of collaborative statements with other societies. For example, we have an updated statement on the role of endoscopy in the bariatric patient that is soon to be published. This was triple endorsed by ASGE and SAGES as well as ASMBS. We created a position statement on accreditation of bariatric surgery centers, which was endorsed by SAGES and is under review by the ACS and SSAT. In addition, under the leadership of Dr. Stacy Brethauer, we have created a standardized reporting outcomes for bariatric surgery that we hope to have approved by all editors of bariatric journals to standardize our reporting of clinical work. We have begun creating evidence-based statements with the American Association of Hip and Knee Surgeons (AAHKS) on the role/timing of bariatric surgery in severely obese patients requiring joint replacement. We are also in the process of partnering with a newer society International Society for Perioperative Care of the Obese Patient (ISPCOP) and working on a white paper on the optimal perioperative care of the obese patient. This past September, a landmark Obesity Summit was held in Chicago and over 20 speciality societies were represented that deal with issues facing obese patients. Based on this event, we have initiated proceedings with several societies, including the National Lipid Association as well the American Diabetes Association. We anticipate even further collaborative evidence-based position statements in the months to come.

References
1.    Ponce J. 2013 ASMBS Presidential Address: 30 years of accomplishments: Where do we go from here? Surg Obes Relat Dis. 2014;10(2):191–197. Epub 2014 Jan 28.
2.    Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ. (Eds.) The ASMBS Textbook of Bariatric Surgery, Volume 1: Bariatric Surgery. Springer Science + Business Media, New York, 2015.
3.    Still CD, Sarwer DB, Blankenship J (Eds.)The ASMBS Textbook of Bariatric Surgery. Volume 2: Integrated Health. Springer Science + Business Media, New York, 2015.
4.    Morton J, Rivas H, Sell T, Leva N. Utilizing National Clinical Data to Drive Quality Improvement. Presented at Obesity Week 2013, November 14, 2013, Atlanta, Georgia.
5.    Morton J. The first metabolic and bariatric surgery accreditation and quality improvement program quality initiative: decreasing readmissions through opportunities provided. Surg Obes Relat Dis. 2014;10(3):377–378.
6.    Sudan R, Nguyen NT, Hutter MM, Brethauer SA, Ponce J, Morton JM. Morbidity, Mortality, and Weight Loss Outcomes After Reoperative Bariatric Surgery in the USA. J Gastrointest Surg. 2014 Sep 4. [Epub ahead of print].
7.    Sudan R, Winegar D, Thomas S, Morton J. Influence of ethnicity on the efficacy and utilization of bariatric surgery in the USA. J Gastrointest Surg. 2014;18(1):130-6. Epub 2013 Oct 8.
8.    Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery. American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014 Feb 22. [Epub ahead of print]

Category: Ask the Leadership, Past Articles

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