ASMBS News and Update—April 2013

by Jaime Ponce, MD, FACS, FASMBS
President, American Society for Metabolic and Bariatric Surgery Medical Director for Bariatric Surgery, Hamilton Medical Center, Dalton Georgia; Co-Medical Director for Bariatric Surgery, Memorial Hospital, Chattanooga Tennessee

ASMBS Mission Statement
The American Society for Metabolic and Bariatric Surgery was founded in 1983 to establish educational and support programs for surgeons and integrated health professionals. Our mission is to improve the care and treatment of people with obesity and related disease; to advance the science and understanding of metabolic surgery; to advocate for health care policy that ensures patient access to high-quality prevention and treatment of obesity. For more information, visit www. ASMBS.org. If you are interested in becoming a member or have questions about ASMBS, please contact Georgeann Mallory, the ASMBS Executive Director, via phone: (352)-331-4900 or e-mail: [email protected].

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
Transition update. Thank you for the many comments and thoughtful contributions on the Standards for the American Society of Metabolic and Bariatric Surgery (ASMBS)/American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). The MBSAQIP Standards Subcommittee is considering all of your input, as well as that of the Executive Council, and has begun the development of a new draft that is expected to be available for a second public comment period this summer. Figure 1 is a timeline for the completion of the standards.

Since this program is critically important to the future of metabolic and bariatric surgery and in ensuring that patients in need have access to the very best treatment, we are moving as quickly as possible while maintaining due diligence to key details.

Top three questions about MBSAQIP.
1.    My ASMBS BSCOE center is due for reaccreditation. What do I do?
All centers that have come due for renewal during the transition period have been granted an extension of their designation until the implementation of the joint MBSAQIP standards. ASMBS Bariatric Surgery Centers of Excellence (BSCOE) centers that came due for re-accreditation during the transition period will be contacted shortly and provided with application materials and further details regarding the application process. Look for this in your inbox in the upcoming weeks.

2.    How will I recertify once the new MBSAQIP standards are in place?
After implementation of the MBSAQIP standards, all centers will be given adequate time to come into compliance with the new standards, at which time centers will be contacted regarding their new designation level under the joint program. Any program that has been recertified before implementation of MBSAQIP will not be required to undergo an additional site visit before receiving their new designation. Centers will continue to be due for their reaccreditation site visits on their existing three-year renewal cycle.

3.    What if I am a new program or my program has been on probation?
New programs seeking accreditation and programs currently on probation for not meeting existing annual volume requirements are able to apply now and will be verified against the existing ACS Bariatric Surgery Center Network (BSCN) program standards.

Centers for Medicare and Medicaid Services Update
CMS National Coverage Analysis (NCA) of bariatric surgery facility certification. In response to an unsolicited request from Dr. John Birkmeyer of the University of Michigan to remove the certification requirement for Medicare bariatric surgery, CMS opened a National Coverage Analysis (NCA) on January 24, 2013 (See Figure 2 for timeline).

For a period of one month, the public was permitted to submit comments on the issue to CMS. In addition to the 212 public comments submitted, John Morton, MD (ASMBS Secretary-Treasurer), coordinated the creation of a comment letter from ASMBS with peer-reviewed scientific evidence supporting facility certification. This letter is available at http://asmbs.org/2013/02/cms-responses-facility-accreditation/

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES), the Obesity Society (TOS), the American Society of Bariatric Physicians (ASBP) and the Academy of Nutrition and Dietetics endorsed this letter. In addition, the ACS, the ASMBS Integrated Health Section, and industry partners also provided strongly supportive comments. ASMBS leadership also confirmed that the four leading insurance companies would continue to support facility accreditation.

Put simply, accreditation and standards have saved lives, prevented complications, averted re-admissions, and improved outcomes. Any effort to reverse all the progress made would be misguided. CMS will announce its proposed decision by July 24, 2013. This will be followed by a public comment period, with a final decision expected by October 22, 2013.

We believe CMS will continue to support accreditation based upon all the available data, evidence, and expert opinion, and the ASMBS and ACS will continue to engage all parties on the importance of accreditation to patient outcomes and access to care.

Evidence supporting proposed volume standard of 50 stapling bariatric cases/year. This NCA has allowed the ASMBS an opportunity to submit supporting peer-reviewed scientific evidence to support the new proposed annual volume criteria of 50 stapling bariatric cases per year (See “CMS Response Volume—March 2013” at http://asmbs.org/2013/03/cms-response-volume-march-2013/)

Under the leadership of Dr. Ninh Nguyen (ASMBS President-Elect), a comprehensive literature review on the volume and outcome relationship in bariatric surgery was created and this review supports the following:
1.    There are ample data to substantiate the volume and outcome relationship in bariatric surgery.
2.    The volume and outcome relationship have only been shown for complex stapling cases.
3.    Volume and outcome relationship in bariatric surgery have been shown for both the institution and the surgeon.
Table 1 lists three different population-based studies and one clinical study substantiating a threshold annual volume of 50 cases per year.
Data from the literature support our recommendation to reduce the annual volume criteria to 50 stapling cases. This threshold keeps a balance of maintaining quality with minimal risk for impeding access to care for patients with morbid obesity. The present requirement of 125 cases per year does not differentiate which type of operations are being performed; therefore, there is a potential loop hole for centers performing a predominate number of gastric banding procedures.  Besides meeting these structural requirements, the MBSAQIP will provide a platform for continuous monitoring of mortality and emphasis on the use of outcomes for continuous quality improvement. This change in the facility volume standard will provide remedy to the stated concerns regarding the current facility accreditation requirement and provide a new, strengthened Facility Certification in Bariatric Surgery for the Treatment of Morbid Obesity.

Please note that the proposed 50-stapling-case-volume threshold has not yet been finalized and that all centers currently designated by either the ASMBS BSCOE or ACS BSCN programs must continue to meet their respective standards for accreditation. The draft MBSAQIP standards are currently under review and will be released for a second public comment period in Summer 2013 (see timeline in Figure 1).

Access To Care Remains At The Forefront
The ASMBS Access to Care Committee continues to work closely with the Obesity Care Continuum and our Washington, DC liaison to understand and resolve Essential Health Benefit/Health Information Exchange issues. In an effort to better educate our membership, committee members are drafting letters for each state chapter explaining their Health Exchange status and requesting that they share this information with their state members. They are also working to develop a plan to approach payors with cogent thoughts about safety, effectiveness, return on investment, and cost-effectiveness of bariatric surgery (similar to what is currently being done for sleeve gastrectomy with CMS).

Improving communication is also a key goal for the committee. As the growth of an increasing number of State Chapters continues, the bidirectional flow of communication becomes more challenging. Therefore, in an effort to streamline the process of communication among access leaders in each state, the Access to Care committee, under the leadership of Wayne English, MD, have outlined a new system of access reporting. Under this new system, the country will be divided into seven different regions, each represented by a Super-STAR (STate Access Representative). The regions align closely, but not exactly, with the existing Medicare Administrative Contractors (MACs). The local STARs serving chapters will report directly to their regional Super-STAR with any local/state access matters. This reporting system is not meant to be a hierarchy, but rather a more efficient means of reporting to one another (and to the Society) on issues related to accessing bariatric care. The hope is that this new model will improve communication between the Access Committee and State Chapters to best aid leadership at all levels in a quick and efficient manner to address access concerns at the local, state, and national levels.

ASMBS 30th Annual Meeting At Obesity Week
The historic inaugural Obesity Week event providing “the most comprehensive agenda on obesity in one place at one time” is coming together in superior fashion. The ASMBS Call for Abstracts is now open. For more information, visit http://asmbs.org/2013/03/call-for-abstracts-asmbs-30th-annual-meeting-at-obesity-week/. You have until May 1, 2013 to submit your abstracts. The preliminary program will be posted on www.obesityweek.org on April 1, 2013, which is the same day registration and housing opens. There are several hotels in the block, but keep in mind that the Atlanta Marriott Marquis is the ASMBS headquarter hotel. There are many excellent programs and events planned so be sure to register early and start making your plans to come to Atlanta.

Sincerely,

Jaime Ponce, MD, FACS, FASMBS
ASMBS President
References
1.    Courcoulas A, Schuchert S, Gatti G, Luketich J. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery. 2003;134:615–621.
2.    Nguyen NT, Paya M, Stevens CM, et al. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg. 2004;240:593-–594.
3.    Parker M, Loewen M, Sullivan T, et al. Predictors of outcome after obesity surgery in New York state from 1991–2003. Surg Endosc. 2007;21:1482–148.
4.    Campos GM, Ciovica R, Rogers SJ, et al. Spectrum and risk factors of complications after gastric bypass. Arch Surg. 2007;142:969–975.

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