Raising the Standards with MBSAQIP: Part 6

| January 1, 2023 | 0 Comments

by Wayne J. English, MD, FACS, FASMBS; David Provost, MD, FACS, FASMBS; Teresa LaMasters, MD, FACS, FASMBS; Richard Peterson, MD, MPH, FACS, FASMBS; Paul Jeffers, BS, BA; and Cassandra Peters, BA

Dr. English is past Co-chair of the MBSAQIP Standards/Verification Subcommittee and Associate Professor of Surgery at Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Provost is past Co-chair of the MBSAQIP Standards/Verification Subcommittee and Professor of Surgery at Baylor Scott & White Medical Center – Temple in Temple, Texas. Dr. LaMasters is current Co-chair of the MBSAQIP Standards/Verification Subcommittee, MBSAQIP Site Reviewer, President of the American Society for Metabolic and Bariatric Surgery, Medical Director at UnityPoint Clinic Weight Loss and Des Moines, Iowa, and Clinical Associate Professor at University of Iowa. Dr. Peterson is current Co-chair of the MBSAQIP Standards/Verification Subcommittee, MBSAQIP Site Reviewer; Professor of Surgery, UT Health San Antonio; Chief, Bariatric and Metabolic Surgery UT Health San Antonio in San Antonio, Texas. Mr. Jeffers was the MBSAQIP Verification Specialist from July 2015 to April 2022 and is currently the Commission on Cancer Standards Development Manager. Ms. Peters is the MBSAQIP Program Specialist, Area of Continuous Quality Improvement, Division of Research and Optimal Patient Care for the American College of Surgeons.

Funding: No funding was provided for this article.

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

Bariatric Times. 2023;20(1):22–23.


The following article is the sixth article of a series discussing the revised version of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) standards that officially became effective October 1, 2022. The article will review Standard 6 and Obesity Medicine Services (Standards 2.8, 5.6, and 6.4). The remaining MBSAQIP standards (Standards 7 and 8) will be reviewed in the next and final article in the series.

Standard 6: Data Surveillance and Systems

Standard 6.1: Data Entry. There was no major change in the language for Standard 6.1. Every metabolic and bariatric procedure (open, laparoscopic, hand-assisted, robotic, or endoscopic) performed for the treatment of metabolic or obesity-related diseases must be entered into the MBSAQIP Registry, and a letter of attestation confirming 100-percent data entry into the MBSAQIP Registry must be signed and confirmed by the metabolic and bariatric surgery (MBS) Director and MBS Clinical Reviewer. A frequently asked question about Standard 6.1 is listed below. 

Q: Our MBS Clinical Reviewer position was vacated unexpectedly, and some cases were not entered into the MBSAQIP Registry. How should this be handled?

A: Your site must keep accurate records of all cases that were not abstracted into the registry and continue to follow those patients long-term. When a new MBS Clinical Reviewer is hired, those cases that are not past the 90-day lock date must be entered into the MBSAQIP Registry.

Any cases that are not abstracted into the registry must be followed long-term, with accurate records of any postoperative occurrences for case review at your center’s next accreditation site visit.

Standard 6.2: 30-day and Long-term Follow-up. There was no major change in the language for Standard 6.2. The center must document a protocol to follow the long-term progress of all their metabolic and bariatric patients, as well as documenting the contact attempts. The center may cease attempts to contact patients after the patient is lost to follow-up or a no-show for two consecutive follow-up timeframes.

Standard 6.3: Data Review. There was no major change in the language for Standard 6.3. All centers are required to monitor their data. Ongoing review of the semiannual risk-adjusted reports (SAR) and unadjusted outcomes data is critical for continuous quality improvement. A frequently asked question about Standard 6.3 is listed below. 

Q: We are an Initial Center/our center has not yet received an SAR. How do we demonstrate compliance with this Standard? 

A: Initial Centers and centers that have not yet received their first SAR are exempt from demonstrating compliance with this standard. Once an accredited center receives their first SAR, the center is required to be compliant with this standard. 

If the center does not receive an SAR because they did not maintain a complete 30-day follow-up rate of greater than or equal to 80 percent, the center will be found noncompliant with Standard 6.3.

Obesity Medicine Medical Director, Obesity Medicine Services, and Data Collection

Standard 2.8: Obesity Medicine Director, Standard 5.6: Obesity Medicine Services, and Standard 6.4: Data Collection. To enhance collaboration between obesity medicine physicians and metabolic and bariatric surgeons, a panel of prominent obesity medicine specialists was gathered in 2018 to help develop obesity medicine standards for the third version of the standards released in 2019. Obesity Medicine Qualifications are separate and distinct from surgical and procedural accreditation, and only MBSAQIP Comprehensive Centers and MBSAQIP Comprehensive Centers with Adolescent Qualifications are eligible to seek MBSAQIP Obesity Medicine Qualifications. Using care pathways developed by an Obesity Medicine Director (OMD), in conjunction with the MBS Committee, MBSAQIP-accredited centers with Obesity Medicine Qualifications must be able to provide comprehensive, multidisciplinary obesity medicine services. Care pathways must be reviewed annually by the OMD in conjunction with the MBS Committee. 

There were no major changes to the Obesity Medicine Services for the new 2019 Standards-Revised. 

Q: Can the OMD also be the MBS Director? 

A: Yes. If the individual in question fulfills all the requirements outlined in both Standard 2.5 (MBS Director) and 2.8 (OMD), the MBS Director and OMD roles can be performed by the same individual.

Q: What data elements are required to comply with the obesity medicine data collection?  

A: The following patient variables must be captured for data collection and outcomes monitoring for obesity medicine patients: 

  • Patient information (Name, ethnicity, demographic information, etc.) 
  • Height and weight at initial presentation 
  • Body mass index (BMI) at initial presentation 
  • Body fat percentage at initial presentation 
  • Comorbidities at initial presentation 
  • Weight percentage change over time 
  • BMI change over time 
  • Body fat percentage change over time 
  • Comorbidity changes over time 
  • Anti-obesity medications
  • Complications and side effects of obesity medicine treatment. 

Capturing additional variables related to patient health and satisfaction and obesity medicine treatment is encouraged, but not required, and is at the discretion of the center’s OMD.

All patients receiving nonprocedural obesity medicine treatment at MBSAQIP-accredited centers with Obesity Medicine Qualifications cannot be captured in the MBSAQIP Registry, and instead must be captured using an independent, local level data collection method.

This concludes the sixth article of Raising the Standards with MBSAQIP. The next and final article reviewing the changes made to the 2019 standards will review Standards 7 and 8.  

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Category: Current Issue, Raising the Standard

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