Reports, Registries, and Education in Perioperative Care of the Obese Patient—A European Update

This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.

Column Editor: Stephanie B. Jones, MD
Dr. Jones is Vice Chair for Education, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

This month’s column by Mike Margarson, MD, FRCA, FFICM. Dr. Margarson is from the Department of Anaesthesia, St. Richard’s Hospital, Chichester, United Kingdom.

Bariatric Times. 2012;9(9):30–31

This month’s column looks at two upcoming reports from major United Kingdom institutions and discusses the latest in obesity anaesthesia education in Europe.

The National Confidential Enquiry into Patient Outcome and Death
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent UK institution that has existed in various forms for 24 years. It originated from a confidential and anonymous pilot study of perioperative mortality associated with anesthesia.1 Its aims were to assess perioperative information in order that the clinical practice of anesthesia might be improved and to provide comparative figures between UK regions to facilitate this. After producing seven consecutive reports, with increasing surgical components, in 1990 it formally amalgamated with a group from the Royal College of Surgeons to produce the first true confidential enquiry into peri-operative death.

Over the subsequent years it has widened its role and now produces specialist reports annually on specific aspects of surgical and anaesthetic perioperative care. NCEPOD has published key reports on aortic aneurysm surgery, pediatric surgery, surgery in the very elderly, emergency surgery, and trauma surgery among others, which have highlighted deficiencies and led to major changes in these areas within the NHS.

On October 18, 2012, it will publish the findings of a study on bariatric surgery and make key recommendations. These are awaited with great interest by those involved in UK bariatric surgery, and there will inevitably be intense media interest.
The primary aim of the study was to describe variability and identify remediable factors in the process of care (from referral to follow up) for patients undergoing bariatric surgery. The report will highlight care related to service commissioning (i.e., funding), adherence to the UK National Institute for Clinical Excellence (NICE) referral criteria, the level of psychological and nutritional support, and the role multidisciplinary team structure and process, as well as the more usual aspects of perioperative care, adverse events, follow-up management, and audit.

All adult patients (>16 years old) who underwent bariatric surgery during the three-month study period, June 1, 2010 to August 31, 2010, inclusive were studied.

The sample size was approximately 2,500 cases. From this group, a population of approximately 500 patients was randomly selected and studied in detail. This involved a full copy of all the notes and charts from each case being submitted and reviewed by an independent panel of experts. Any case where concerns of variability from accepted standards was identified and discussed further: the final report will include detailed clinical vignettes where learning points are highlighted.

An additional sample of 100 patients with longer length of stay or unplanned critical care admissions is to be studied. It is hoped that this latter sample of patients will allow for a qualitative assessment of the management of early complications associated with bariatric surgery.

The final randomly selected study population includes no more than five patients from any one hospital to reflect activity across different types and sizes of institution, with different volumes of bariatric surgical practice. All hospitals that perform bariatric surgery or admit patients with complications of bariatric surgery in both the National Health Service and Independent sector in the United Kingdom (excluding Scotland) and associated Islands will be included.

The results will be reported in full on October 18, 2012, in London, with an expert analysis and commentary on the results from surgical, metabolic medicine and anaesthetic specialists. Thereafter the report and commentaries will be available to view online: http://www.ncepod.org.uk/bs.html

The Intensive Care National Audit and Research Centre
While over the last 20 plus years the UK mainstream anesthesia world has enjoyed NCEPOD reports (and the obstetric world has had a series of Confidential Enquiries into Maternal Death, CEMD), the jewel in the crown of these UK registries is within critical care. The Intensive Care National Audit and Research Centre (ICNARC) originated in 1984 with a very similar purpose to the other registries—to evaluate aspects and quality of critical care across the nation—thus allowing benchmarking and identification of discrepancies in delivery of care.

The core component of this is a national registry of intensive care admissions across the whole of the UK, known as the Case Mix Programme, with over 90 percent of UK critical care admissions recorded in this national dataset. There are 34 key data fields for each patient (every ICU has a dedicated officer to collect these) which allow calculation of APACHE and other outcome prediction models. The predicted outcomes and actual outcomes for every patient are recorded, and the relative standardised mortality ratios for every critical care unit in the UK are available for review.

So what is the relevance to bariatric surgery? Since the introduction of version 3.1 of the dataset three years ago, weight and height have become a core component of the recorded data, such that ICNARC now have the ability to calculate body mass index (BMI) and hence to assess the impact of obesity and morbid obesity on outcomes across a whole host of ICU conditions. This year they produced their first audit looking at the impact of body weight on mortality, length of stay, and other outcome measures in a series of over 120,000 intensive care unit (ICU) admissions, both surgical and medical.

This is a large dataset of high quality data, representing an entire country. Like the NCEPOD report, only preliminary data from this study have been presented, and details will be published this autumn. For me, however, there were quite a few surprises in the crude outcomes. The protective effect of moderate overweight and obesity was confirmed, but having expected to see a significantly increased morbidity in the patient with superobesity (i.e., BMI>60kg/m2, n=1,340) there was very little evidence to suggest that this group’s outcomes are any worse than those of normal BMI when admitted to ICU. The highest mortality without any doubt is in the underweight group, with crude moratlity of 35 versus 20 percent in the super-obese. There are confounding factors in the crude data; for instance, the incidence of elective surgical cases was higher than for other groups, so the risk-adjusted data will be awaited with great interest to see if the outcomes reported in case series from individual institutions are supported and confirmed by this massive series.

Education and Standards
As the obesity epidemic spreads, and the nonspecialist anesthetist has to deal more and more with the morbidly obese, a number of societies have formed within Europe, aimed at educating and influencing the curricula and teaching processes for anesthesia, both at the undergraduate and fellowship level.

Within the UK, the Society for Obesity and Bariatric Anaesthesia (SOBA) has led the way. In December, it will run its 12th educational meeting, and with the feedback from these meetings this society has refined its obesity anaesthesia core topics. These have been recognized and are now being integrated into the national Royal College curriculum for the future benefit of all patients. With a basic one-day course of “How to Safely Anaesthetise the Obese Patient” run 2 to 3 times a year, SOBA is successfully propagating this fundamental knowledge, with its next course taking place in London in early December.
Across Europe, we have an active group in the European Society for Bariatric Anaesthesia and Critical Care, based in Vienna, who has their second conference at the end of November. Austria has a strong tradition of bariatric surgery, and this is a group with a highly academic background who has produced an excellent previous meeting.

Bariatric and obesity anesthesia is high on the agenda in the UK today, and in a number of other European countries there are formal groups doing work to educate colleagues and improve patient care.

For more information on NCEPOD, visit http://www.ncepod.org.uk/index.htm
For more information on ICNARC, visit https://www.icnarc.org/
For more information on SOBA, visit http://www.sobauk.com/
For more information on the European Society meeting, visit http://www.esbacc.org/

References
1.    Lunn JN, Mushin WW. Mortality associated with anaesthesia. Anaesthesia. 1982;37(8):856.
Funding: No funding was provided.

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

Category: Anesthetic Aspects of Bariatric Surgery, Past Articles