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Invited Critique
April 20, 2009

Bariatric Surgery Outcomes at Designated Centers of Excellence vs Nondesignated Programs—Invited Critique

Arch Surg. 2009;144(4):325. doi:10.1001/archsurg.2009.18

This study by Livingston uses the NIS administrative database to examine mortality outcomes in accredited vs nonaccredited bariatric surgery centers. As with any study, there are methodological limitations. However, we would like to focus this commentary on improving the quality of bariatric surgery and care.

Clearly, outcome is an important issue for improving most types of medical care. Studies using administrative data, such as the current one, frequently use inpatient mortality as the outcome because it is available and well coded in administrative discharge databases. However, if the bariatric surgeon and patient communities had their druthers, a number of equally, if not more, meaningful outcomes would probably be used to measure the quality of bariatric surgery. At the current time, bariatric procedures have become markedly safer, with substantially lower inpatient mortality rates compared with reports from years past. So, to evaluate the quality of a bariatric surgery program, other outcomes such as weight loss, patient satisfaction, quality of life, and functional status should probably be used in addition to hospital mortality.

A second issue is that quality improvement is an iterative process, and, therefore, striving to continually move forward with improving quality of care requires data—high quality and appropriate data. Although some may contend that data collection and feedback might not produce improved quality in the private sector as they do in the Department of Veterans Affairs health care system, there are a number of well-known private sector quality improvement models (eg, Lean/Toyota, Six Sigma, Northern New England Cardiac Project, etc) that have led to markedly improved care. The common thread of these and other quality improvement programs is data collection, feedback, intervention, and more data collection.

How do we obtain high-quality, standardized, valid data on clinically meaningful outcomes? Currently, one of the better ways is through the formal bariatric surgery quality programs. Two such programs are those of the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Although the latter is designed as a COE program, the former is a bariatric surgery network that includes large and small facilities achieving quality. Regardless of philosophical constructs, both include databases that require the facilities to input data, not just mortality data but also data that are more appropriate measures of bariatric surgery quality.

This notion of “iterativeness” is also important, not only because it pertains to the process of clinical quality improvement but also because it relates to the quality improvement of the programs themselves. When current bariatric quality improvement programs began, procedure volume was used as a proxy for quality care because of the lack of known quality indicators. Using procedure volume is nothing new and, in fact, is being seen in other current quality initiatives, such as programs for esophagectomy and pancreatectomy. However, as programs mature, better insight is gained into quality evaluation, improvement, and maintenance, and, increasingly, more process and outcome indicators other than procedure volume should be used. This iterative progression is how a number of quality programs are advancing, and it is likely how the bariatric programs will also progress.

Overall, the quality train has already left the station, and the field of surgery (bariatric or otherwise) needs to continue to recognize this. Although many believe the movement is going too far, too fast, the movement is indeed continuing—and to this point, it is not slowing. Rather than pushing back or ignoring the issue, it may be best to engage in the movement and to have surgeons determine what is best for our field and our patients. Evaluations, such as the one performed by Livingston, are important for us to continually evaluate, refine, and advance our programs.

Correspondence: Dr Ko, Department of Surgery, University of California–Los Angeles, Campus Box 956904, 72-215 CHS, Los Angeles, CA 90095-6904.

Financial Disclosure: None reported.