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ASMBS Update Fall 2011. Robin Blackstone, MD, FACS, FASMBS President, ASMBS. ASMBS Focus 2011/2012 Building a Bridge to the future. ASMBS Focus 2011/2012 Building a Bridge to the future. Current Coverage Landscape. Federal: Covered by Medicare - PowerPoint PPT Presentation
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ASMBS Update Fall 2011Robin Blackstone, MD, FACS, FASMBSPresident, ASMBS
Mechanism of Action of SurgerySafety and Efficacy of SurgeryAccess to CareMedicalization of Obesity
ASMBS Focus 2011/2012Building a Bridge to the future
Mechanism of Action of SurgerySafety and Efficacy of SurgeryAccess to CareMedicalization of Obesity
ASMBS Focus 2011/2012Building a Bridge to the future
Current Coverage Landscape Federal: Covered by Medicare States: covered as a standard benefit in 43/50 State employees
and 47/50 State Medicaid Plans Employer Coverage:
40% of plans <500 employees Small employers coverage is growing at 8% per year This is the group targeted by EHB 76% of plans with 20,000 or more employees
Mandated Coverage: New Hampshire, Indiana, Maryland Georgia and Virginia – employers have to be offered the ability to buy
coverage State Rule regarding medical necessity and HMO regulation also
require coverage: Michigan, New York, California
0%
10%
20%
30%
40%
50%
60%
70%
80%
2006
2007
2008
2009
2010
Between 2006 and 2010, bariatric surgery coverage expanded both among small as well as large employers.
Bariatric Surgery Coverage by Number of EmployeesMercer National Survey of Employer-sponsored Health Plans
Rapid Response Team of the Access Committee
Figure 3. Annual rate of bariatric surgery per 100,000 adults, 1990 to 2008. Data from1990 to 1997 was derived from Pope and colleagues7; data from 1998 to 2002 wasderived from Nguyen and colleagues Inpatient sample 2008 124,000 in-patient cases
Figure 2. Number of bariatric surgeons with membership in the American Society for Metabolic and Bariatric Surgery (ASMBS), 1998 to 2008.
Endoscopic Therapies and FDA: Read the report on the ASMBS website
Need to prepare surgeons to participate in endoscopic therapies and new devices and procedures
ASMBS Position Statements have clout – Clinical Issues CommitteeStacy Brethaur, Chair HCSC: BCBS of Illinois, Texas, New Mexico and Oklahoma ASMBS Position Statement on Preoperative weight loss
mailed to all medical directors in the United States Decision to Change Medical Policy for this requirement (last
week) Will not have an immediate effect on the Self Funded
employer plans but eventually medical policy should align it Data has a profound impact on medical policy
Patients should have access to obesity treatment through the essential health benefit
Recent all for Public Comment to HHS:Blackstone at HHS in Washington DCEvery major city surgeons and patients partnered to testify (Obesity Action Coalition)We have a presence on the hill every month visiting key people
ASMBS is the source of credible information on metabolic treatment of obesity Keavin Revis, Chair, Communication Committee
New and improved website Keith Kim, Chair Public Education Committee
Drive patients to our website for information and linkages to
Summary – Access to Care Continue effort to expand coverage to employers with 10-
499 employees through essential health benefit and expanded coverage among employers – John Morton, Chair Access to Care Committee
Prepare surgeons to participate in new technologies and procedures (Endoscopic training, central system for new procedures and technologies to be studied and approved through ASMBS) – Marc Bessler, EC; Bipan Chand, Chair Emerging Technology, Ninh Nguyen Sec/Treasurer
Continue to put out high impact position statements Stacy Brethaur, Chair Clinical Issues Committee
Continue to partner with Obesity Action Coalition, The Obesity Society and other colleagues to promote treatment across the continuum of care
Mechanism of Action of Surgery
Safety and Efficacy of Surgery
Access to Care
Medicalization of
Obesity
Bariatric Surgery 2011Bridge to the future
EPIGENETICS:Obesity, Diabetes and Kidney Disease
in Children
Increased Risk due to Fetal Exposure to
Diabetes
Prevention May be Possible During
Pregnancy
http://nihroadmap.nih.gov/EPIGENOMICS/images/epigeneticmechanisms.jpg 2005
Rapidly growing research field that investigates heritable alterations in gene expression
caused by mechanisms other than changes in DNA sequence.
Mechanism of Action of Surgery
Safety and Efficacy of Surgery
Access to Care
Medicalization of
Obesity
Bariatric Surgery 2011Bridge to the future
Mechanism of Action Mechanical
Calorie Restriction Malabsorption
Physiologic
Hormones from intestinal track
Hormones from Fat Cells Neuromodulation through
changes in signaling of vagus nerve
Weight Dependent effects only – Adjustable Gastric BandWeight Dependent and Weight Independent effects – Sleeve, Gastric Bypass and Switch
The Biology of Obesity and Mechanism of Action of Surgery
Key Theme of the ASMBS Annual Meeting in San Diego June 2012
Mechanism of Action of Surgery
Safety and Efficacy of Surgery
Access to Care
Medicalization of
Obesity
Bariatric Surgery 2011Bridge to the future
COE was Established for a Reason To improve quality and patient safety
It has contributed to a decrease in mortality (0.4 to 0.1%)
Established a culture of outcomes reporting in community hospitals/surgeons
Primary quality discriminator was facility volume of >125 cases
Very low volume programs dropped out of the market
Original 10 standards were interpreted by BSRC and “details” added over time – making it more “prescriptive” and more expensive for facilities to provide
Support from CMS in 2006 and other payers
ASMBS BSCOE ProgramProgram Participants
HospitalsFully Approved 458Provisionally Approved 143Provisional in Process 83 (52 new added through August 2011)
Total Participants 684
SurgeonsFully Approved 849Provisionally Approved 260Provisional in Process 147 (83 new added through August 2011)
Total Participants 1,256
50
As reported by personal communication with Gary Pratt
Drivers for Evolution of the ASMBS BSCOE Program Membership have questioned the volume requirement– they feel they
cannot impact this type of structural measure and it does not reflect the quality of work they are doing
Volumes are going down in some places making it difficult to continue to qualify for programs that have participated
The quality conversation has moved forward to use composite measures of quality for outcome discrimination
No quality improvement process in place within our structure at this time
Continue to have two quality programs in our field (ASMBS and ACS) Basis of some recommendations (based on surgeon best opinion)
may not contribute to quality and is expensive for programs to maintain. Need to clarify this within our requirements
Payer have compared their data to our programs and found that some of our programs have worse outcomes than other programs in their network but not in our program (BCBS Michigan and Leapfrog are no longer requiring the ASMBS BSCOE or ACS BSN designation)
ASMBS Quality and Standards Committee
Chair: Robin Blackstone, MD Co-Chair William Inabnit, MD Representing ASMBS
Chair of State and Local Chapters Committee Lloyd Stegeman, MD Chair of the Research Committee Ranjan Sudan, MD Chair of the Rural Subcommittee Wayne English, MD Chair of Bariatric Training Committee Samer Mattar, MD Chair of Insurance Committee Jaime Ponce Chair of Pediatric Committee Kirk Reichard Chair of Access to Care Committee John Morton President Elect of Integrated Health Karen Schulz, RN
Representing ACS Ninh Nguyen, MD and Matt Hutter, MD
Representing MBSC John Birkmeyer, MD, Justin Dimick, MD and Nancy Birkmeyer, MD
Representing the Bariatric Surgery Review Committee David Provost, MD
Representing BOLD Database Debbie Winegar, PhD
At large member: David Flum, MD At large member: Joe Nadglowski
Collaborations American College of Surgeons Michigan Bariatric Surgery Collaborative
GOAL is to find common ground and establish areas of collaboration
Areas that represent common ground between ASMBS and ACS Collaborative Design of the ASMBS Bariatric Quality
Improvement Program with joint implementation Database and Analyses of Data Facility Credentialing Advocacy
Meeting with David Hoyt in September, 2011 in ChicagoMeeting with ACS Regents on the Division of Research and Optimal Patient CareVote by the Board of Regents to support the collaboration of the two societies:October of 2011
To evolve the program…. Predictable Quality to allow programs to compare their
outcomes to their peers with quality data Over time would lead to using the composite risk adjusted
outcomes measures to qualify for the program Eventually public reporting would be possible
Process Improvement to Improve Patient Safety Key project for the future with a goal to decrease morbidity and
improve long term outcomes Improve access for patients to surgery in their local area
If access to care for obesity surgery/treatment improves then we need to be prepared with well trained surgeons in programs involved in continuous QI
Step 4: Facility/Surgeon Credentialing
ASMBS BSCOE/NBQI
P
ASMBS Bariatric Quality Improvement ProgramASMBS Bariatric Surgery Center of Excellence Program
An outcomes measure that allows us to Predict Quality
Step 1:Development of a Bariatric Surgery Composite Measure
Currents measures for assessing excellence with bariatric surgery
• Structural measures (e.g., volume)– Narrow in scope, proxy for true performance– Not always strongly related to outcomes
• Process measures – Important processes are controversial/unknown in
bariatric surgery• Outcomes measures (e.g., risk-adjusted morbidity)
– “Noisy” due to small sample sizes at some hospitals– Need detailed data for risk-adjustment
Composite Measure Allows outcomes from a variety of quality signals to be taken
into account Includes surgeon and facility volume All quality signals used are “risk adjusted” prior to
incorporation into the model Gives the most accurate prediction of future performance
available
Composite Measure Approach: Shrink to the mortality for volume group
0%
20%M
orta
lity
rate
(%)
Mortality rates forhigh-risk surgery 10%
Mor
talit
y ra
te (%
)
15%
5%
Observed mortality rates
Low volume
Medium volume
High volume
Mortality rates
Composite mortality
Preliminary findings
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Hospital volume Serious complications Composite measure
3-star2-star1-star
Hospital rankings (2008-09)
Risk-adjusted serious complications
(2010)
3.3
2.72.4
3.4 3.43.0
3.2
4.0
4.6
Hospital volumeSerious
complicationsCompositemeasure
Odds Ratio (95% CI), 1-star vs. 3-star 0.85 (0.43-1.68) 1.56 (0.84-2.91) 1.99 (1.14 -3.47)
% VariationExplained 0% 28% 89%
Step 2: Establish a new quality matrix (currently in development) Mandatory
Has established the ASMBS National QI Database to enter all patients Participates in the ASMBS BSCOE NBQIP Has the ASMBS/ACS/SAGES Credentialing for surgeons doing bariatric surgery in place Has put in place a thromboprophylaxis protocol Has a transfer agreement to a tertiary center for rescue of complicated patients
Recommended Staff in service on recognizing signs and symptoms of complications Patients satisfaction surveys Other key process protocols (SCIP measures, MOC CME’s)
Best Practice Bariatric Service Line Medical Director Tertiary Care (Receives complex cases from smaller/rural programs through network of
agreements, revisions, sophisticated rescue techniques (24 hour ICU care) Sensitivity Training
Step 3: ASMBS National BSIP Database Select or develop further a database that allows us to have
increased functionality and be able to generate risk adjusted and reliability adjusted composite measures and areas to target improvement for continuous quality improvement
Provide monthly data abstracting to lower volume/rural programs through the society so that ongoing data validation can be performed and standardized (this option currently being explored) After each data entry is done (monthly) reports are immediately available to give feedback to the surgeons/program
Initial instruction on data entry and then annual data validation for larger programs
Step 3: Collaborative Quality Improvement
Basic idea: Physicians/hospitals collaborate with and learn from each other in improving outcomes
Robust data and feedback re process and outcomes
Empirical and non-empirical identification of best practices Leveraging “natural experiments” associated with variation in practice across
hospitals and physicians
Continuous development, implementation and testing of QI interventions Use the ASMBS State Chapters and ACS State Chapters to focus this
effort regionally and the annual meeting to focus nationally
Michigan Bariatric Surgery Collaborative
Example:
Variation in medical prophylaxisPreoperative Postoperative Post discharge NLMW LMW None 2,594
UF UF None 873UF None LMW 610UF LMW LMW 510None UF None 382None LMW None 223UF None None 221UF LMW None 175
Other Combinations 788
Preop prophylaxis vs. outcomes
Postop prophylaxis vs. outcomes
What MBSC did Developed prediction rule for stratifying baseline risk of VTE
by patient factors Statewide practice guidelines for prophylaxis according to
patient risk Based on both empirical analysis and group consensus
VTE Risk Predictor
Example:Risk Factor PointsSleeve 4Age 50 4BMI 50 3Female 0Smoker 2Total 14
MBSC Practice Guidelines
Trends in VTE Rates
QI intervention
Step 4: Joint (ASMBS/ACS/SAGES) credentialing guidelines for surgeons practicing bariatric surgery
Step 4: Facility/Surgeon Credentialing
ASMBS BSCOE/NBQI
P
ASMBS Bariatric Quality Improvement ProgramASMBS Bariatric Surgery Center of Excellence Program
Step 5: Align our goals with CMS, Leapfrog Group and major payors
Timeline: Public comment period December 15, 2011 Presentation of Composite Measure from BOLD data to EC January 2012
ASMBS NBQIP ASMBS BSCOE
ASMBS NBQIP : National Bariatric Quality Improvement Program
ASMBS BSCOE: Bariatric Surgery Center of Excellence
ASMBS NBQIP : National Bariatric Quality Improvement Program
ASMBS BSCOE: Bariatric Surgery Center of Excellence ACS BSN: American College of Surgery Bariatric Network
ASMBSACS NBQIP
ASMBS BSCOE
ACS BSN
ASMBSACS NBQIP
ASMBS BSCOE The most impactful quality and safety program on a nationwide
basis in bariatric surgery Established a culture of compliance with requirements to
implement structure and process and reporting of outcomes Poised to transform into a outcomes based and process
improvement program – based on composite measure (predictive) rather than volume (proxy)
Composite measure rich enough to give programs targets for improvement
Site inspections for data validation (RN team) Site inspections to improve process (surgeons/others
depending on need) All programs engage in process improvement at the first
National Quality Forum June 2012 at the ASMBS Annual Meeting
“Knowing is not enough, we must apply.Willing is not enough, we must do.”-Goethe
Thank you for your service to ASMBSRobin Blackstone, President
Mechanism of Action of Surgery
Safety and Efficacy of Surgery
Access to Care
Medicalization of
Obesity
Mentor Leadership