Patients who undergo bariatric surgery at hospitals designated as centers of excellence do not appear to have lower mortality rates or lower rates of complications than those whose procedures are performed at other hospitals, according to a report in the April issue of Archives of Surgery, one of the JAMA/Archives journals.
Center of excellence designation is awarded to bariatric surgery centers by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery, according to background information in the article. The nearly identical guidelines require that centers perform at least 125 operations per year; employ a bariatric surgery coordinator and personnel to follow up patients long-term; and enter outcomes into proprietary databases, which requires trained staff and a subscription to a database. "These criteria make intuitive sense but lack an evidence base for their application," the author writes. In 2006, the Centers for Medicaid and Medicare Services began requiring that patients they insure undergo bariatric surgery at designated centers of excellence.
Edward H. Livingston, M.D., of the University of Texas Southwestern School of Medicine and Department of Veterans Affairs, Dallas, analyzed data from the 2005 National Inpatient Survey for 19,363 patients who underwent bariatric surgery that year, including 5,420 (28 percent) whose procedures were performed at bariatric surgery centers of excellence. Overall, 0.1 percent of patients died in the hospital and 6.4 percent developed complications.
More bariatric operations were performed at the 9.5 percent (24 of 253) of hospitals in the database designated as centers of excellence (an average of 226 procedures per year vs. 79 at other facilities). At centers of excellence, 0.17 percent of patients died and 6.3 percent developed complications, compared with a 0.09 death rate and 6.4 percent complication rate at other facilities. Patients spent an average of 2.6 days in the hospital both at centers of excellence and other facilities, but average costs per patient were higher at centers of excellence ($11,527 vs. $10,984).
"It has been shown that the minimal annual procedure volume required to be designated as a center of excellence (125 cases per year) does not necessarily result in better outcomes and that the minimum volume requirement is not evidence based. Most important, this volume criterion significantly restricts access for bariatric surgery care," Dr. Livingston writes. "The number of bariatric operations performed each year was the most striking difference between bariatric surgery centers of excellence and hospitals that were not centers of excellence. Patient and facility characteristics were similar as were complication and death rates."
"Designation as a bariatric surgery center of excellence does not ensure better outcomes. Neither does high annual procedure volume," Dr. Livingston concludes. "Extra expenses associated with center of excellence designation may not be warranted."
(Arch Surg. 2009;144[4]:319-325. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: This study was funded by the Hudson-Penn endowment, grants from the National Institutes of Health and a grant from the Department of Veterans Affairs. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Journal
Archives of Surgery