Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice

Safety Net Hospitals and the Quality of Surgical Care

Objective

To investigate the number of safety net hospitals (SNHs) that have American College of Surgeons (ACS) accreditation for surgical programs.

Background

SNHs provide healthcare to a substantial proportion of uninsured and underserved patient populations and rely heavily on public funding to sustain their operations. ACS accreditation emphasizes evidence-based care and standardization to improve patient outcomes. However, SNHs face financial and administrative barriers to ACS accreditation.

Methods

We investigated the number of SNHs with ACS accreditation for specific programs by utilizing the publicly available listing of ACS-accredited programs and the listing of SNHs from the America's Essential Hospitals membership. We then performed a descriptive analysis of the number and geographic distribution of SNHs within the United States and the number of SNHs with ACS-accredited programs.

Results

SNHs vary by regional disparities and demographic characteristics of respective states. Almost 20% of states are without access to SNHs. Most SNHs do not pursue ACS accreditation. Of 322 SNHs, 36% were accredited for cancer care (Commission on Cancer), 31% for trauma (Trauma Quality Improvement Program), 21% for bariatrics (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program), 13% for breast care (National Accreditation Program for Breast Centers), and 5% for rectal cancer (National Accreditation Program for Rectal Cancer).

Conclusions

ACS accreditation can benefit SNHs in improving guideline-concordant care for medically underserved patients and SNHs should be encouraged to attain ACS accreditation to improve access to and quality of care for vulnerable patient populations.

A Cross-Sectional Study on Awareness and Knowledge of Sleeve Gastrectomy in the Eastern Province of Saudi Arabia

BACKGROUND

Obesity is a global health concern associated with a plethora of chronic diseases. Genetic and lifestyle factors play a pivotal role in its development, making it a significant challenge for healthcare systems worldwide. In this context, sleeve gastrectomy has emerged as a prominent bariatric surgical intervention, but the level of awareness and knowledge regarding its indications and complications in the Eastern Province of Saudi Arabia is underexplored.

METHODS

This descriptive cross-sectional study was conducted over one year, from January 2022 to December 2022. The study aimed to assess the level of awareness among adults residing in the Eastern Province of Saudi Arabia regarding the indications and potential complications associated with sleeve gastrectomy. The study utilized random sampling and distributed a well-designed questionnaire in both English and Arabic. The questionnaire, validated for reliability, covered demographic data, general knowledge of sleeve gastrectomy, awareness of its indications, and knowledge of potential complications.

RESULTS

The study included 1730 participants, with a majority in the 18-25 age group, predominantly female, and possessing a bachelor's degree. Awareness of sleeve gastrectomy was remarkably high, with 99% of respondents having heard of it, but only 50.1% accurately recognized the correct body mass index range for classifying obesity. Knowledge scores revealed 61.7% with poor knowledge, 31% with moderate knowledge, and 7.2% with good knowledge levels. Only 56.1% correctly identified the indications for sleeve gastrectomy. While participants displayed awareness of common complications, such as nutritional deficiencies, knowledge gaps persisted.

CONCLUSION

This study exposes significant gaps in awareness and knowledge regarding sleeve gastrectomy, particularly concerning its indications and potential complications. It underscores the urgent need for targeted educational initiatives and active healthcare provider engagement in disseminating accurate information. Bridging these knowledge gaps through tailored public health campaigns can empower individuals to make informed decisions about the management of obesity.

Impact of geographic distribution of accredited breast centers

The National Accreditation Program for Breast Centers (NAPBCs) is dedicated to improving the quality of care in patients with breast disease. Geographic distribution of health care resources is an important measure of quality, yet little is known regarding breast center allocation patterns concerning population demand and impact on health outcomes. The purpose of this study was to analyze the distribution of NAPBC programs in the United States (USA) and evaluate the impact on breast cancer survival. Using the Centers for Disease Control and Prevention 2014 data base, we identified the incidence and mortality rates for breast cancer by state. We also determined the concentration of NAPBC programs in each state (ie, the number of centers per 1000 cases of breast cancer). Data were analyzed using Spearman's (nonparametric) rank correlation coefficients. Five hundred and seventy NAPBC programs were identified. Across the United States, there was a mean of 2.8 programs/1000 breast cancer diagnoses. A positive correlation (r = .45) between breast cancer incidence and the number of programs was identified (P = .0009). There was no statistically significant correlation between mortality and NAPBC program concentration (r = -0.20, P = .16). NAPBC-accredited program distribution within the United States correlates with breast cancer incidence per state. However, the number of NAPBC programs per state did not alter overall mortality rates. Added measures beyond survival, as well as further insight into referral patterns to NAPBC programs, may be required to demonstrate the value and impact of NAPBC accreditation.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Change in Total Body Water as a Metric for Predicting Need for Outpatient Intravenous Fluids in Postoperative Bariatric Patients

BACKGROUND

Dehydration drives a significant proportion of readmissions following bariatric surgery. Routinely performed body composition testing and total body water (TBW) calculations may present a novel method for diagnosing dehydration for outpatient intervention. We sought to determine if a change in TBW from preoperative baseline could help identify bariatric patients requiring outpatient intravenous fluid (IVF) administration for dehydration.

METHODS

The VUMC Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was retroactively queried for all patients undergoing bariatric surgery at an accredited bariatric surgery center from January 1, 2017 to May 31, 2018. Body composition test results presurgery and postsurgery were extracted from the electronic health record. Change in TBW was compared between patients requiring outpatient IVF and those who did not use multivariable logistic regression.

RESULTS

583 patients underwent surgery over the study period (388 laparoscopic Roux-en-Y gastric bypass, 195 sleeve). 62 (10.6%) required outpatient fluid administration for dehydration. After multivariable analysis, patients with an increased hospital length of stay at index operation were more likely to require outpatient IVF (odds ratio [OR] 1.65, 95% CI 1.22-2.2). Preexisting diabetes diagnosis was protective (OR 0.35, 95% CI 0.16-0.74). Neither 1-week nor 1-month change in TBW from preoperative baseline was significantly different between patients receiving outpatient IVF and those who did not.

CONCLUSION

Increased hospital length of stay predicts patients at risk of postoperative dehydration requiring IVF administration. Body composition testing and TBW were not useful in distinguishing between populations. Further research is needed to examine the efficacy of outpatient IVF in preventing hospital readmissions for dehydration.

Concurrent bariatric operations and association with perioperative outcomes: registry based cohort study

Objective To determine whether perioperative outcomes differ between patients undergoing concurrent compared with non-concurrent bariatric operations in the USA.Design Retrospective, propensity score matched cohort study.Setting Hospitals in the US accredited by the American College of Surgeons' metabolic and bariatric surgery accreditation and quality improvement program.Participants 513 167 patients undergoing bariatric operations between 1 January 2014 and 31 December 2016.Main outcome measures The primary outcome measure was a composite of 30 day death, morbidity, readmission, reoperation, anastomotic or staple line leak, and bleeding events. Operative duration and lengths of stay were also assessed. Operations were defined as concurrent if they overlapped by 60 or more minutes or in their entirety.Results In this study of 513 167 operations, 739 (29.5%) surgeons at 483 (57.8%) hospitals performed 6087 (1.2%) concurrent operations. The most frequently performed concurrent bariatric operations were sleeve gastrectomy (n=3250, 53.4%) and Roux-en-Y gastric bypass (n=1601, 26.3%). Concurrent operations were more often performed at large academic medical centers with higher operative volumes and numbers of trainees and by higher volume surgeons. Compared with non-concurrent operations, concurrent operations lasted a median of 34 minutes longer (P<0.001) and resulted in 0.3 days longer average length of stay (P<0.001). Perioperative adverse events were not observed to more likely occur in concurrent compared with non-concurrent operations (7.5% v 7.4%; relative risk 1.02, 95% confidence interval 0.90 to 1.15; P=0.84).Conclusions Concurrent bariatric operations occurred infrequently, but when they did, there was no observable increased risk for adverse perioperative outcomes compared with non-concurrent operations. These results, however, do not argue against improved and more meaningful disclosure of concurrent surgery practices.