Quality Initiative Cuts Sleeve-Gastrectomy Readmissions

Marlene Busko

November 07, 2016

NEW ORLEANS —Overall, 30-day hospital readmissions after primary laparoscopic bariatric surgery (sleeve gastrectomy, adjustable gastric band, or Roux-en-Y gastric bypass) were reduced by 3.2% after a year in US hospitals that participated in the Decreasing Readmissions Through Opportunities Provided (DROP) program.

The benefit was primarily driven by a significant decline in the 30-day readmission rate after sleeve gastrectomies, which fell by 12%.

"Weight-loss surgery has already become one of the safest operations in America, comparable to gallbladder and joint-replacement surgery, but we saw readmissions as an area we could improve even further," said lead study author John M Morton, MD, director of bariatric surgery at Stanford Hospital & Clinics, in Palo Alto, California, and immediate past-president of the American Society for Metabolic and Bariatric Surgery (ASMBS).

Dr Morton presented the 1-year findings from DROP — a quality-improvement initiative that is part of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) — at the Obesity Week 2016 meeting.

DROP covers preoperative to postoperative care measures (such as ensuring that patients are well informed about nutrition), but it does not cover leaks or surgical complications, Dr Morton explained.

"At the end of a year we did see a significant decline in readmissions, primarily for sleeve gastrectomy," which is now the most commonly performed bariatric surgery procedure in the United States, he said.

"The discharge phone call and the postop visit with the nutritionist and surgeon mattered the most."

Furthermore, hospital readmission rates in centers that initially had rates in the top quartile improved the most, dropping from 7.31% to 4.47%. This shows that these centers with the worst performance "bought into this bundle" of quality measures, said the assigned discussant of this paper, Amir A Ghaferi, MD, program director at the Michigan Bariatric Surgery Collaborative and assistant professor at University of Michigan, Ann Arbor.

However, readmission rates in centers with low initial rates did not improve. Thus, it would be useful delve deeper and determine what quality measures the various hospitals were already implementing at baseline and what worked in different regions, he added.

There is a clear need for this type of standardized, quality-improvement program, session chair Michel Gagner, MD, bariatric surgeon at Hôpital du Sacré-Coeur, in Montreal, Quebec, told Medscape Medical News.

"We need to have these protocols implemented worldwide, [to] increase the quality of our [bariatric-surgery] programs," he said. "They're commonsense, low-cost solutions where people can make a phone call, look at some checklist, and give information to the patient about what to do."

Readmission More Often Due to Nutrition Than Leaks

Dr Morton explained that "mortality after bariatric surgery has declined more than 10-fold in less than a decade, [and] now…it's important to see if there's opportunity for improvement in other areas," such as 30-day readmission. This is also a quality measure that payers are focusing on, he noted.

Readmission to the hospital after bariatric surgery is most often due to preventable dietary indiscretions that cause nausea, vomiting, or electrolyte and nutritional deficits, he noted. A recent paper reported that nutrition accounted for a third of all readmissions after bariatric surgery, whereas leaks only explained about 6% of readmissions.

The MBSAQIP — the joint accreditation and quality-improvement program of the American College of Surgeons (ACS) and the ASMBS that came about in 2012 — developed the DROP program to improve readmission rates and tested it in a pilot study before implementing it on a larger scale.

The preoperative components of the program include giving patients standardized educational videos, prescriptions (for after the surgery), and phone numbers to call with any questions.

The inpatient components include a visit with a dietician and a completed discharge checklist. The postoperative components include a discharge phone call, a postoperative visit with a surgeon and dietician, a letter to the referring physician, and a review of any readmissions.

The participating hospitals were representative of institutions performing bariatric surgery in the United States and were located in the Northeast, Midwest, South, and West. Most hospitals (85%) were nonprofit, and half had more than 375 beds. Under a third were teaching hospitals and a fifth were rural hospitals.

All patients aged 18 or older who had an initial adjustable gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass — all performed laparoscopically — from March 1, 2015 to March 31, 2016 in one of the participating hospitals were included in the DROP program.

In the year before the program was implemented, 1446 of 30,204 patients (4.79%) who had one of these types of surgeries were readmitted to the hospital within 30 days.

Before and after the DROP quality initiative was implemented for a year, 30-day readmission rates for laparoscopic adjustable gastric banding and for laparoscopic Roux-en-Y gastric bypass both increased slightly: from 1.88% to 1.95% and from 6.53% to 7.13%, respectively.

But 30-day readmission rates for laparoscopic sleeve gastrectomy (LSG) fell from 4.02% to 3.54%, which drove the overall decline in readmission rates, which fell from 4.76% to 4.61%.

Notably, the 30-day readmission rates after sleeve gastrectomies increased during the first 3 months (first quarter) of the implementation of the DROP program but thereafter fell in the remaining quarters, falling by 27% in the last quarter.

The most common causes for 30-day hospital readmission remained the same before and after the DROP program was implemented. These were (in descending order): nausea and vomiting; fluid, electrolyte, or nutritional depletion; other; abdominal pain; anastomotic/staple-line leak; bleeding; and intestinal obstruction.

Program limitations include that this "bundle" of quality measures primarily affects 30-day readmissions after sleeve gastrectomy and it did not affect centers with preexisting low readmission rates, Dr Morton said.

"It was really the postoperative…elements that really make a difference," stressed Dr Morton. It might be a cumulative effect, where patients learn more over time, or it might be a latency effect, where they remember the most recent thing they hear, he speculated.

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Obesity Week 2016: The American Society for Metabolic and Bariatric Surgery and the Obesity Society Joint Annual Scientific Meeting; November 2, 2016; New Orleans, Louisiana. Abstract A101.

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