First National MBSAQIP Quality Improvement Project. Decreasing Readmissions through Opportunities Provided (D.R.O.P )

First National MBSAQIP Quality Improvement Project Decreasing Readmissions through Opportunities Provided (D.R.O.P ) John Morton, MD, MPH, FACS, FASMBS Chief, Bariatric and Minimally Invasive Surgery, Stanford President-Elect, American Society for Metabolic and Bariatric Surgery Co-Chair, ACS Cmte on Metabolic and Bariatric Surgery

Disclosures No relevant disclosures

Structure Quality Hospital Accreditation Process Multidisciplinary Evaluation, Treatment and Coordination Outcomes Readmissions

These studies demonstrate that there are vulnerable patient populations and potential additional costs associated with surgery but suggest that surgical volume helps mitigate these risks and costs," wrote Bruce M. Wolfe, M.D., of Oregon Health & Sciences University in Portland and John M. Morton, M.D., M.P.H., of Stanford in an accompanying editorial. "Bariatric surgery may be a potentially life-saving intervention in the right patients and in the right surgeons' hands," they added. "The studies presented in this issue indicate that experience and technique count."

BARIATRIC SURGERY: AMERICAN SURGICAL SUCCESS STORY

UHC data: In-Hospital Mortality 4.5 Bariatric Surgery In-hospital Mortality by Year 2002-2009 (N = 105,287) 4.0 4.0 3.5 Deaths per 1,000 3.0 2.5 2.0 1.5 2.6 2.3 1.6 1.5 1.0 1.0 0.8 0.6 0.5 0.0 2002 2003 2004 2005 2006 2007 2008 2009 Year Nguyen et al. SOARD 2012

Summary of Accreditation Literature PRO (8) (1) Morton, Ann Surg 2014 (2) Telem, SOARD 2014 (3) Nguyen, Surg Endo 2013 (4) Kwon, SOARD 2012 (5) Nguyen, JACS 2012 (6) Flum, Ann Surg 2011 (7) Nguyen, Arch Surg 2010 (8) Kohn, JACS 2010 CON (3) (1) Livingston, Arch Surg 2009 (2)Birkmeyer, JAMA 2010 (3) Dimick, JAMA 2013

Does hospital accreditation impact bariatric surgery safety? John Morton 1, MD, MPH, FACS, FASMBS Trit Garg 1, BA Ninh T. Nguyen 2, MD, FACS, FASMBS 1 Stanford University 2 University of California, Irvine 134 th Annual Meeting of the American Surgical Association

In-Patient Outcomes Morton, Ann Surg 2014 Unaccredited Accredited P value Total charges (mean), $ Any complication, % 51,189 42,212 <0.0001 12.3 11.3 0.001 Mortality, % 0.13 0.07 0.019 FTR, % 0.97 0.55 0.046 Abbreviations: FTR, failure to rescue

Mechanisms for Improved Outcomes at Accredited Centers Experience in Recognition Multi-Disciplinary Team Resources Risk Assessment Established Processes-VTE, SSI Technical-Leaks, Splenectomy, Reoperation

Implications for Accreditation Competing Hospital Resources Data collection through registry with risk-adjusted reports & implement best practices through multidisciplinary team Can t Manage What You Don t Measure

Sun setting Quality? Surgical Evolution 1913- American College of Surgeons 1922- Committee on Fractures 1933- Commission on Cancer 1951- JCAHO 1964- Society for Thoracic Surgeons 1991-NSQIP 2006-Bariatric Surgery Center of Excellence

ACS Quality Family (Years of Existence) (81) (1) (23) (15) (10)

Beyond Mortality

Four Guiding Principles of Continuous Quality Improvement Standards Right Infrastructure Rigorous Data Verification Individuali zed by patient Backed by research Staffing levels Specialists Equipment Checklists Clinical Backed by research Postdischarge tracking External peer-review Creates public assurance Continuously updated

Dashboard x Bariatric Surgery Volume & Re-operations Surgery Type and Volume Re-operations within 30 days CY 2012 6% CY 2011 5% CY 2010 CY 2009 CY 2008 0 50 100 150 200 250 Bypass Sleeve Band Stomaphyx VBLOC 4% 3% 2% 1% 0% CY 2008 SHC CY 2009 National CY 2010 CY 2011 CY 2012 Source: American College of Surgeons (ACS) Bariatric Surgery Center Network (BSCN) report Slide Summary Total bariatric surgery cases increased from 120 in 2008 to 241 in 2012 Re-operations decreased from 3.1% in 2009 to 0.8% in 2012 Goal: Re-operations to remain below BSCN national average 18 Re-admissions decreased from 8.3% in 2008 to 2.1% in 2012 (see next slide)

We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. 90% Unplanned Readmissions 22.4 % of Conditions at Index Discharge Surgical

Patient Safety Patient Satisfaction Provider Satisfaction Cost Readmissions Meta-Outcome

Causes for Readmissions Dehydration Nausea Medication Side-Effects Patient Expectations DVT 0.1%, SBO 0.2%, Leak: 0.4%, Bleed 1%, Readmissions 5-7%

Bariatric Surgery QI Plan 3: Actions Reducing Re-admissions Goal: Reduce re-admissions for complications within 30 days to remain below national average. Improved patient education/ discharge planning Provided direct phone numbers BMI Clinic RN calls each ptday s/p dc Same day appointments now available for concerns Using Clinical Decision Unit for 23 hour stays 8 to 2.5 % 69% Reduction % patients readmitted w/in 30 days

Evaluating the value of a combined physician-dietician follow-up after bariatric surgery

MD-alone MD+RD p-value n (%) Complications ALL Minor 16 (5.63) 6 (2.41) 0.080 Diet-related 6 (1.99) 3 (1.12) 0.511 Readmissions ALL 18 (6.04) 12 (4.63) 0.573 Diet-related 9 (3.03) 0 (0.00) 0.004 Binary categorical: Fisher s exact

95%

Readmission Bundle Preop Education Module Postop Appointment Made/HELP CARD Postop Rx/Clinic Phone Numbers Given Nutrition, Nursing, Pharmacist Review Hospitalization Clinical Roadmap/DC Checklist Postop Nurse Phone Call Made Day After DC (1, 2 or 3 week post op appointment with nutritional counseling

I. Decreasing Readmission Bundle Pre-Op Patient Education Module Postop Appointment Made Postop Rx Given Clinic Phone Numbers Given Nutrition Review-Module Nursing Review- Wound Care Pharmacist- Med Reconciliation High Risk Pt, Review w Family/PCP Modifiable Risk Factors- Wgt Gain>5%, HgA1c HELP CARD

Surgeon Module Keynote Emphasize utility of complication prevention strategies: walking, incentive spirometer use and intraoperative leak test, drain and/or upper gastrointestinal series. Also note that patients will be closely monitored and kept in safe care

Nurse Reviews the flow of the hospitalization particularly the length of stay and the milestones of the care pathway Review warning signs of complications including for bleeding, leak, surgical site infection and obstruction Describe the physical transitions in care from operating room, recovery room, hospital bed, discharge and home State when patient can exercise, drive and return to work Mention directly who to call if there are any concerns and remind patient that RN will be calling the day after DC.

Dietician Highlights the dietary requirements including: maintaining or losing weight before surgery, being NPO the night before surgery and what to expect after surgery in the hospital and home until their first postop appointment Recounts transition from liquids to pureed to soft foods Emphasis on maintaining hydration and protein intake as well reminding patients to slowly drink to avoid nausea and to frequently drink to avoid dehydration. Take Vitamins/Avoid straws, ice cream, milkshakes, juicers, and Ensure type of drinks.

Pharmacist Review required for medications that are either weight promoting or no longer required after surgery Specific recommendations need to be made for opoids, antihypertensives, glycemic agents, antidepressants, statins, NSAIDS/ASA, Coumadin, and ImmuneSuppressants CHECKLIST 1. Do I still need to take this medication? 2. When will I stop taking this medication? 3. Does this medication cause weight gain? 4. Is there an alternative to this medication? 5. Can I crush or convert these medications to liquid?

Psychologist A short review of stress management, selfacceptance, anxiety management, coping tools, teaching resiliency, and attention to mood

B.M.I. Clinic 900 Blake Wilbur Dr., Suite W0048 Stanford, CA 94304 Bariatric Surgery HELP Card Use this Card if you have: ANY Problems, Questions, or Concerns We want to know about it! Abdominal Pain Dehydration Nausea & Vomiting Diarrhea Fatigue Contact Information on Reverse

CONTACT NUMBERS EMERGENCY Call 911 or the Stanford ER at (650) 723-5111 I M NOT SURE Call the On-Call Surgeon at (650) 723-6661 AT ANOTHER HOSPITAL Call our Transfer Center at (650) 723-4696 or Toll-Free at (800) 800-1551 NON URGENT Call the BMI Clinic from 9a-5p and make an appointment for any day at (650)736-5800

The High Risk Patient Once a high-risk patient is identified preoperatively then coordination of care should be escalated. The patient s care should be reviewed in detail with patient family and the patient s primary care physician. In addition, the hospital case manager should be employed early and consideration of a discharge to shortterm nursing unit should be entertained.

Patients at High Risk for Readmission BMI>50 Hypertension, Diabetes, and Hyperlipidemia: Metabolic Syndrome COPD LOS>4 Medicare & Medicaid Complication or Extended Surgery at Index Hospitalization

Risk-Factors For Readmission ACS 2014, Morton 18, 296 (N) No 30-day Readmision 30-Day Readmission (5.22%) P value BMI>50 30.2 24.6 0.001 Operative Time (min) 132 115 0.001 LOS>4, % 9.57 3.36 0.001 Diabetes, % 31.1 27.7 0.02 2012 ACS NSQIP PUF, all primary bariatric surgeries

Risk-Factors For Readmission ACS 2014, Morton 18, 296 (N) No 30-day Readmision 30-Day Readmission (5.22%) P value SSI 15.5 1.15 <0.001 UTI 3.15 0.65 <0.001 DVT 3.58 0.13 <0.001 Return to OR 22.6 0.92 <0.001

Risk-Factors For Readmission ACS 2014, Morton Common readmissions were GI-related (45.0%), dietary (33.5%), and bleed (6.57%). Logistic regression found readmission was associated with: White race (OR=1.53, p=0.02) Complication (OR=11.3, p<0.001) Resident involvement (OR=0.53, p=0.04)

Best Practices Smoking Cessation Opoid Detoxification Glycemic control for Hemoglobin A1C >8 Prevent Weight gain >5% from consult to preop Proton Pump Inhibition H Pylori eradication Actigall Use

II. Decreasing Readmission Bundle In-Patient Clinical Roadmap with Fixed LOS Water Bottle Ceremony by RN Nutritional Consult Discharge Checklist

Discharge Checklist 1. Clinic Phone Numbers Given 2. Prescription Given 3. Appointment Made 4. Diabetes/Nutrition Counseling Done 5. Do you have someone to care for you at home? 6. Are you in pain? 7. Can you drink? 8. High Risk Patient (Discuss with Surgeon & Case Manager)

Water Bottle Ceremony emphasis on hydration and caring, linking clinic to hospital, and marketing for the hospital and program

III. Decreasing Readmission Bundle Post-Operative Nurse/PA Phone Call Made Day After DC (If High Risk Patient, additional call made on Friday of week of surgery). 1, 2 or 3 week post op appointment with nutritional counseling PCP given Discharge Summary and Recommendations Monthly Readmission Review Conference

Post-DC Phone Call 1. Post op pain- taking pain med regularly. 2. Laparoscopic Incision/Wound Care-steri-strips 3. Bowel Movements 3. Diet- tolerating full liquid 4. Vitamins- has mvi 5. Fluid intake- reminded to get 48 ounces a day- working on this 6. Protein intake- reminded to get 60-80 grams a day- has Unjury, etc 7. Mobility- walking around 8. Medications-reminded of need for Protonix 9. On call MD number- pt has # 10. Follow up appointments- pt has # 11. Review discharge summary- on sliding scale # 12. If pt needs to go to Emergency room- prefer them to come back home

Quality Improvement Tools In-depth analysis of root causes to problems Use the 5 whys, Getting Organized-Team charter, Problem focus.patient benefit. Team members, including the team leader. Stakeholders Time requirements/logistics. Requirements for PI team visits to the area Acquisition of current state data and sources of information. Team ground rules promote functional team meetings. Focus on the high-level steps that occur 80 percent of the time. Map the current process, not what the process should be. Brainstorming Keep Off Event/Retreat Celebrate the PI team's work and communicate findings

Obesity Week 2013 Readmission Symposium Chair, J Morton, Stanford M Hutter, MGH, Why Readmissions Matter Tony Petrick, Geisinger, ProvenCare Stuart Verseman, Borges Hospital, MBSC Experience Karen Schulz, CC, Nursing David Sarwer, UPenn, Psych Raul Rosenthal, CCF, Technical

Working Together Apart A New Paradigm Regional Collaboratives Florida, TN, MI, WA National Colloborative Video Educational Tools Powerpoints FAQs/Call Blog Training and Monthly Webinars 2 In-Person Meetings, Obesity Week &Spring Event

Decreasing Readmissions Why do it? through Opportunities Provided (D.R.O.P ) Specific complications (DVT/Leaks) rare. Readmissions are important to payors. Opportunity for improvement. Fulfills Quality Improvement project as in MBSAQIP standards.

Inclusion Criteria/Requirements MBSAQIP Comprehensive Center Ages >17, Primary Cases Only Custom Fields Established for Readmission Bundle Elements First 100 Hospitals Nationally Representative- Survey, Geography, Teaching Status, Hospital Size/Pay Model

GOAL Reduce re-admissions within 30 days to decrease by 20% nationally. Over 700 Hospitals @150,000 cases annually 7,500 6000 Readmissions 35K * 1500= 52.5 Million

Conclusion Utilizing national, clinically derived data can drive quality improvement

Accreditation Improves Access for Medicare beneficiaries Nguyen et al. Arch Surg 2010: 29% reduction within 2 quarters after NCD but returned to baseline within 1 year and exceeded baseline after 2 years. Flum et al. Ann Surg 2011: 17.8 procedure/100,000 pre NCD to 23.8 post NCD. Dimick et al. JAMA 2013: 249 Medicare pts./mo. pre NCD vs. 352 pts./mo. post NCD

Summary of Accreditation Literature CON Livingston. Arch Surg 2009 Birkmeyer, JAMA 2010 Dimick, JAMA 2013

Demographics Before NCD After NCD Mean no. institutions 60 45 Total No. of cases 3,196 3,068 Female gender (%) 2,638 (82.5) 2,500 (81.5) Age (%) <30 years 31-50 years 51-64 years >65 years Race (%) Caucasians African American Hispanic Nguyen et al. Arch Surg 2010 429 (13.4) 1,649 (51.6) 879 (27.5) 239 (7.5)* 2,161 (67.6)* 623 (19.5) 199 (6.2)* 418 (13.6) 1,531 (49.9) 826 (26.9) 293 (9.6) 1,942 (62.3) 643 (21.0) 255 (8.3)

Ethnic minority Non-white Dimick JAMA 2013 12 States Database Nicholas JAMA 2013 8 States Database Medicare (pre vs. post NCD) 27.1% - 25.2% 27.5% - 25.9% -1.9-1.6 Non-Medicare (pre vs post NCD) 25.7% - 28.3% 26.2% - 29.1% +2.6 +2.9 Conclusion Rates of demographics were similar before and after NCD No Minority Access Issue A policy intended to improve pt. safety associated w/ unintended consequence of reduced use of BS by minority

Is Bariatric Surgery Included in the State s Qualified Health Plan? Health Insurance Exchange (HIE) Coverage of Weight-Related Services AK Affordable Care Act Beginning January 2014 WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI IN KY TN AL OH GA NY PA WV VA NC SC NJ DE MD RI CT ME DC NH VT MA TX LA HI Does not cover bariatric surgery nor weight loss programs Covers weight loss programs but does not cover bariatric surgery Covers bariatric surgery but does not cover weight loss programs Covers bariatric surgery and weight loss programs Source: Center for Consumer Information and Insurance Oversight summary of EHB benchmark plans based on 2012 benefits STOP Obesity Alliance, Weight and the States Policy Research Bulletin, December 2012. Obesity Action Coalition Spreadsheet, May 2013. (States that have not selected an EHB benchmark plan defaulting to the largest small-group employer plan in the state.) FL Current as of 05-06-2013; Coverage may have changed since this printing

CMS Evidence Review Process is Accepted as the Gold Standard CMS analysis: We found NO evidence suggest a worsening of outcomes (at non-coe centers) Nguyen et al. JACS 2012, Mortality (0.06% AC vs. 0.21% NAC) 3-Fold Reduction in Mortality Jafari et al. Surg Endosc, Mortality (0.06% AC vs. 0.22% NAC) 3-Fold Reduction in Mortality