Commentary on: “Ensuring Excellence in Centers of Excellence Programs”

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We read with interest the article by Mehrotra and Dimick titled “Ensuring Excellence in Centers of Excellence Programs.”1 We disagree with several statements made in this Surgical Perspective. Fundamentally, we believe that accreditation has resulted in better outcomes and lower mortality without restricting access and that, when the entire body of literature on this issue is reviewed, the data support these claims. Additionally, an accreditation system provides a platform for uniform methods of patient selection, clinical pathways and processes of care, and a data collection system, providing a report card of risk-adjusted data, and most importantly, local and regional quality improvement efforts. Without accreditation, none of the above will take place.
Specifically, the authors state, “several recent empirical evaluations of such programs have found that designated hospitals are, at best, only modestly better than nondesignated hospitals.” To date, there are numerous studies that have compared outcomes of accredited versus nonaccredited centers.2–6 The vast majority have reported significantly lower mortality rates at accredited centers. We believe that any and all reductions in operative mortality, however modest, are of clinical significance.
With regards to surgical volume, the authors conclude that “Although volume-outcome relationships are strong for rare, high-risk surgical conditions, they are much weaker for the common conditions that are often the focus of programs (eg, bariatric surgery).” The American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons have established the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) with data-driven standards regarding volume and substantial feedback from the membership to ensure that appropriate volumes are maintained without restricting participation in the program.7 Compared with the previous ASMBS Center of Excellence program that required 125 cases per year, MBSAQIP has lowered the volume requirements based on the best available evidence to 50 bariatric stapling cases per year for comprehensive centers and to 25 cases per year for low acuity centers. Of note, Jafari and colleagues have reported a higher operative mortality at high-volume, nonaccredited centers compared with high-volume, accredited centers, indicating that the crucial component to improve outcomes is not volume but accreditation.8 In addition, this implies that there is lower rate of “failure to rescue” in patients who develop complications at accredited centers, reinforcing the utility of specific structure and process measures in place to recognize and expeditiously treat complications.6
We also disagree with the authors’ statement that “The goal of these programs is to encourage patients to change hospitals.” The goal of accreditation has never been to regionalize bariatric surgical care, but, instead, to improve care. The MBSAQIP standards were established with the goal of being inclusive of surgeons and health systems performing bariatric surgery in a wide variety of safe settings and regions. By taking into account the broad perspectives of the ASMBS membership and by lowering the volume requirements, the MBSAQIP program is designed to make high-quality bariatric surgery available in more hospitals, not fewer. The authors also noted potential disadvantages in designating bariatric accreditation centers including a negative impact on access for racial minorities and the need for patients to travel to obtain care. At the current time, there are 732 MBSAQIP designated centers nationwide with center representation in all 50 states. Therefore, it is unlikely for patients to have to travel a meaningful distance to obtain quality bariatric care.

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