Friday, May 20, 2005

The Politics, and Money, of Bariatric Surgery Accreditation

A while back, I received an e-mail from the American College of Surgeons outlining a proposal to credential bariatric surgery centers. The idea of credentialling has many sources, but basically revolves around the understanding that there has been an explosion of programs across the country, some perhaps without proper training and without a full-fledged "program" to complement the operation. There have been high-profile deaths in some centers, and as a result there has been a desire for some sort of oversight and credentialling for centers performing this procedure. Enter the ACS, who announced their credentialling program in an e-mail today:

We are writing in follow-up to our previous communication concerning the ACS Bariatric Surgery Center Program. The communication is intended to let you know that the College is currently inviting institutions to enroll in this new program. For many years, the ACS has led our nation's efforts to ensure safe and effective treatment of all patients requiring surgical care. For example, the Joint Commission on Accreditation of Healthcare Organizations evolved from the ACS Committee on Hospital Standards. The ACS and its Committee on Trauma verify 197 trauma centers.
Sounds great! There's just one problem --- there is already a national organization providing credentialling for bariatric surgery programs. The ASBS started this process over a year ago, and literally hundreds of programs have gone through the initial screening process. It is being administered by the Surgical Review Corporation, and the initial "Centers of Excellence" are due to be announced at the ASBS meeting in June.

So why reinvent the wheel? If this is an important policy goal, why doesn't the ACS get together with the ASBS to jointly administer accreditation? If one reads the SRC web site, the program goals are essentially the same as those laid out by the ACS:
(ACS e-mail)...we have reviewed the available information, consulted with experts in the field of bariatric surgery, listened to ACS leadership, developed standards, defined necessary resources, organized the means to collect data, and organized the processes for conducting site visits to accredit hospitals and outpatient facilities in an ACS Bariatric Surgery Center Network. In addition, the ACS assembled a team to manage and lead this project.
If they have consulted with experts in the field of bariatric surgery, that in essence means the ASBS and its leadership (and no, I'm not an ASBS member). Consultation should have led to cooperation....but that is too much to ask, it seems, particularly from the organization that has given us JCAHO (see above). This announcement smacks a little too much of the "town and gown" phenomenon, IMHO, along with a healthy dose of monetary incentive:
Centers will report outcome data on all bariatric surgery patients, whenever possible
using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). For centers not enrolled in the ACS NSQIP the ACS will provide an alternate data management resource.
What's not stated there is that participation in NSQIP is expensive, costing about $40 per operation to run (Khuri SF.Quality, advocacy, healthcare policy, and the surgeon. Ann Thor Surg 2002;74:641–649). In addition to the costs incurred by the hospital complying with the program (any of you involved with JCAHO, the ACS Trauma Program, and the ACS cancer center accreditation processes can relate), it costs $35,000/year to participate with NSQIP. Apparently there will be an alternative for those hospitals not participating with NSQIP. The new ACS Bariatric Surgery Program? That will set your hospital back a few more bucks:
When we receive your signed Participation Agreement and enrollment fee of $10,000, you will become a provisional member of the program...To maintain full accreditation through the ACS Bariatric Surgery Center Program, your facility will complete an annual status report (five-page document similar to the enrollment application) and undergo a site visit every three years. Your facility will be required to pay $10,000 for the tri-annual site review.
Now, imagine you are the CEO of a reasonable sized hospital, trying to make income at least match cash outflow. You have a well run, reasonably busy bariatric program, and you have spent so far about $35,000 in fees and compliance with the ASBS Centers of Excellence application process. Are you going to be interested in paying the ACS to do essentially the same thing?

Politically, it appears that the ACS and ASBS are in the same straits as the Republicans and Democrats in the Senate. Right now, there is no compromise --- the ACS says the ASBS criteria are too strict, the ASBS says the ACS wants total control of the process. In the end, I suspect there may be competing "centers of excellence" in some communities, accredited by different organizations. In the end, I fear that the American College of Surgeons will lose because of the way that this has been handled. I hope that there can be some meeting of the minds in the near future --- that precedent was set when SAGES and the ACS worked together to ensure proper credentialling for laparoscopic surgery.