Laparoscopy Today

CONFERENCE REPORT: Bariatric Surgery

ALEX GANDSAS, MD

Obesity has increased dramatically as has the amount of money spent in treating major weight-related comorbidities. The cost of health care in morbidly obese patients has increased 5 times in the last 18 years. Although an increase has occurred in the number of patients requesting revisional surgery, few centers offer such surgery and few centers offer bariatric surgery in the ambulatory setting.

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Bariatric Centers of Excellence as Another Pay-for-Performance Program

PAY-FOR-PERFORMANCE

ALEX GANDSAS, MD, MICHAEL SCHWEITZER, MD

INTRODUCTION

Historically, employees in the corporate world have been financially rewarded for outstanding performance and for their contribution to the organization. This reward usually comes in quarterly or yearly bonuses, stocks, or both of these. In the current healthcare system, financial incentives are based solely on productivity measured by volume only, irrespective of the quality of care or outcomes. Doctors and hospitals are equally financially compensated regardless of the quality of care delivered to patients. In the current healthcare reimbursement system, a fee-for-service approach rewards volume productivity without concern for quality, the capitation model incentivizes efficiency while penalizing utilization with again the risk of compromising quality, and a salary system awards constancy without nurturing innovation or productivity. The current models leave the provider with few incentives to strive for or compete for high-quality medicine. A new paradigm of how patient care will be assessed, known as pay-for-performance (P4P), promises to motivate healthcare providers and health organizations by providing higher reimbursements as long as high “quality” evidence-based-medicine is delivered. Moreover, performance measures will be published to give the consumer a selection tool that will ultimately have an impact on provider image, market share, and income. For a program to be deemed successful, the financial rewards to physician groups should be the result of collaborative work between health plans, medical directors, academia, and industry experts. Furthermore, payments should vary depending on the type of incentive program chosen.

HISTORY

Following the report Crossing the Quality Chasm in 2001 [1], in which more than 98,000 preventable deaths were attributed to medical errors [2], a growing consensus was reported that the new approach to health care should include fair payments to providers as a reward for good clinical management and outcome.

The concept of pay-for-performance is not new. Programs that compensated clinicians for being compliant with quality assurance programs were attempted in the past but failed due to the lack of physician support. These programs focused mainly on cost and utilization, rather than on clinical outcomes. With the incorporation of information technology as a means to better track patient data, most programs in charge of developing quality measures are likely to request reports of clinical outcomes. In the year 2000, the Integrated Healthcare Association, a California leadership group of health plans, physician groups, health systems, pharmaceutical industry, and consumer representatives, developed the concept of rewarding physician groups for good documented performance. Basically, this plan was based on (a) patient satisfaction (40%), (b) prevention (25%), (c) chronic care management (25%), and (d) use of information technology (10%) [2].

In general, most pay-for-performance programs establish clinical goals, either as direct implementation of a therapy (eg, give patient aspirin after being diagnosed with myocardial infarction) or as an outcome measurement (eg, morbidity and mortality). Nonclinical goals usually refer to the use of information technology applied to electronic medical records and patient satisfaction. Electronic medical records and computerized follow-up are the main ingredients of the P4P proposition. Practices will need to establish an electronic health infrastructure to provide the payer with performance data.

MEDICARE JOINS THE GAME

Medicare has studied more than 270 hospitals enrolled in its program, looking specifically at the treatment of pneumonia, heart attacks, coronary artery bypass graft operations, and hip arthroplasties. After the first 9 months of implementing the program, an increase was noted in the median score of 6% for all conditions. In this test, hospitals scoring in the top 10% in quality ratings received an extra 2% financial compensation per case, while those scoring in the next 10% received payment increments of 1% per case. On the other hand, a reduction of 2% in payments was made to hospitals that failed to increase their baseline scores [3].

PAY-FOR-PERFORMANCE
STILL IN THE WORKS

Proponents of pay-for-performance promise a new way of improving quality and reducing cost by offering financial incentives to those health-care organizations, physicians, or both, who implement evidence-based medicine to improve clinical outcomes and who adopt a robust information technology infrastructure capable of handling electronic medical records. However, because it seems to be a new way of getting reimbursed for high-quality outcome data, risk adjustment parameters should be implemented to prevent physicians from drawing back from the high-risk patient.

In addition, a close collaboration should exist between providers and payers in setting up feasible goals and defining quality measures and bonus payment parameters, including payment timelines. This new relationship may impact new contract negotiations and caution should be exercised in order not to infringe on antitrust laws. 

On another note, some practitioners may be concerned because this type of program may tend to lower the threshold, resulting in lower payments for those not participating or not achieving quality goals. Furthermore, a successful practice may capture a greater market share once it is identified as being “quality approved” by the payer. Concomitantly, data should be cautiously analyzed because outliers may skew small-volume practices.

In an ideal world, the participation in P4P programs should be completely voluntary, without punishing low-volume practices. Actually, the American Medical Association is concerned that these P4P models are simply “old-fashioned” withholding programs, in which payments from a withheld pool are returned to the practice once medical groups or hospitals meet specific performance criteria.

The fact that so many private payers and Centers for Medicare & Medicaid Services are experimenting with P4P programs indicates that this new paradigm in health care will continue to expand. Currently, more than 400 hospitals have enrolled in P4P programs, and it is thought that by the end of 2006 more than 100 programs will be available. Pay-for-performance has the potential to modify the current approach of health care by rewarding acute preventive care and promoting better use of medical resources.

CENTERS OF EXCELLENCE FOR BARIATRIC SURGERY
RATIONALE

Obesity in America has reached epidemic proportions. It is estimated that more than 97 million Americans are overweight or obese. Furthermore, approximately 7 million are considered morbidly obese with a body mass index of 40 or higher and at least 100 pounds over their ideal body weight.

Studies have shown that a surgical option is the most effective way to achieve and maintain weight loss, significantly reducing major comorbidities, such as hypertension, type II diabetes, sleep apnea, and dyslipidemias [4].

Over the last 10 years, a significant increment has been noted in weight loss procedures performed in the United States per year, reaching more than 175,000 cases in 2005. Furthermore, last year, the Centers of Medicare and Medicaid Services have defined obesity as a disease instead of a condition. It has been estimated that the cost of treating obesity in the United States was approximately $117 billion, of which $61 billion is related to direct medical costs [5].

To maintain a level of efficacy, efficiency, and safety, the American Society of Bariatric Surgery (ASBS) and the American College of Surgeons (ACS) have launched the Centers of Excellence Programs, aimed at identifying practices, surgeons, and institutions able to deliver care to bariatric patients in the safest possible way. Both programs have set 125 as the minimum number of cases per year performed by surgeons to obtain full approval status (Table 1).

In many ways, the Bariatric Centers of Excellence Programs share similar principles with a pay-for-performance program.

1.    Improve Clinical Outcomes:  Bariatric surgery is known to be a challenging field because it has to deal with a high-risk population suffering from multiple comorbid conditions. Insurance companies and malpractice premiums are closely linked to physician performance. Good outcome data with a low morbidity and mortality rate may help contain or decrease premiums and the overall cost per patient.

2.    Information Technology: Although not specifically required by Bariatric Centers of Excellence Programs, as seen in traditional pay-for-performance programs, information technology is a “must have” tool for data submission and subsequent analysis to qualify as a participating program.

3.    Indirectly assess patient satisfaction by ensuring that the following resources are available:
    a.    Access to healthcare providers
    b.    Gowns
    c.    Sensitive in-services
    d.    Nutritional counseling
    e.    Support groups
    f.    Well-equipped facilities (furniture, bathrooms)

4.    Financial reward is not rendered monetarily but instead with assumed growth of market share and fast precertification processing.

Several third-party payers have already launched their own Centers of Excellence criteria to identify centers that have a comprehensive bariatric surgery program, including preoperative medical, psychological, and surgical assessment and long-term postoperative follow-ups. The program must also meet volume thresholds and surgeons should demonstrate a commitment to reporting outcome data.

Most of these criteria focus on outcomes, because these parameters are linked to hospital utilization. It is expected that while those practices with higher complication rates will drive costs up by utilizing several hospital resources, practices with good outcomes, mainly low morbidity, mortality, or both, will result in lower hospital readmissions, specifically those that fall outside the global period.

Centers of Excellence programs, like P4P, will lead to an ultimately less expensive approach to weight-loss surgery, financially rewarding surgeons who perform procedures with documented lower complication rates. Hospital administrations will be in a stronger position to capture a larger market share, negotiate a better case rate with insurance companies, and have better leverage to negotiate with malpractice insurance companies. Recently, Blue Cross and Blue Shield of North Carolina increased the average reimbursement rates by 30% to 50% to surgeons and bariatric surgery practices that have been endorsed as Centers of Excellence [6].

Proponents of the Center of Excellence concept believe that this will help patients decide which surgeon or practice has an excellent track record and comparable outcome data with benchmark standards.

CONCLUSION

Centers of Excellence programs are in many ways a preamble to pay-for-performance programs, where the patient and payers are empowered to choose a surgeon or practice with an excellent track record and comparable outcome data against benchmark standards.

Address reprint requests to: Alex Gandsas, MD, Hoffberger Professional Building, 2435 W. Belvedere Ave, Ste 41, Baltimore, MD 21215, USA. Telephone: 410 601 4838, E-mail: webmaster@laparoscopy.com

 Alex Gandsas, MD, is Associate Professor of Surgery at The Johns Hopkins University School of Medicine and Head, Division Bariatric and Minimally Invasive Surgery at the Sinai Hospital of Baltimore. Dr Gandsas sits on the Society of Laparoendoscopic Surgeons Board of Directors and is active in several other societies including the American Society for Bariatric Surgery. He has authored numerous scientific articles and is founder of the popular Laparoscopy.com Internet site for laparoscopic surgery. 

Michael Schweitzer, MD, is Assistant Professor of Surgery at the The Johns Hopkins University School of Medicine and Director of Minimally Invasive Bariatric Surgery at the Johns Hopkins Bayview Medical Center. Dr Schweitzer has published his scientific findings in several journals and has presented his work throughout the United States. He is a member of several societies including the American Society for Bariatric Surgery and sits on the editorial board of three journals.

References

1.  Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

2.  Achieving high performance in health care: Pay-for-performance. Moving the bar on quality reporting and accountability. Available at: http://www.accenture.com/NR/rdonlyres/ACE1C0B8-6130-4A65-A73B-853751BADD2F/0/pay_performance.pdf. Accessed February 2006.

3.  Kahn III CN, Ault T, Isenstein H, et al. Snapshot reporting and pay-for-performance under medicare of hospital quality. Health Affairs. 2006;25(1):148-162.

4.  Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic roux-en-y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529.

5.  Kelly J, Tarnoff M, Shikora S, et al. Best practice recommendations for surgical care in weight loss surgery. Obes Res. 2005;13:227-233.

6.  The AIS Report on Blue Cross and Blue Shield Plans, November 2004. Available at: http://www.aishealth.com/ManagedCare/BluesNews/BLUObesityRelatedBluesBulge.html. Accessed November 17, 2005.

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JOURNAL WATCH: J Am Coll Surg LAGB

Laparoscopic Adjustable Gastric Banding: 1,014 Consecutive Cases. Ponce J et al. 2005;201:529-535 • Ponce, et al. examined the LAGB procedures that were performed at their center from October 2000 to December 2004. The authors were able to follow up with over 85% of the patients for 48 months. Women comprised 81.8% of the patients. Nine slippages occurred in the 44 patients who had perigastric dissection, while 14 occurred in the 970 patients with the pars flaccida technique. Ponce et al concluded that LAGB can achieve effective and safe weight loss, and that the pars flaccida technique reduced slippage when compared to the perigastric technique.

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MEDICARE STANCE ON LAPAROSCOPIC BARIATRIC SURGERY

The Centers for Medicare and Medicaid (CMS) has reconsidered its stance on Medicare coverage for bariatric surgery. As of February 21, 2006, the list of nationally-covered procedures includes open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch. Coverage was even extended to those over the age of 65 years, a segment of the population previously excluded by last year's preliminary proposal. With new data and analyses demonstrating that surgeons with more experience have similar outcomes for patients of all ages, the CMS decided to include this segment of the population with the stipulation that the procedures be performed in facilities most likely to achieve better outcomes.

All other surgical bariatric procedures remain non-covered. In order to qualify for coverage, patients must have additional health problems, such as hypertension, type 2 diabetes, and heart disease.

According to the National Institutes of Health, approximately 34 percent of Americans are overweight and 27 percent are obese. With the average cost for a bariatric surgical procedure being about 25 thousand dollars, this is a much needed relief to patients who cannot possibly afford this life saving surgery.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Surg Endosc Bariatric Surgery

The Impact of Laparoscopy on Bariatric Surgery • Cottam DR et al 2005;19(5):621-627. As compared with the open approach, the laparoscopic approach to bariatric surgery elicits different biologic responses and offers clinical advantages that the authors suggest have contributed to the growing popularity of the surgery. In this review, the authors attempt to understand the differences between and advantages of the open and laparoscopic approaches.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Esophageal Carcinoma

Esophageal Carcinoma Following Bariatric Procedures • Allen JW et al. 2004;8:372-375. The effect of bariatric procedures on gastroesophageal reflux is not known. Three patients in this study developed esophageal malignancy years after the weight loss operation. It is suggested that patients who develop symptoms after bariatric procedures to induce weight loss should have endoscopic evaluation and that epidemiologic studies should be initiated to analyze the incidence of esophageal cancer following bariatric surgical procedures.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Lap-Band Surgery Outpatient

How We Perform Lap-Band Surgery Outpatient • Montgomery KF, Watkins BM. September 2004:62-65. Advantages of the outpatient approach are reviewed: reduced cost, better patient environment, smoother recovery. The surgeons walk through the pre-op process, the surgery, and the post-op process. Results and reimbursement are discussed. According to the authors, they have experienced few complications, and patients average 50% excess-weight loss after 1 year.

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Training and Credentialing for the Performance of Laparoscopic Bariatric Surgery

GAINING EXPERIENCE

DANIEL R. COTTAM, MD, SAMER G. MATTAR, MD, JEFFREY L. LORD, MD, PHILIP R. SCHAUER, MD

INTRODUCTION

Obesity is a global epidemic that currently affects over 300 million adults worldwide with over one third of them living in developing nations [1]. It is estimated that 15% of all overweight individuals have a body mass index (BMI=weight kg/height m2) greater than 35. The National Institutes of Health reported [2,3] in 1991 that any patient with a BMI>35 with a comorbid condition related to obesity or a BMI>40 without a comorbid condition is an eligible candidate for surgery. Compared with surgical therapy, no diet or medication can offer morbidly obese individuals the opportunity for successful long-term weight loss.

Therefore, because of the persistent rise in the incidence of obesity, the demand will increase for adequately trained surgeons with the skill and expertise needed to treat these patients [4] (Table 1). The aim of this paper is to review the materials, methods, and means available for surgeons interested in performing weight-loss operations to gain the needed experience to perform these complex procedures.

The first decisional steps that any surgeon must take include the following: (1) analyze the population and determine the need for bariatric surgical services; (2) determine whether he or she can be committed to life-long follow-up and care of these patients; (3) develop an infrastructure and team to support the surgical services, including trained medical assistants, primary care physicians, anesthesiologists, pulmonologists, psychologists, and other specialists as needed; and (4) decide whether he or she will perform these operations through a traditional laparotomy or using advanced laparoscopic techniques. The University of Pittsburgh’s program emphasizes that any surgeon entering this field should take the necessary measures to learn the laparoscopic approach. When compared with traditional laparotomy, the laparoscopic approach offers the patient the benefit of less perioperative morbidity and mortality and this translates into less recovery time for the patient.

Among the specific areas where less perioperative morbidity can be demonstrated with laparoscopic surgery in general are preserved pulmonary function with fewer pulmonary complications [5]; shorter episodes of postoperative ileus [6]; fewer wound-related complications, such as hematomas, seromas, infections, hernias, and dehiscences [7]; and a reduction in postoperative adhesion formation [8].

Other longer term postoperative benefits from laparoscopic Roux-en-Y gastric bypass (LRYGBP) include lower rates of wound infection, lower rates of incisional hernia formation, and higher quality of life scores for the first 6 months postoperatively [9,10]. The end result is that laparoscopic patients return to their activities of daily living much faster than those patients who undergo traditional laparotomy [10]. Although these reports are impressive in demonstrating the benefits of laparoscopy over laparotomy, it is the individual surgeon who must make the choice as to which operative approach is best suited for his or her patients and his or her abilities.

LEARNING CURVES

Whether laparoscopy or laparotomy is ultimately chosen, each surgeon should be aware that a definite learning curve is associated with these procedures. The concept of a procedure-specific “learning curve” first began in the late 1980s when higher rates of common bile duct injury were noticed with the first laparoscopic cholecystectomies done by experienced surgeons [11-13]. As new laparoscopic procedures have been developed, almost every known procedure has demonstrated specific learning curves [14-20]. Operations for obesity are no different as each one has its own learning curve.

Laparoscopic adjustable gastric banding (LAGB) is currently regarded as the simplest of the operations performed for morbid obesity. Only 1 FDA-approved device is available in the United States, the LAP-BAND®, (BioEnterics, Carpinteria, CA); however, several others are available worldwide. These devices, despite their being somewhat easier to insert surgically, nonetheless require accrual expertise. Both Chevallier et al [21] and O’Brien et al [22] noted a significant decrease in their conversion rates to open procedures as their experience increased. Chevallier et al [21] had 8 conversions in his first 50 procedures and 4 in his last 350. Similarly, O’Brien et al [22] had 5 conversions to open in his first 72 cases and none in his last 230 patients. O’Brien et al [22] also demonstrate that their rate of band prolapse decreased from 22% in their first 100 patients to 2.5% in their last 200 patients. The most convincing demonstration of the LAGB learning curve was made by Favretti et al [23]. In their first 100 patients, the major complication rate (complications requiring reoperation) was 20%. In the second 100 patients, the major complication rate was only 6%. In the next 300 patients, the major complication rate was 3.0%. In the last 300 patients, the major complication rate was zero with 97% follow-up. Despite the relative ease of LAGB insertion, achieving good placement that does not result in band slippage, malposition, or port-site complications may be far more difficult.

The most popular laparoscopic weight-loss surgical procedure performed in the United States today is the Roux-en-Y gastric bypass. This procedure is technically challenging because it requires laparoscopic skills not generally utilized in routine general surgical practices. These advanced skills include intracorporeal suturing, stapling, and 2-hand dissection techniques. The size of these obese patients also heightens the complexity of the procedure by decreasing the intraabdominal space and increasing the intraabdominal visceral fat. Patient size makes standard instrumentation inadequate in many instances. Additionally, the presence of hepatomegaly and the high incidence of previous abdominal surgery present major technical barriers to completion of the procedure laparoscopically. Many of the patients require numerous concomitant procedures, such as ventral or incisional hernia repair and cholecystectomy, that require adjunctive modalities that must also be mastered.

In a prior study conducted at the University of Pittsburgh [24], it was noted that wound infections, anastomotic leaks, operative times, and complications all decreased significantly after 100 patients. These results were mirrored by other authors [25-28] who also found a steady decrease in operative time and complications after operative experience extended beyond 100 cases.

SKILL ACQUISITION

In light of these results, it becomes obvious that many surgeons in practice today and residents in training may not have the technical expertise or proper training to care for these complex patients [29,30]. The question then becomes what is the most effective way to acquire these skill sets?

Rosser and colleagues [31] have described methods for reliably, reproducibly, and objectively evaluating surgical skill sets irrespective of prior experience. Once deficits are found, they can often be overcome with a 2-day course that reinforces objective performance criteria and monitors progress [32]. The surgeon’s progress can then be compared with that of thousands of other surgeons who have previously taken the course.

In addition to skill acquisition, it is often necessary to obtain procedural-specific educational training. This is especially true for bariatric surgery as several different procedures are done around the world as well as several different variations of those procedures, each with its own side effects and unique short- and long-term complications. An example of such a course is the University of Pittsburgh Annual Update on Morbid Obesity [33]. This course and others like it offer in a didactic format an extensive review of the various aspects of bariatric surgery. They are usually taught by world-renowned faculty and give the practitioner a succinct overview of most topics related to bariatric surgery. They last from 2 to 4 days.

These courses should not be confused with the workshop concept that was popularized in 1977. A workshop involves procedural-specific information in combination with proven animal models in teaching laparoscopic surgical methods [34]. This usually includes an 8-hour didactic lecture, half a day of animal lab, and half a day observing live surgery. These courses are tailored for surgeons already in practice who wish to begin practicing bariatric surgery and who already have some laparoscopic skills. These courses have been found highly effective at the University of Pittsburgh for a large segment of surgeons beginning bariatric surgical practices. However, these courses, in and of themselves, do not represent adequate training.

CREDENTIALING

In the United States, each individual hospital or health system governing board is responsible for granting clinical privileges at that hospital or health system [35]. The health system then forms credentialing committees that review the board certification, training, and experience of each individual applicant. Typically, board certification or board eligibility implies that the applicant is competent to perform procedures he or she was trained in. However, as seen in Table 2, most residents who are leaving residency today have not performed sufficient numbers of cases to be considered proficient in open or laparoscopic bariatric surgery. This situation also applies to surgeons who are already in practice and who wish to start doing bariatric surgery. Problems like these have led most credentialing committees to adopt criteria published by specialty boards or specialty societies [36]. For bariatric surgery in the United States, the American Society of Bariatric Surgeons (ASBS) has taken the lead in publishing guidelines for obtaining privileges in bariatric surgery (The Society of American Gastrointestinal Endoscopic Surgeon [SAGES] co-authored the statement on the granting of laparoscopic privileges in bariatric surgery) [37].

The ASBS suggests that every surgeon interested in beginning a bariatric program should attend a bariatric training course of at least 2 days, which includes both didactic teaching and a hands-on laboratory. Additionally, ASBS suggests that the hospitals require documentation of 3 proctored cases in which the assistant is a fully trained bariatric surgeon, and the completion of an approved preceptorship program. These are the same provisional requirements for both open and laparoscopic surgeons.

The statement also suggests that perioperative outcomes should be reviewed after the first 10 independent laparotomy cases or 15 laparoscopic cases. After 6 months, the surgeon’s outcome data should be compared with published outcome benchmarks in terms of patient safety and results.
Hospitals should also require the surgeon to show that his or her bariatric program has provisions for ancillary services, such as specialized nursing care, dietary instruction, counseling, support groups, exercise training, and psychological assistance. Documentation should be available indicating that a program is in place to prevent, monitor, and manage short- and long-term complications. In addition, a system should be in place to provide follow-up for all patients, with the expectation that at least 50% of the patients who receive restrictive procedures and 75% of those with malabsorptive operations will be seen on a regular basis for at least 5 years.

Just as institutions can expect performance requirements of the surgeon, so too can the surgeon expect performance requirements of the hospital. The American College of Surgeons has provided guidelines for facilities wishing to perform bariatric surgery [38]. These include specialized operating suites with tables to accommodate patients weighing up to 750 pounds, appropriate retractors, staplers, and longer instruments. Anesthesiologists should be specially trained in bariatric surgery and regularly assigned to bariatric procedures as members of the bariatric surgery team. Hospital staff with regular contact with bariatric patients should be educated on the special needs of the morbidly obese, which include intensive respiratory care regimens, assisting with ambulation, the recognition of potential problems with intravascular volume, cardiac, diabetic, and vascular conditions, and the use of special beds, chairs, and commodes. All facilities should conform to standards mandated by the Joint Commission on Accreditation of Health Care Organizations.

FELLOWSHIP TRAINING

These extensive demands placed on surgeons have led to the concept of the “mini-fellowship.” These training programs in bariatric surgery last from 1 to 6 weeks and involve all phases of bariatric education with extensive operative and outpatient clinical experience. Several such programs are now being offered throughout the United States (The University of Pittsburgh, Tufts, University of Texas Southwestern, and Mount Sinai are some of the institutions that offer these fellowships). These typically allow the surgeon enough experience to satisfy the privileging bodies of institutions, such as hospitals and societies like ASBS [37].

After completing their surgical training, residents who wish to make laparoscopic bariatric surgery their specialty often seek additional training by doing a laparoscopic fellowship. Over the last few years, laparoscopic fellowships have increased in number from 20 to 90 [39,40]. Most of these fellowships offer extensive training in laparoscopic bariatric surgery with some being “primarily bariatric.” The rise in laparoscopic fellowship opportunities coincides with the explosion in the prevalence of obesity, which in turn, has created an acute demand in the community. Many of these fellowships are 2 years in length with the first year devoted to research. This fact reflects the growing complexity of the field of bariatric surgery as well as the recognition that obesity is a condition of multiorgan dysfunction. However, for purely clinical experience, it is generally agreed that 1 year is sufficient to master the techniques needed to perform these operations. It is hoped, although not yet proven, that this new cadre of fellowship-trained surgeons will result in lower complication rates, improved outcomes, and new research that enriches the surgical treatment of obesity.

MALPRACTICE INSURANCE

One immediate benefit of fellowship training relates to malpractice insurance premiums. Prior to 2000, bariatric surgery was not recognized as a surgical subspecialty by the insurance industry. This effectively meant that any general surgeon could perform bariatric surgery without being placed in a different category than other general surgeons who did not perform bariatric surgery. However, the insurance industry realized that bariatric surgery was unique, not for the number of claims per se, but for the potential of huge awards to relatively few patients (ie, most bariatric surgical patients are young and therefore have many productive years left, thus raising the possibility of higher damage awards). This has caused the average bariatric surgeon’s premiums to be 40% to 100% higher than that of comparable general surgeons nationwide. It has also resulted in fewer companies offering bariatric surgical malpractice insurance (currently, only 2 exist, down from 5 two years ago). These companies noticed that most of the claims brought against physicians were against surgeons who performed relatively few bariatric procedures yearly. These findings have been incorporated into a pricing structure for underwriting bariatric surgeons. Typically, 5 things can lower the rates that a typical bariatric surgeon will pay. The first is the skill of the surgeon. A surgeon’s practice must demonstrate low complication rates. The lower the complication, the lower the premium the surgeon pays. This also relates to the number of procedures a surgeon does: higher volume surgeons have lower rates than lower volume surgeons. The second criterion is the number of claims against the surgeon both in terms of volume and in terms of awards. The third is the surgeon’s educational background in performing bariatric surgery, meaning a surgeon who has 10 cases proctored by an experienced surgeon will pay a much higher rate to begin doing bariatric surgery than a surgeon who has completed a laparoscopic bariatric fellowship. The fourth is whether the surgeon is a member of ASBS. The insurance industry feels that membership demonstrates that the surgeon is committed to lifelong education in the nuances associated with the surgical treatment of obesity. The last is whether the surgeon is practicing in a center of excellence, meaning that the surgeon has the support staff to adequately follow these patients and provide them with appropriate lifelong counseling. These could make a big difference in the costs of a typical retro-inception policy that currently runs between $75 to $110000 a year ($1 million per occurrence, $3 million aggregate per year with a $10000 deductible per occurrence) (Personal communication from K. Keenan of John Burnham Associates about bariatric surgical malpractice rates in the United States, April 4, 2003).

CONCLUSION

Bariatric surgery is the fastest growing field of general surgery. A definite learning curve exists for bariatric surgery in general and for laparoscopic surgery in particular. To learn the skills needed to help this population, several methods have been applied. General didactic meetings alone are insufficient to begin a bariatric surgical practice. Workshops alone may be beneficial for some surgeons. The mini-fellowship may be the ideal compromise for surgeons in practice who wish to begin a bariatric surgical practice. However, a 1-year fellowship may be the ideal training modality for those surgeons who may not have obtained sufficient skill in advanced laparoscopy during their residency. This situation applies to the majority of candidates who seek additional training in laparoscopic bariatric surgery.

Address reprint requests to: Philip R. Schauer, MD, Magee Women’s Hospital, Ste 5500, 300 Halket St, Pittsburgh, PA 15213, USA. Tel: 412 647 4162, Fax: 412 692 2144, E-mail: schauerpr@msx.upmc.edu

Fellow in minimally invasive surgery, Mark Ravitch/Leon C. Hirsch Center for Minimally Invasive Surgery at the University of Pittsburgh, Pittsburgh, Pennsylvania (Drs Cottam, Lord).

Assistant Professor, Department of Surgery, Division of Minimally Invasive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Matter).

Assistant Professor of Surgery, University of Pittsburgh; Director of Endoscopic Surgery; Director of the Surgical Weight Loss Center; Co-Director of the Mark Ravitch/Leon C. Hirsch Center for Minimally Invasive Surgery (Dr Schauer).

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9.    Nguyen NT, Wolf B. Laparoscopic versus open gastric bypass. Semin Laparosc Surg. 2002;9(2):86-93.

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11.    Deziel DJ, Millikan K, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165:9-14.

12.    Club SS. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324:1073-1078.

13.    Hunter J. The learning curve in laparoscopic cholecystectomy. Min Invas Ther Allied Technol. 1997;6:24-25.

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