Semiannual Report, March 2015 Dates of Surgery: July 1, 2013 – June 30, 2014 Released March 2015

MBSAQIP MBSAQIP is the only nationwide accreditation and quality improvement program for metabolic and bariatric surgery. MBSAQIP centers are accredited in accordance with nationally recognized metabolic and bariatric surgical standards.

MBSAQIP Standards and Pathways Manual Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2014 MBSAQIP Standards and Pathways Manual Released February 4, 2014

History In March of 2012 the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) unified their respective bariatric surgery accreditation programs. In April of 2012, centers under the ACS Bariatric Surgery Center Network (ACS BSCN) program and the ASMBS Bariatric Centers of Excellence (ASMBS BSCOE) program were extended joint MBSAQIP accreditation. All centers currently submit data to the existing MBSAQIP Data Registry.

MBSAQIP Data Registry The MBSAQIP Data Registry is the first nationwide metabolic and bariatric surgery outcomes database to produce a comprehensive, risk-adjusted report of aggregate and site-level data. Risk-adjusted reports will be available on a semiannual basis to participating centers that maintain a minimum of 80% complete 30-day patient follow-up rate.

MBSAQIP Data Registry The MBSAQIP Data Registry includes approximately 150,000 cases per year from over 700 different participating centers. The MBSAQIP Data Registry collects prospective, risk-adjusted, clinically rich data based on standardized definitions. All centers are responsible for submitting accurate, complete, and timely data to the MBSAQIP Data Registry in accordance with the MBSAQIP standards.

Other Benefits of MBSAQIP Participation CMS approved Qualified Clinical Data Registry (QCDR) - surgeons may participate in Physician Quality Reporting System (PQRS) Reporting in 2014 http://www.mbsaqip.org/?page_id=1721 The American Board of Surgery has stated that participation in MBSAQIP satisfies the requirement for surgeons to be compliant with Maintenance of Certification (MOC), Part 4 Practice Assessment http://www.absurgery.org/default.jsp?exam-mocpa

Quality Improvement Process Centers abstract data. Data are analyzed by MBSAQIP. Data are reported back to centers. Centers act on their data. Centers monitor interventions with data.

quality monitoring All centers are expected to monitor their data. Ongoing review of risk-adjusted and unadjusted outcomes and processes is critical for continuous quality improvement. Data must be reviewed by each center and compared to national comparison data.

Program Overview Includes all elective primary and revisional procedures, as well as complications and reoperations related to metabolic and bariatric surgery Uses clinical data, not administrative data Outcomes are assessed at 30 days after primary surgery (inpatient or outpatient) Highly standardized and validated data definitions Data are collected by trained data collectors Advanced data analytics and center audits ensure data quality Provides data-driven tools for clinical decision making

Data Collection Preoperative data Demographics Clinical laboratory variables Intraoperative data Surgical Profile Clinical variables and complications Postoperative data 30-day outcomes (inpatient and outpatient) Complications and discharge variables Custom fields Allows sites to create their own variables for internal tracking and evaluation

Data Available to Centers Online Reports (non risk-adjusted) Allows sites to analyze data over time by using pre‐defined indicators of quality Semiannual Reports (risk-adjusted) Provides risk-adjusted comparisons of all MBSAQIP centers regarding morbidity, reoperation, readmission, and bariatric-specific complications Data Downloads Allows sites to download all case details for selected cases

Utilizing Site Outcomes for Quality Improvement All sites have an opportunity to improve care. Even sites with “Exemplary” or “As Expected” outcomes can benefit from quality improvement efforts. Quality improvement is a multi-disciplinary effort. Collaboration with quality management, center administration, and clinical providers from all specialties promotes success.

Accessing your MBSAQIP SAR MBSAQIP SAR materials can be accessed through the MBSAQIP Data Registry Workstation under the “Reports” tab on the MBSAQIP Main Page. A list of all available documents will appear under the “March 2015 SAR” link.

Included Centers

The Semiannual Report Prepared twice a year for administrators and surgical services staff to compare their risk-adjusted surgical outcomes to other participating MBSAQIP centers. Risk-adjusted outcomes are computed for each participating center using hierarchical models and performance is evaluated as a site odds ratio (OR). An OR of 1.0 indicates your center may be doing as expected. An OR <1.0 indicates your center may be doing better than the average center. An OR >1.0 indicates your center may be doing worse than the average center.

SAR Supplemental Materials Individual Site Summary - Provides eligible participating centers with site-specific odds ratios for specific occurrences for applicable surgery types. All important site-specific semiannual report data are provided in this document. Individual Bar Plots - Provides a graphical depiction of an individual center’s odds ratio, the odds ratio confidence interval, and your outlier status against all other MBSAQIP centers included in each particular model. The range of all MBSAQIP centers OR values in the data set are also displayed. PowerPoint - Includes basic MBSAQIP information and report data. The presentation can be customized to include your center’s report results and data. Case Occurrence Reports - The case occurrence reports will give each site a list of their cases included in each SAR model. Model Reports - The Model Reports list the variables that were used for risk-adjustment in all models included in the SAR.

Semiannual Report Typically referred to as the “SAR document.” The SAR document provides an overview of the report, any important changes that take place from SAR period to SAR period, a list of all included models in the report, an overview of the included cases that appear in the report, SAR model summary reports, a glossary of all SAR-relevant statistical terms and concepts, and an overview of the statistical modeling process and odd ratios used in the report.

Individual Site Summary Report The site summary report provides critical information regarding individual site performance for each model. This document is beneficial in that all important site-specific semiannual report data are provided on a single, one-page, document.

Individual Site Bar Plot The site-specific bar plots provide a graphical description of the information contained in the site summary report. The plots allow a quick, comprehensive view of your site’s performance across all outcomes for each procedure group. In addition, the bar plots give a view of the general performance of all sites in a particular model. The images on the next slide highlight the vital features to your site-specific bar plots.

Individual Site Bar Plot (Cont.)

Case Occurrence Reports The case occurrence reports will give each site a list of their cases included in each SAR model.

Model Reports The Model Reports list the variables that were used for risk-adjustment in each of the models included in this SAR.

Director of Metabolic and Bariatric Surgery Manually fill-in MBSCR Manually fill-in

Further Assistance MBSAQIP Contact: Email: mbsaqip@facs.org MBSAQIP Website: http://www.mbsaqip.info/

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