Marc Michalsky, MD - 2024 Pediatric Bariatric Surgery Update Course

I'm uh glad to introduce our next speaker, Mark Mikowski, from Nationwide Children's. He's also been in the, in, in this space for a lot of years, probably going on more than 15 years now. Um, it was one of the early adopters of the, uh, the band, I remember. But, um, has gotten off that bandwagon and is, uh, is now, um, you know, doing still a lot of uh uh sleeves like the rest of us, but he's also been very involved in the American College of Surgeons MBSAQIP program, trying to see what makes sense of the All of the program criteria and standards for uh adolescent programs and so uh we're really honored to have him here. He's unfortunately at 30,000 ft right now and couldn't quite get a good Wi Fi connection there, so he recorded and uh, so, uh, take it away, Mark. For the invitation to present uh an update uh and current status on metabolic and bariatric surgery accreditation and quality improvement, and obviously within the context of uh pediatric bariatric surgery. These are my disclosures. Um, over the next few minutes, um, I hope to just go through a very brief, uh, history of the development of national metabolic and bariatric Surgery standards and accreditation. Touch base uh in terms of just some of the basic programmatic elements and, uh, related resources that uh serve as the foundation for this program and, um, give you a quick snapshot of the current status of MBSAQIP, which is Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, including uh where PES falls into this whole big picture. And then finally, uh, wrap up. Um, with some specific points on consideration for where pediatric programs fit into this paradigm and what the future may or may not hold. When we talk about centers of excellence, I, I think the history is actually a little important here because we do owe really a debt of gratitude to our adult bariatric surgical colleagues. And so in and around the time frame of 2004 to 2005, because of public and professional concerns related to patient safety, ASMBS really charged itself with the development of a Centers of Excellence or COE framework. Remember, COE is a common A term that was used back in the early 2000s, and we really have Ken Champion and Walter Porre to thank for putting this all together within the context of a consensus conference that was held in 2004 and that specifically was meant to address these issues, and they wrote a very nice treatise. Which is referenced at the bottom here and soared in 2005. And among the structural elements that that were really delineated, they really made the argument that COE provided a means to identify bariatric surgery programs here in the United States that provide comprehensive and standardized care and long-term follow-up. And that it would also serve as a way to report and compile patient outcomes within the within the context rather of a national registry which would provide an opportunity to assess and verify risks and benefits of this type of therapy. Also, at the same time, the American College of Surgeons had a very similar plan, and really what was happening where there were two parallel but completely separate programs that were in development at the same time. And there's some politics around this that really I think are not relevant for this type of talk. But the principles of both of these programs, even though they were independent, were, were, you know, effectively. That being surgical leadership, a multidisciplinary care model, and development of a national registry. Organizational elements that made up the foundation of these two programs were again very similar and predicated on similar but, but, you know, somewhat different case volume requirements and institutional structural elements that needed to be in place. Between 2005 and 2012, while both of these systems were maturing. Major payers really took notice, I think, in part because of some of the reduction in mortality that was attributable to the presence of this type of national accreditation framework, and they effectively declared that authorization for bariatric surgical care really in many instances needed to be done in accredited centers. So, um, flash forward, flash forward a little bit, a little bit later to about 2012 and ASMBS and ACS decided to combine forces, which was a great idea. And this is really where the concept of where do pediatrics fall into this whole equation really started to take root. And again, we owe a lot of gratitude. Uh, to these folks on your screen, including Robin Black Blackstone, who led this merging of these two programs and really was quoted as saying we're going to incorporate pediatrics, which I can tell you from personal experience being involved was not an easy thing to do because to Robin's point, it was the right thing to do. Um, so thanks to Robin. In 2014, MBSAQIP was released and it has undergone a number of iterations over the last several years. In combination with the ASMBS best practice guidelines led by Janie Pratt and others, this whole structure, not only serving as a framework, but specifically for pediatrics has informed a number of more recent and very, very important documents, including the recent policy statement. from the American Academy of Pediatrics as well as the recently released clinical practice guidelines, uh, which really has, um, uh, brought bariatric surgery in the pediatric world front and center, as I'm sure many of you know. The framework for MBSAQIP is simply a series of standards that include institutional and administrative commitment, program scope and governance, facilities and equipment. Resources, personnel, and services that are required, patient care in terms of expectations and related protocols, data surveillance and systems, quality improvement and professional and community outreach as far as educational aspects. All of these are measured and accounted for during regularly scheduled site visits across centers. In terms of a snapshot, right now there are about 958 accredited programs throughout the United States, of which, and you know, for the purposes of our interest. Uh, there are 109 programs that represent adult care with adolescent designation in addition, that represents 11% of all centers, and then an additional 7, freestanding children's hospitals where adolescents only are, um, are able to get bariatric surgery representing about 1% of total. In terms of the pediatric volume, to just give you an idea, a recent snapshot that I did very informally over the last several years, um, shows that volume seems to be increasing within the registry itself. If you look at the year that just closed out 2023, coming up with a predicted extrapolation based on the months that we do have locked in the database, we're approaching 500 cases within the database. And again, this is done. These cases are accounted for by adult programs that have adolescent designation, including some pediatric, you know. Formed pediatric enterprise around it and some of, some of whom may be represented during this meeting as well as the seven freestanding children's hospitals. But the real opportunity and you know, really what I would like to impart in part of this meeting is the rest of the centers that are doing a high quality, high volume work that are not part of MBSA QIP. And again, you know, I would say that the push is Uh, to, um, get everybody, uh, you know, into the same boat so that we can make the most power of this kind of program. Um, why should pediatric centers join NBSAQIP? I've already mentioned organizational accountability. What does that mean? I mean, it really translates into, um, having an institution be committed to providing the resources, uh, and equipment that are required to provide safe, um, uh, safe and timely care for our patient population. The centralized database that I've mentioned, this is more than just an academic practice and a way to publish patients, rather public, publish, published papers. You know, this type of database allows for the generation of risk adjusted institutional-specific data analysis. So on a biquarterly basis, every center receives a risk-adjusted report. That looks at the most common measurable outcomes as you can see here, and these types of outcome actually inform required QI projects and initiatives using standard, you know, PDSA or QI framework to do these kinds of initiatives. Just a quick example here is the development of ERAS at Nationwide Children's Hospital. Well, I think we definitely served our patients better. We showed a reduced hospital length of stay as well as reduced opioid use as a part of that project, and one of the many projects we've, uh, we've had to be involved with. You know, last but not least, of course, access to care. We all know that access to care for the pediatric population is quite challenging, and what I would point to is age less than 18 is cited as the most common reason for denials. Put that into context with what I've Already alluded to in terms of major payers requiring MBSAQIP accreditation for adult programs. What does this mean for the pediatric programs moving forward? It still is unclear. And you know, the last word I would say about this is that we know bariatric surgery is really front and center now. American Academy of Pediatrics has really stepped up and made this a widely disseminated therapeutic. Paradigm, at least in terms of education about it. It would seem quite likely that major payers are going to pay attention to this, and in fact they've been asked to pay attention to this. What that means for authorization framework moving forward again has yet to be really fleshed out. And will they require MBSAQIP accreditation for all pediatric centers? Again, it's a big unknown. So in conclusion, you know, pediatric metabolic and bariatric security accreditation is well established. It continues to grow. There's a significant number of high volume centers that remain unaccredited, and that's really an opportunity, I, I believe. Key benefits of accreditation include institutional support, risk adjusted outcome analysis, and national registry participation for the reasons that I've pointed out briefly. Future requirements for MBSAQIP accreditation at freestanding children's hospitals is uncertain. Thank you. Again, I'm sorry I couldn't be here. And of course, uh my contact information is below. Please feel free to reach out for me if you have more questions or need some guidance, uh, if you're considering joining NBSA QIP. Thanks and I hope everybody enjoys the rest of the meeting. Hey, good morning. Thanks, Mark. That's, uh, definitely the fastest presentation, uh, I think I've ever heard you give, and so much appreciated, um. Uh, so reactions, uh, Mark isn't here to defend himself nor to, uh, answer for himself. So, um, it looks like he's here. I, I, I, I actually am waiting to board a flight. So, uh, thanks, thanks for, thanks for the compliment on my speedy, on my speedy talk, but I can take a couple of questions. So, so, Mark, Mark, I, I have a question. So, tell me, so I'm one of those centers, and full disclosure, we're trying to get ready, uh, to submit, but Tell me why I should do this. What's, what's the, what's the compelling reason and why? What do I tell my hospital administra administrators when you tell me how much it costs? That was the last slide. You made it on the last slide there, yeah, to submit the application. Yeah, I, so thanks, uh, and, you know, and I think I, I, I sort of alluded to it a little bit, but, but let me just start by reiterating, I think to me, in my mind, the biggest, the biggest unknown and the biggest question mark here is what are payers going to do? I mean, you know, and your guess is as good as mine, and we've tried to have conversations with folks at CMS about this and various other places. I can tell you from personal experiences having been. You know, leading an accredited center for, you know, for many, many years now, we have gotten patients from other centers that have been denied by their payer because the, the, you know, the institution that they went to was not ASM was, was not MBSA QIP accredited, and I think that that is, you know, that's a signal to me, you know, I don't, I don't have any more insight than anybody else here, but it, it certainly is concerning, and I guess to, to, to summarize it. You know, in brief, I would say that my assumption is that at some point, um, payers are going to get wise, uh, to what's going on here, and they're going to turn around and, um, and, and probably apply the same sort of approach that they've widely applied, you know, in the adult world. So that's, that's, I think, first and foremost secondarily, you know, again, I think, and, and, and now I'm speaking from the vantage point. Someone who's been doing site reviews for over a decade, you know, we are all at these big children's hospitals that all, you know, get it more or less, but you know, I can tell you, and some of these people may be on this call right now, you know, there are some children's hospitals that conceptually, I think are, are, are not as free flowing with the resources that are required to to do these, to do. These operations into, you know, to set up a safe service, you know, within your organization so I think that in terms of your hospital and the leadership of, you know, asking them to commit to this really, um, requires that they live up to, you know, these 8 standards, including, and not the least of which is to make, um, all of the uh required. Uh, uh, equipment, uh, and resources available within your organization, which is, uh, you know, everybody knows costs money, um, and I can tell you that, that's, that's not a given everywhere, even though, um, for many of us on, on, you know, uh, at least for, you know, for the core people here. Uh, that, that's a given. I don't think that's a given everywhere. So, Mark, my producers, my producers telling me I gotta pull the hook out. So, yeah, let me, let me say one last thing. Let me, let me say one last time until now. Let me say 11 last thing while the hook is pulling me off. The price is high, um, but you know, we, we are involved in active discussions on how to accommodate for pediatric programs. So stay tuned. I think the price is gonna wind up coming down. Excellent. Good. Awesome. Thank you. We're gonna go to break and uh thanks to our sponsors uh for being here with us.