Mirto Foletto, MD

Bariatric Unit - Padova University Hospital (Italy)

mirto.foletto@unipd.it

Lessons from a Week Surgery Unit

standard of careresources

3rd millennium biggest challenge

matchin'

Mainstays of bariatric practice

• Multidisciplinary discipline

• Private or Public settings

• Community or Academic Institutions

• Dedicated or intermingled wards

• Outcomes and costs

• Covering (insurance, self payer, NHS)

Bariatric procedures, on average, cost from $20,000 to $25,000

CoE policy

Accreditation should impact on outcomes and costs

THE SETTING IS THE KEY ISSUE !

healthcare = complexity

•Organizational pathologies (1)

•High variation of clinical processes•underuse of effective care, overuse of supply-sensitive care and misuse, i.e. failures to execute procedures properly

•Low reliability (failure-free operation over time) of clinical processes

••Trust paper tools, memory, and hard work••Ample tolerance toward clinical autonomy••Reliability goals not explicitly stated••Performance judged against (mediocre) averages of outcomes rather than benchmarks of processes

Organizational pathologies (2)

Lack of system thinking

little understanding of interactions between structures, processes,patterns and results; little involvement of keystakeholders, esp. front-line professionals

Lack of statistical thinkingoverreactions in front of common causes, i.e. thinking that change hasoccurred and decisions are necessary when infact there is no change

Lack of quality improvement methods messy use of fragments of improvement models

System thinkingAll work occurs in a system of inter-relatedprocesses, i.e. sets of sequential activities that turn inputs into outputs and outcomes, which affect customers

A system is heavily influenced by connectionsamong its parts, more than by the isolatedperformance of its elements; hence optimizingeach one independently can result in an evenpoorer performanceProcesses should be studied systematically visualizing them through flowcharts and measuring their important stepsEvery system is perfectly designed to get the results it gets. If we want different results, we must change the system

Statistical analysis is essential in order to turn data into useful knowledge

AIM

TO ASSESS WHETHER A MODIFICATION TO THE APPROACH OF A PATIENT CANDIDATE FOR BARIATRIC SURGERY CAN IMPACT ON OUTCOMES AND COSTS

setting: academic hospital

intermediate intentensity of care

"week surgery" ward

Methods•6-MONTH ACTIVITY PROSPECTIVE ANALYSIS OF

LSG •SINGLE SURGEON - SINGLE INSTITUTION BASED •BEFORE (GROUP A) AND AFTER (GROUP B) Wk

SURGERY UNIT ACTIVATION

VARIABLES

Operating Room Time (OR)

Hospital stay (HS)

Early complications rate (EC)

STATISTICSt-TEST FOR PARAMETRIC

Fisher for non parametric

set point p < 0.005

COSTSASSESSED ACCORDING ACTIVITY BASED COST MODEL

The "Week Surgery" model Improving care through affordability

what we had

standardized clinical pathwaypatients' selection health professionals

24-bed ward

2 ORs 8-14

10 scrub nurses

10 ward nurses

0-24 Mo-Th

Gates closed Fr 20

patients surgeons

anesthesiologists

The "Week Surgery" model Improving care through affordability

OR SLOTSwk surgerystakeholders

bariatric unit endocrine surg E-G junctionbreast unit

miscellaneousskin and SQgall bladderhernia surg

mo-wed

thu-fri

standard of care

who does what

risk management

Group AGroup A

ord wardord ward

(55 pts)(55 pts)

Group BGroup B

WS wardWS ward

(67 pts)(67 pts)

•F F 32 (58,2%)32 (58,2%) 47 (70,1%)47 (70,1%)

•M M 23 (41,8%)23 (41,8%) 20 (29,9%)20 (29,9%)

Age (anni)Age (anni) 47,2 ± 10,447,2 ± 10,4 45,5 ± 9,845,5 ± 9,8

BMI (kg/mBMI (kg/m22)) 48,4 ± 7,848,4 ± 7,8 46,9 ± 7,746,9 ± 7,7

•comorbiditiescomorbidities 7 (12,7%)7 (12,7%) 10 (14,9%)10 (14,9%)

•morbid obesitymorbid obesity 25 (45,5%)25 (45,5%) 35 (52,2%)35 (52,2%)

•Super obese Super obese 23 (41,8%)23 (41,8%) 22 (32,8%)22 (32,8%)

Previous bariatric Previous bariatric surgerysurgery

16 (29,1%)16 (29,1%) 8 (11,9%)*8 (11,9%)*

6-mos LSG outcomes by ward

Results Results

Group AGroup A

55 pts55 pts

Group BGroup B

67 pts67 pts

Operative time (min)Operative time (min) 89,3 ± 2989,3 ± 29 57,9 ± 12*57,9 ± 12*

early complicationsearly complications 10 (18,2%)10 (18,2%) 4 (6%)4 (6%)§§

Hospital Stay (days)Hospital Stay (days) 5,3 ± 2,65,3 ± 2,6 3,4 ± 0,5*3,4 ± 0,5*

** p<0,0001 p<0,0001

§§ p<0,04 p<0,04

COSTSCOSTS

OR + EC + HS

=

2000 Euros

Group A vs Group B

CONCLUSIONSCONCLUSIONS

Bariatric Surg A MODEL for elective Surgery

Patterns of care IMPACT ON:

• OUTCOMES

• PERFORMANCE

• COSTS

COE accreditation alone is not enough