B. D. Boodaie1, A. H. Bui1, D. L. Feldman1,2, M. Brodman1, P. Shamamian3, R. Kaleya4, M. Rosenblatt1, D. Somerville2, P. Kischak2, I. M. Leitman1 1Icahn School Of Medicine At Mount Sinai,Surgery,New York, NY, USA 2Hospitals Insurance Company,New York, NY, USA 3Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA 4Maimonides Medical Center,Brooklyn, NY, USA
Introduction:
The surgical management of obese patients is very complex and plagued with relatively high rates of postoperative complications. In 2012, a perioperative care map for obese patients was developed with the goal of eliminating these disparities in outcomes. The care map expanded best practices and precautions already used for bariatric patients to obese patients undergoing all types of surgery. The care map calls for a supplemental consent form, various perioperative medical assessments including nutritional and mobility assessments, more stringent guidelines for anesthetic care, the availability of bariatric medical equipment, and evaluation for anticoagulation among other items. In 2013, the care map was implemented at four major urban teaching hospitals, which required its use for morbidly obese patients undergoing all types of surgery. By 2015, surgeons and anesthesiologists reported a significant change in their management to match best practices while random audits showed 98% care map compliance. Here, the impact of these behavioral changes on patient outcomes was evaluated.
Methods:
National Surgical Quality Improvement Program (NSQIP) data was collected for 2013 and 2015 from four urban teaching hospitals that implemented the care map. Morbidly obese patients that met hospital criteria for care map implementation were identified; this criteria is defined as BMI>=40, or BMI>=35 with diabetes or hypertension. 30-day outcomes for morbidly obese patients between 2013 and 2015 (before and after mass implementation) were compared. To control for secular trends in care quality in these hospitals caused by factors other than care map usage, changes in these metrics for morbidly obese patients were compared to those for non-obese patients.
Results:
Of 11,117 surgical cases reviewed in 2013, 16.5% were morbidly obese; of 10,417 cases reviewed in 2015, 17.7% were morbidly obese. For morbidly obese patients, rate of return to operating room (ROR) decreased from 3.3% to 1.7% (p=0.002). Unplanned readmission rate decreased from 7.0% to 4.0% (p<0.001). Average length of stay (LOS) decreased from 3.7 to 2.8 days (p<0.001). Using multivariate analyses that adjusted for differences in patient demographics and preoperative variables between 2013 and 2015, significant decreases were found for morbidly obese patients in ROR (OR=0.47, p=0.002), unplanned readmission (OR=0.59, p<0.001), and LOS (-0.81 days, p<0.001). The decrease in unplanned readmission rate was 28.9% greater for morbidly obese patients than for non-obese patients (p=0.04). LOS for morbidly obese patients decreased by 0.81 more days compared to non-obese patients (p<0.001).
Conclusion:
Unplanned readmission rate, ROR rate, and LOS significantly decreased in morbidly obese patients between 2013 and 2015. Implementation of the obesity care map may have contributed to these favorable outcomes. This care map should be further investigated and considered for more widespread use.