Guideline is skirted on obesity surgeries

At least five Massachusetts hospitals continue to perform obesity surgery although they don't do enough of the operations to meet voluntary patient-safety guidelines issued more than a year ago. But now the state's largest health insurer, Blue Cross and Blue Shield of Massachusetts, plans to add teeth to the recommendations: Starting in 2007, it will no longer pay for the procedure at hospitals that fall significantly short of these and other standards.

Responding to a highly publicized patient death, a committee appointed by state public health officials urged in August 2004 that hospitals and doctors adopt strict standards for gastric bypasses and other types of increasingly popular obesity surgery. The committee recommended dozens of safeguards, including a suggestion that hospitals handle more than 100 cases per year and that individual surgeons perform at least 50 operations per year. Studies suggest that high volumes of surgeries give a medical staff experience and are associated with better outcomes and fewer medical errors.

The Globe surveyed hospitals that did not meet the volume standard in 2004 and found that at least five hospitals continue to perform obesity surgery despite treating fewer patients than recommended: Caritas St. Elizabeth's Medical Center in Boston, Morton Hospital in Taunton, Beverly Hospital, Tobey Hospital in Wareham, and Winchester Hospital.

The hospitals did between seven and 70 of the surgeries during the fiscal year that ended Sept. 30, 2005, though they defended their programs and several said they expect to exceed 100 cases by the time the Blue Cross payment policy takes effect.

The Globe did not ask hospitals whether they comply with each of the panel's other recommendations, which include how to train surgeons, what type of expertise hospital staff should have, and how to select patients.

State officials said 22 Massachusetts hospitals performed 3,040 obesity surgeries in the fiscal year that ended Sept. 30, 2004, a huge jump from the 402 operations in 1998.

Obesity surgery carries a 1 percent risk of death on average and a 1 to 15 percent risk of complications, depending on the complication, according to the committee that developed the recommendations. A recent study indicates that the risk of death is much higher for the elderly: 2 percent within 30 days of surgery and 4.6 percent within a year.

The death of Howard Reid, a 37-year-old computer technician and Harvard University security guard, in January 2004, shortly after obesity surgery at Beth Israel Deaconess Medical Center, led to formation of the panel of specialists apponted by the state. His widow has filed a malpractice lawsuit against his caregivers.

Executives at Blue Cross, which spent $20.5 million to cover obesity surgery for 1,214 members in the year ended June 2004, said it should be done only at hospitals that demonstrate high-quality care.

''We know there is a significant variability in care across Massachusetts," said Dr. John Fallon, Blue Cross's chief physician executive and a member of the committee that developed the surgery guidelines. Blue Cross, which insures 2.8 million people, plans to mail applications to hospitals next month, asking for detailed information on obesity surgery programs and giving them one year to comply with recommendations.

The debate over which hospitals should perform obesity surgery highlights several movements in the healthcare industry. Insurers increasingly are paying doctors and hospitals bonuses when they can prove they provide high-quality care or docking their pay when they don't. The Blue Cross program is a step in that direction and the first time the insurer has decided to base coverage on measures of hospital quality.

''What Blue Cross is doing is what a lot of insurance companies and even Medicare are likely to do," said Dr. John Kelly, who does obesity surgery at UMass Memorial Medical Center in Worcester.

The controversy also reflects tensions between teaching hospitals and community hospitals, where executives and surgeons said they need time to build up their programs to the recommended volumes. The committee that developed the guidelines consisted mostly of surgeons from large academic medical centers, not from community hospitals.

Of the hospitals that are not performing the recommended number of surgeries, only St. Elizabeth's is a large teaching hospital, and executives there said they expect to reach 100 cases in 2006. The hospital's surgeons did 46 obesity surgeries in the fiscal year that ended Sept. 30, and a spokeswoman said there had been no deaths and few complications.

Dr. Ray Kruger -- director of the obesity surgery program at Tobey Hospital, which performed 20 operations in the fiscal year that ended Sept. 30, 2004, and 70 in fiscal year 2005 -- said he anticipates doing 120 cases next year. He said the hospital has had no deaths or major complications. ''We took great pains to make sure we meet every single step of the guidelines."

Mark Whitney, a spokesman for Winchester Hospital, said that even though the hospital did only 61 obesity operations in the fiscal year that ended Sept. 30, executives will make the point when applying for Blue Cross coverage that caseload is only one indicator of quality. The hospital, he said, has a ''multidisciplinary team" of caregivers and has hired another surgeon, which will push up patient volume. He said the hospital's mortality and complication rates are within the average, but he would not say what those are.

Morton Hospital spokeswoman Dori Bingham said the research on volume and quality is not as straightforward as it seems. She said that the studies have focused on higher-risk patients, such as extremely obese males over 55 years old, and that the hospital's obesity surgeon, Dr. Bruce Bodner, refers such patients to larger academic medical centers for surgery. He did 10 cases in the fiscal year that ended Sept. 30, she said, and has had one death among the 180 patients he has operated on in the past 10 years.

At Beverly Hospital, which has the smallest program, surgeon Thomas Johnson said Blue Cross's decision is ''unfortunate." He said the hospital needs time to build its program, which started 2 1/2 years ago and handled seven cases in the fiscal year that ended Sept. 30. ''It's hard to come from the community," he said, ''and deal with big city guidelines."

He said the program has had no deaths or major complications. Johnson acknowledged he does not meet the committee's recommendations for training -- successful completion of 10 cases while being monitored by a senior surgeon who is expert in weight loss surgery -- but noted that he had extensive training in obesity surgery during residency.

Mount Auburn Hospital in Cambridge and Caritas Good Samaritan Medical Center in Brockton suspended their obesity surgery programs in the last two years when their surgeons left. Saint Anne's Hospital in Fall River suspended its program because it could not meet the state guidelines, executives said.

Dr. George Blackburn, a physician at Beth Israel who cochaired the state committee, applauded the new Blue Cross policy, but said hospitals that meet all other guidelines should be given time to meet caseload requirements.