ITH RATES INCREASINGover the last decade, 1 bariatric surgery has become the second most common abdominal operation in the United States. Despite trends toward declining mortality rates, 2 payers and patient advocacy groups remain concerned about the safety of bariatric surgery and uneven quality across hospitals. In response, 2 major professional organizations-the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery-have implemented programs for accrediting hospitals as centers of excellence (COE) in bariatric surgery. Standards for COE accreditation vary somewhat between the programs, but they generally include minimum procedure volume standards, availability of specific protocols and resources for managing morbidly obese patients, and submission of outcomes data to a central registry.Context Despite the growing popularity of bariatric surgery, there remain concerns about perioperative safety and variation in outcomes across hospitals.Objective To assess complication rates of different bariatric procedures and variability in rates of serious complications across hospitals and according to procedure volume and center of excellence (COE) status.Design, Setting, and Patients Involving 25 hospitals and 62 surgeons statewide, the Michigan Bariatric Surgery Collaborative (MBSC) administers an externally audited, prospective clinical registry. We evaluated short-term morbidity in 15 275 Michigan patients undergoing 1 of 3 common bariatric procedures between 2006 and 2009. We used multilevel regression models to assess variation in risk-adjusted complication rates across hospitals and the effects of procedure volume and COE designation (by the American College of Surgeons or American Society for Metabolic and Bariatric Surgery) status.Main Outcome Measure Complications occurring within 30 days of surgery.Results Overall, 7.3% of patients experienced perioperative complications, most of which were wound problems and other minor complications. Serious complications were most common after gastric bypass (3.6%; 95% confidence interval [CI], 3.2%-4.0%), followed by sleeve gastrectomy (2.2%; 95% CI, 1.2%-3.2%), and laparoscopic adjustable gastric band (0.9%; 95% CI, 0.6%-1.1%) procedures (PϽ.001). Mortality occurred in 0.04% (95% CI, 0.001%-0.13%) of laparoscopic adjustable gastric band, 0 sleeve gastrectomy, and 0.14% (95% CI, 0.08%-0.25%) of the gastric bypass patients. After adjustment for patient characteristics and procedure mix, rates of serious complications varied from 1.6% (95% CI, 1.3-2.0) to 3.5% (95% CI, 2.4-5.0) (risk difference, 1.9; 95% CI, 0.08-3.7) across hospitals. Average annual procedure volume was inversely associated with rates of serious complications at both the hospital level (Ͻ150 cases, 4.

With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

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Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

We have developed and validated a population-based risk scoring system for serious complications after bariatric surgery. We expect that this scoring system will improve the process of informed consent, facilitate the selection of procedures for high-risk patients, and allow for better risk stratification across studies of bariatric surgery.