Outpatient surgery is the solution at hand for reducing costs and hospital stays for pediatric surgery too: a hospital trial.

BACKGROUND: Outpatient management has proven to be the most useful method of treatment for various minimally complex surgical specialties compared to day-hospital management or ordinary inpatient processes, a fact confirmed by numerous technical documents and works in the literature. METHODS: We analyzed 27,713 surgical interventions carried out in our hospital between 2005 and 2017. This analysis included all interventions for which the indication of the level of care has moved, over the years, to an outpatient setting. We evaluated the direct costs of these services, comparing them by year and by treatment setting. RESULTS: From the analysis of costs in general, for the same number of services, a reduction of 56.6% can be seen in the comparison between 2005 and 2017. In addition, the analysis of the length of stay shows an average reduction in the number of days of hospitalization from 2.9 to 1.2 between 2005 and 2017. On the basis of a large quantity of data, our study confirms that outpatient surgery can have a significant impact in reducing costs and days of hospitalization, even in a pediatric setting, demonstrating that it is the best choice in terms of saving resources and, above all, clinical and organizational appropriateness. CONCLUSIONS: Outpatient surgery is in fact a valuable solution that provides an advantage for both the patient and his/her family, especially in the pediatric field, for the hospital and more generally for the health system as a whole.

Elective ambulatory surgical care in Ireland-why it needs to be better coded, classified and managed.

BACKGROUND: In the year to July 2017, surgical disciplines accounted for 73% of the total national inpatient and day case waiting list and, of these, day cases accounted for 72%. Their proper classification is therefore important so that patients can be managed and treated in the most suitable and efficient setting. AIMS: We set out to sub-classify the different elective surgical day cases treated in Irish public hospitals in order to assess their need to be managed as day cases and the consistency of practice between hospitals. METHODS: We analysed all elective day cases that came under the care of surgeons between January 2014 and December 2016 and sub-classified them into those that were (A) true day case surgical procedures; (B) minor surgery or outpatient procedures; (C) gastrointestinal endoscopies; (D) day case, non-surgical interventions and (E) unclassified or having no primary procedure identified. RESULTS: Of 813,236 day case surgical interventions performed over 3 years, 26% were adjudged to accord with group A, 41% with B, 23% with C, 5% with D and 5% with E. The ratio of A to B procedures did not vary significantly across the range of hospital types. However, there were some notable variations in coding and practices between hospitals. CONCLUSION: Our findings show that many day cases should have been performed as outpatient procedures and that there were variations in coding and practices between hospitals that could not be easily explained. Outpatient procedure coding and a better, more consistent, classification of day cases are both required to better manage this group of patients.

Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society.

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO2 laser transoral microsurgery or CO2 TOLMS or CO2 laser transoral surgery only (with a handpiece) would be defined as CO2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO2 wave-guide with a handpiece would be a CO2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

BACKGROUND: There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are "observed" for one or more nights. Current regulations in the United States allow these "observed" patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, "outpatient" means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data. QUESTIONS/PURPOSES: The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of "inpatient" and "outpatient" (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions. METHODS: Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed "outpatient" by the hospital. The actual hospital LOS of "outpatients" was characterized. "Outpatients" were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors. RESULTS: Of 72,651 patients undergoing THA, 529 were identified as "outpatients" but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as "outpatients" but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found "inpatient" THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with "outpatient" THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort. CONCLUSIONS: Future THA, TKA, or other investigations on this topic should consistently quantify the term "outpatient" because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Recomendaciones de pruebas preoperatorias en el paciente adulto para procedimientos en régimen de cirugía ambulatoria / Preoperative tests recommendations in adult patients for ambulatory surgery

Tradicionalmente, la valoración anestésica ha incluido una serie de pruebas de laboratorio con la intención de detectar patologías no diagnosticadas y garantizar que el paciente concurre a la cirugía bajo unos criterios de seguridad. Estas pruebas sin una indicación clínica específica suponen un gasto innecesario, de cuestionable valor diagnóstico y son en general inútiles. En el contexto de la cirugía sin ingreso, recientes evidencias sugieren que los pacientes de cualquier edad y sin comorbilidad importante, estado físico ASA I y II, no necesitan pruebas preoperatorias complementarias de forma rutinaria. El objetivo de estas recomendaciones es determinar las indicaciones generales de las pruebas a realizar antes de la cirugía en el paciente adulto ASA I y II que se va a intervenir en cirugía ambulatoria (AU)

Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status grade i and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA grade i and grade ii patients undergoing ambulatory surgery (AU)

The role of a paediatric day surgery unit at the Royal Hospital for Sick Children, Glasgow between 1993 and 2006.

A retrospective analysis was carried out on all day surgery admissions at Glasgow's Royal Hospital for Sick Children between 1993 and 2006. The aim of the study was to analyse the total number of operations per day, month and year; specialties involved; and age range of the children admitted, to examine how these factors changed over the 13-year study period. We also studied the specific operations performed in 2006 by each specialty.

Does procedure profitability impact whether an outpatient surgery is performed at an ambulatory surgery center or hospital?

Ambulatory surgery centers (ASCs) are small (typically physician owned) healthcare facilities that specialize in performing outpatient surgeries and therefore compete against hospitals for patients. Physicians who own ASCs could treat their most profitable patients at their ASCs and less profitable patients at hospitals. This paper asks if the profitability of an outpatient surgery impacts where a physician performs the surgery. Using a sample of Medicare patients from the National Survey of Ambulatory Surgery, we find that higher profit surgeries do have a higher probability of being performed at an ASC compared to a hospital. After controlling for surgery type, a 10% increase in a surgery's profitability is associated with a 1.2 to 1.4 percentage point increase in the probability the surgery is performed at an ASC.

Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report.

AIM: To present the early experience of establishing a community-funded and volunteer-staffed hospital in Christchurch, New Zealand. This was to provide free selected elective healthcare services to patients in the Canterbury region who were otherwise unable to access treatment in the public health system or afford private healthcare. METHODS: Data were reviewed relating to the establishment, financing, staffing and running of the Canterbury Charity Hospital. Details were provided of patients referred by their general practitioners who were seen and treated during the first two and a half years of function. RESULTS: Canterbury Charity Hospital Trust, established in 2004, completed the purchase of a residential villa in 2005 and converted it into the Canterbury Charity Hospital, which performed its first operations in 2007. By the end of December 2009, 115 volunteer health professionals and 79 non-medical volunteers had worked at the Hospital, provided a total of 966 outpatient clinic appointments, of which 609 were initial assessments, and performed 610 surgical procedures. Funding of $NZ4.3 million (end of last financial year) came from fundraising events, donations, grants and interest from investments. There has been no government funding. CONCLUSIONS: There is a substantial unmet need for elective healthcare in Canterbury, and this has, in part, been addressed by the recently established Canterbury Charity Hospital. The overwhelming community response we have experienced in Canterbury raises the question of whether the current public health system needs attention to be re-focused on unmet need. We contend that unless this occurs it might be necessary to establish charity-type hospitals elsewhere throughout the country.

Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes?

This study explores associations between patient outcomes (7- and 30-day hospitalization and mortality) and healthcare provider (physician and facility) volumes of outpatient colonoscopy, cataract removal, and upper gastrointestinal endoscopy performed in outpatient surgical settings in Florida. Findings indicate that patients treated by high-volume physicians or facilities had lower adjusted odds ratios for hospitalizations and mortality. When physician and facility volume were assessed simultaneously, physician volume accounted for larger effects than facility volume in hospitalization models. When assessing both physician and facility volume together for mortality, facility volume was a stronger predictor of mortality outcomes at 30 days. Further examinations of associations of outpatient physician and facility volumes and patient outcomes are suggested.

Grado de satisfacción de pacientes de traumotología programados para cirugía mayor ambulatoria / No disponible

Objetivo: Conocer el grado de satisfacción percibido por los pacientes en el proceso asistencial de traumatología en cirugía mayor ambulatoria. Material y métodos: Estudio prospectivo observacional de pacientes traumatológicos intervenidos en un programa de cirugía ambulatoria. Para ello, se diseñó una encuesta anónima con diferentes ítems que corresponden a las distintas fases del proceso asistencial. Resultados: De los 150 cuestionarios entregados, se recogieron un total de 79, lo que significa el 53% de respuestas. De estas, un 54% de los pacientes considera mejorable la información, un51% considera larga/excesivamente larga la espera desde la primera consulta de Atención Primaria hasta el diagnóstico y un 54% desde este hasta la intervención. Un 20,3% consideró la sala de espera incómoda/poco íntima y un 38% dijo lo mismo sobre el vestuario. Consideraron buena en un 94% la atención del equipo de enfermería y celadores y un 96% la atención médica en quirófano. El grado de satisfacción el día de la intervención con el servicio de admisión, quirófano y unidad de recuperación fue superior a un 90%.Conclusiones: Los resultados de este trabajo muestran que hay áreas del proceso asistencial en las cuales hay mucho margen para mejora (la información, los tiempos de espera, espacio y comodidad vestuarios), la creación de una consulta de enfermería sería una buena herramienta para este fin. Sin embargo, el grado de satisfacción global que manifestaron los pacientes, con respecto a los profesionales que les atienden durante todo el proceso asistencial en cirugía ambulatoria traumatológica, ha sido muy elevado (AU)

Objetive: To know the degree of satisfaction perceived by the patients in the welfare process of orthopedic surgery in ambulatory surgery. Material and methods: Observational market study of orthopedic patients who have undergone surgery in a program of ambulatory surgery. For this purpose, an anonymous survey was designed with different items that refer to the different phases of the welfare process. Results: A whole of 79 questionnaires were gathered out of 150delivered questionnaires, which means 53% of answers. Of these,54% of the patients consider the information could be improved,51% consider that the wait from the first consultation of Primary Care until the diagnosis is long/too long and 54% from this one until the operation. 20.3% considered the waiting room to be uncomfortable/with little privacy and 38% had the same opinion about the changing room. They considered to be good at 94% the attention of the nursing staff and watchmen and 96% considered to be good the medical attention at operating room. The degree of satisfaction on the day of the operation with the service of admission, operating room and unit of recovery, was superior to 90%.Conclusions: The results of this work show that there are areas of the welfare process in which there is a big margin for improvement(the information, the waiting times, space and comfort in the changing rooms), the creation of an infirmary would be a good tool for this purpose. Nevertheless, the degree of global satisfaction that the patients demonstrated, with regard to the professionals who attend them during the whole welfare process in ambulatory orthopedic surgery has been very high (AU)

Evaluación de la telemedicina aplicada a la cirugía ambulatoria / No disponible

Objetivo: El objetivo de este trabajo es evaluar la utilidad de un sistema de control mediante telefonía móvil en el contexto del postoperatorio domiciliario de cirugía ambulatoria. Material y métodos: Se elijen aleatoriamente dos grupos de60 pacientes intervenidos de la misma patología. A ambos grupos se les somete a una entrevista telefónica protocolizada y estandarizada. A los pacientes del grupo estudio se les entrega un teléfono móvil multimedia preprogramado para enviar imágenes desde el domicilio y un pulsioxímetro. A los del grupo control se le realiza el control telefónico convencional. Se realiza una encuesta de satisfacción. Resultados: Se realiza un incremento de un 9,1% en el número de llamadas efectivas para los pacientes con móvil. Se reduce en un 63,6% el número de visitas a urgencias con respecto a los pacientes sin móvil. El tiempo medio de control telefónico es mayor (41,40 minutos/paciente) en los pacientes del grupo piloto con respecto al grupo control (16 minutos/paciente). En cuanto acostes se observa que el ahorro producido por evitar que el paciente acuda a urgencias es de un 5,6% con respecto al grupo control. El 93,8% de los pacientes opinan que el sistema ha tenido un resultado positivo en su evolución. Conclusiones: El mayor impacto clínico del sistema es que evita en un 63,6% las visitas a urgencias de los pacientes del grupo estudio. Este hecho tiene un beneficio directo en el incremento de la calidad de vida del paciente así como en el incremento de la calidad del cuidado que recibe. También aumenta el tiempo que el personal tiene que dedicarle. Aunque el tiempo de control es mayor en el grupo piloto que en el grupo control, el sistema es un5,6% más barato que el control telefónico convencional. Además tiene una alta aceptación entre los usuarios llegando a un nivel de satisfacción del 93,8% (AU)

Objective: The goal of this study was to evaluate the use of a mobile telephone control system for post-operative follow-up after ambulatory surgery. Material and methods: Two groups of patients underwent a protocolized and standard telephone interview. Patients in the study group were given a multimedia mobile telephone, pre-programmed to send images from the patient’s home as well as a pulsioxymeter. The control group was followed through the usual telephone calls. A satisfaction questionnaire was given. Results: There is a 9.1% increase of effective phone calls for patients with a mobile phone. The number of patients seen as emergency visits was reduced 63.6% compared to patients without a phone. Median phone call time was higher (41.40 min/patient)in the pilot group compared to the control group (16min/patient). Regarding costs, there is a 5.6% reduction by avoiding patients going to emergency compared with the control group. 93.8% of patients thought that the system had a positive result on their evolution. Conclusions: The biggest clinical impact of this system is that it avoids 63.6% of visits to the emergency department of the patients in the study group. This has a direct benefit on patients’ increased quality of life and on the increase in quality of the care received. The time the care givers dedicate to each patient is also increased. Although the control time is high in the pilot group, this system is5.6% cheaper than conventional telephone control. It is also very well accepted by patients with a satisfaction index of 93.8% (AU)

The use of ambulatory patient groups for regulation of hospital ambulatory surgery revenue in Maryland.

The Maryland Health Services Cost Review Commission (HSCRC or the commission) is a government agency with the authority to establish rates for both inpatient and outpatient services for all general acute care hospitals in the state. By law and consistent with the state's unique Medicare waiver, all payers (including Medicare and Medicaid) must pay hospitals on the basis of these rates. The HSCRC has used diagnosis related groups to set case-mix-adjusted limits on the revenue per discharge for inpatient services (similar to Medicare inpatient prospective payment nationally) yet, the Maryland rate-setting system for outpatient services has not embodied incentives to control utilization of services. Beginning in the state's fiscal year 2008, the HSCRC is implementing regulation of ambulatory surgery services using ambulatory patient groups to provide better incentives to control utilization, and to facilitate comparisons of the case-mix-adjusted charges per ambulatory surgery case across hospitals. Maryland has been an innovator in the design and successful implementation of payment systems and other incentive mechanisms to constrain hospital cost, maintain payment equity, and ensure access to needed hospital care. The HSCRC's adoption of all patient refined diagnosis related groups and the hospital-specific relative value method for establishing diagnosis related group weights in 2005 was relevant to the Centers for Medicare and Medicaid Services' decision to move to Medicare severity diagnosis related groups beginning in federal fiscal year 2008, and to consider the use of hospital-specific relative value weights. The HSCRC's decision to use ambulatory patient groups for ambulatory surgery is an attempt to apply the most effective features of inpatient payment systems, prospective payment, including incentives to control service volumes. As such, it represents a radical departure from prevailing payment arrangements in that it seeks to remove the traditional distinction between inpatient and outpatient surgical services, a distinction that has blocked the development of effective and well-integrated outpatient payment systems for decades. This article describes the policy rationale for this system, the analysis that was performed, and the methods that will be used to control the revenue per case and compare the relative charges of the hospitals.

Índice de infección postoperatoria de la UCMA de un hospital comarcal, tras la implantación de la cobertura desechable en su área quirúrgica / Index of post-operative infections in the out-patient department of a hospital after implanting single use drapes in the surgical area

OBJETIVO: Determinar el porcentaje de infección postoperatoria de los procedimientos más representativos de cirugía limpia que se practican en la Unidad de Cirugía Mayor Ambulatoria de nuestro centro, antes y después de instaurar la cobertura desechable en su área quirúrgica. Describir las características de los pacientes que presenta dicha infección. MATERIAL y MÉTODO: Estudio quasi-experimental antes y después (before-after) de los pacientes intervenidos por Cirugía Mayor Ambulatoria de unos de los siguientes procedimientos quirúrgicos de cirugía limpia: hernia inguinocrural, ligadura tubárica por laparoscopia, varices y síndrome del túnel carpiano. RESULTADOS: Ha sido estudiada una muestra de 815 procedimientos quirúrgicos, 388 (47.6%) realizados mediante cobertura textil y 427 (52.4%) con cobertura desechable. El porcentaje de infección de la muestra fue de 1.7%. En el grupo de cobertura textil de 2.5% y el 1.5% en el grupo de cobertura desechable, sin ser esta diferencia estadísticamente estadísticamente significativa. No se observaron diferencias significativas entre ninguna de las características sociodemográficas y clínicas descritas, respecto a la presencia o no de infección nosocomial (AU)

OBJECTIVE: To determine the percentage of postoperative infection of the most procedures of clean surgery that take place in ambulatory surgery in our center, before and after restoring the drapes and gowns of nowoven fabric. To describe the characteristics of the patients with this infection. MATERIAL AND METHODS: Study quasi-experimental (before-after) of operated by ambulatory surgery of one of the following surgical procedures of clean surgery: hernia, laparoscopy tubaric tie, varices and syndrome of the carpian tunnel. RESULTS: A sample of 815 surgical actuations has been studied, 388 (47.6%) were surgical procedures (..) (AU)