Ambulatory surgery: an overview

Budget impact analysis of the new reimbursement policy for day surgery in Thailand

Introduction

In 2017 the Thai Ministry of Public Health proposed a new financing mechanism to promote day surgery under the Universal Coverage Scheme – the main public insurance arrangement for Thais. The key feature of the policy is health facilities performing day surgery can claim the treatment expense based on relative weight (RW) instead of adjusted RW (adjRW). Procedures for 12 diseases (so-called “candidate procedures”) are eligible for the new reimbursement. The objective of this study was to assess the current day surgery situation in Thailand and analyze potential budget impact from the new policy.

Methods

A quantitative cross-section design was employed. Individual inpatient records of the Universal Coverage Scheme during 2014–2016 were analyzed. Descriptive statistics and simulation analyses were applied. The analyses were divided into three subtopics: 1) case volume and expense claim, 2) utilization across facilities, and 3) case mix index and budget impact.

Results

Overall, day surgery accounted for 4.8% of admissions with candidate procedures. Inguinal hernias, hemorrhoids, and common bile duct stones caused the largest sum of admission numbers and admission days. Currently, the annual reimbursement for candidate procedures treated as inpatient cases is around 290.8 million Baht (US$ 8.8 million), with about 12.4 million Baht (US$ 0.38 million) for day surgery cases. If all candidate procedures were performed as day surgery and diagnostic-related groups (DRG) version 6 was applied, the incremental budget would amount to 1.9 million Baht (US$ 58,903).

Conclusions

The new reimbursement policy will likely lead to minimal budget burden. Even in the case of maximal uptake of the policy, the needed budget would increase by just 15%. The marginal budget increment was explained by the infinitesimal RW–adjRW difference. Apart from the financial measure, other qualitative aspects of the policy, such as infrastructure and health staff readiness, should be explored.

Satisfactory Analgesia with Minimal Emesis in Day Surgeries (SAME DayS): a protocol for a randomised controlled trial of morphine versus hydromorphone

INTRODUCTION

There has been an exponential increase in the number of ambulatory surgeries (AS). Pain and postoperative nausea vomiting (PONV) affects the recovery, discharge and overall satisfaction of patients having AS. Opioids remain the primary modality for moderate to severe pain. Since there is no perfect opioid, physicians should ideally use the opioid that optimally balances benefits and risks. Present decisions on the choice between morphine (M) and hydromorphone (HM) are based on individual experience and observation. Our primary objective is to compare the proportion of patients having AS achieving satisfactory analgesia without significant PONV when using M compared with HM. Secondarily we will compare the proportion of patients with adverse events, analgesic used, patient satisfaction, time to discharge and postdischarge symptoms.

METHODS AND ANALYSIS

This is a two-arm, multicentre, parallel group, randomised controlled trial of 400 patients having AS. Eligible patients undergoing AS of the abdominal and pelvic regions with a potential to cause moderate to severe pain will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomised to M or HM. Patients, healthcare providers and research personnel will be blinded. Study interventions will be administered in the recovery using equianalgesic doses of M or HM in concealed syringes. Patients will be followed in hospital and up to 3 months. Intention-to-treat approach will be used for analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton integrated research ethics board. We plan to publish our trial findings and present our findings at scientific meetings.

TRAIL REGISTRATION NUMBER

NCT02223377; Pre-results.

Intravenous versus inhalational anaesthesia for paediatric outpatient surgery

BACKGROUND

Ambulatory or outpatient anaesthesia is performed in patients who are discharged on the same day as their surgery. Perioperative complications such as postoperative nausea and vomiting (PONV), postoperative behavioural disturbances and cardiorespiratory complications should be minimized in ambulatory anaesthesia. The choice of anaesthetic agents and techniques can influence the occurrence of these complications and thus delay in discharge.

OBJECTIVES

The objective of this review was to evaluate the risk of complications (the risk of postoperative nausea and vomiting (PONV), admission or readmission to hospital, postoperative behavioural disturbances and perioperative respiratory and cardiovascular complications) and recovery times (time to discharge from recovery ward and time to discharge from hospital) comparing the use of intravenous to inhalational anaesthesia for paediatric outpatient surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 8); MEDLINE (1948 to 1 October 2013); EMBASE (1974 to 1 October 2013); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) (1982 to 1 October 2013). We also handsearched relevant journals and searched the reference lists of the articles identified.

SELECTION CRITERIA

We included randomized controlled trials comparing paediatric outpatient surgery using intravenous versus inhalational anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. When necessary, we requested additional information and clarification of published data from the authors of individual trials.

MAIN RESULTS

We included 16 trials that involved 900 children in this review. Half of all the studies did not describe the generation of randomized sequence and most studies did not describe adequate allocation sequence concealment. The included studies showed variability in the types and combinations of drugs and the duration of anaesthesia, limiting the meta-analysis and interpretation of the results.For the induction and maintenance of anaesthesia there was a significant difference favouring intravenous anaesthesia with propofol; the incidence of PONV was 32.6% for sevoflurane and 16.1% for propofol (odds ratio (OR) 2.96; 95% confidence interval (CI) 1.35 to 6.49, four studies, 176 children, low quality evidence). The risk of postoperative behavioural disturbances also favoured intravenous anaesthesiaas the incidence was 24.7% for sevoflurane and 11.5% for propofol (OR 2.67; 95% CI 1.14 to 6.23, four studies, 176 children, very low quality evidence). There were no differences between groups in the risk of intraoperative and postoperative respiratory and cardiovascular complications (OR 0.75; 95% CI 0.27 to 2.13, three studies,130 children, very low quality evidence) and there was no difference in the time to recovery from anaesthesia and discharge from hospital. These results should be interpreted with caution due to heterogeneity between studies in the type and duration of operations, types of reported complications and the high risk of bias in almost all studies. Two studies (105 participants) compared halothane to propofol and showed heterogeneity in duration of anaesthesia and in the type of ambulatory procedure. For the risk of PONV the results of the studies were conflicting, and for the risks of intraoperative and postoperative complications there were no significant differences between the groups.For the maintenance of anaesthesia there was a significant difference favouring anaesthesia with propofol, with or without nitrous oxide (N2O), when compared to thiopentone and halothane + N2O (OR 3.23; 95% CI 1.49 to 7.02, four studies, 176 children, low quality evidence; and OR 7.44; 95% CI 2.60 to 21.26, two studies, 87 children, low quality evidence), respectively. For the time to discharge from the recovery room, there were no significant differences between groups. The studies were performed with different ambulatory surgeries and a high risk of bias.Four studies (250 participants) compared the induction of anaesthesia by the inhalational or intravenous route, with inhalational anaesthesia for maintenance, and found no significant differences between groups in all outcomes (the risk of PONV, behavioural disturbances, respiratory and cardiovascular complications and time to discharge from recovery room). Meta-analysis was not done in this comparison because of significant clinical heterogeneity.Readmission to hospital was not reported in any of the included studies. No other adverse effects were reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether intravenous anaesthesia with propofol for induction and maintenance of anaesthesia in paediatric outpatients undergoing surgery reduces the risk of postoperative nausea and vomiting and the risk of behavioural disturbances compared with inhaled anaesthesia. This evidence is of poor quality. More high-quality studies are needed to compare the different types of anaesthesia in different subsets of children undergoing ambulatory surgery.

Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005

OBJECTIVE

Day case surgery is safe and offers potential benefits to both patients and healthcare providers. This study aimed to describe national changes in colorectal day case workload between 1998 and 2005.

METHODS

Admission data relating to Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) (OPCS-4) coloproctology operation codes were analysed using the Hospital Episode Statistics (HES) database. Day case rates (DCRs) were calculated as the proportion of elective cases performed on an ambulatory basis.

RESULTS

In total, 3 119 058 colorectal admissions were recorded on the HES database between 1998 and 2005; 1 891 474 (61%) of these were for lower gastrointestinal endoscopies. Emergency cases accounted for 527 665 (17%), elective inpatient cases for 406 368 (13%) and elective day cases for 293 551 (9%) admissions. Throughout the study period the DCRs for five commonly performed elective colorectal procedures were: 0.70 for anal lesion excisions (OPCS-4 codes: H48.1, H48.2 and H48.3); 0.16 for haemorrhoidectomy (OPCS-4 code: H51.1); 0.63 for anal fissure procedures (OPCS-4 codes: H56.2 and H56.4); 0.39 for elective procedures for anal fistula (OPCS-4 codes: H55.1, H55.2, H55.3 and H55.4); 0.37 for elective pilonidal surgery (OPCS-4 codes: H59 and H60.2). Two emergency operations, drainage of perianal and pilonidal abscesses (OPCS-4 codes: H58.2 and H60.3 respectively), were identified as operations potentially amenable to day surgery. Over the seven study years, an annual average of 8559 (+/-SD 307) admissions were coded to drainage of a perianal abscess and 4676 (+/-SD 478) admissions to drainage of pilonidal abscess. The average annual bed usage associated with these procedures was 18 831 (+/-SD 718) and 7623 (+/-SD 436) bed days respectively.

CONCLUSIONS

Colorectal day case surgery is currently under-exploited in the NHS. By lifting some of the barriers to day case surgery significant resource savings may be possible.

Multimodal approach to rapid discharge after endoscopic thoracic sympathectomy

BACKGROUND

After a large experience (more than 10 years) with bilateral endoscopic thoracic sympathectomy (ETS) surgery on an outpatient basis, we studied prospectively a multimodal approach to rapid discharge patients undergoing this procedure.

METHODS

One hundred and seventeen consecutive patients, aged 13-60 years, ASA physical status I or II, undergoing outpatient ETS under general anaesthesia were enrolled in this study. All patients were managed using a predefined multimodal clinical care protocol consisting of a general balanced anaesthesia. Basic demographic information was collected from each patient. Duration of surgery and anaesthesia and times to PACU and home discharge were recorded as well as intraoperative and postoperative complications like nausea and vomiting.

RESULTS

Surgery took 41.4 +/- 22.1 min and anaesthesia lasted 63 +/- 21.5 min. Time between induction of anaesthesia and beginning of surgery and end of surgery to extubation was 15.0 +/- 2.0 and 7.2 +/- 3.1 min, respectively. It took 4.9 +/- 1.5 min from extubation to OR discharge. Time from PACU arrival to discharge was 12.8 +/- 6.3 min. Time of hospital stay was 132 +/- 18 min. No patient experienced vomiting and two had nausea, representing an incidence of 1.7%. The only anaesthetic cause for hospital admission was a severe allergic reaction.

CONCLUSION

Multimodal management to rapid discharge after ETS surgery did result in a short time to patient discharge. We confirm that endoscopic thoracic sympathectomy can be performed safely on an outpatient basis with brief postoperative hospital care and a low rate of complications.

Perioperative Plasma Concentrations of Stable Nitric Oxide Products Are Predictive of Cognitive Dysfunction After Laparoscopic Cholecystectomy

In this study our objectives were to determine the incidence of postoperative cognitive dysfunction (POCD) after laparoscopic cholecystectomy under sevoflurane anesthesia in patients aged >40 and <85 yr and to examine the associations between plasma concentrations of i) S-100beta protein and ii) stable nitric oxide (NO) products and POCD in this clinical setting. Neuropsychological tests were performed on 42 ASA physical status I-II patients the day before, and 4 days and 6 wk after surgery. Patient spouses (n = 13) were studied as controls. Cognitive dysfunction was defined as deficit in one or more cognitive domain(s). Serial measurements of serum concentrations of S-100beta protein and plasma concentrations of stable NO products (nitrate/nitrite, NOx) were performed perioperatively. Four days after surgery, new cognitive deficit was present in 16 (40%) patients and in 1 (7%) control subject (P = 0.01). Six weeks postoperatively, new cognitive deficit was present in 21 (53%) patients and 3 (23%) control subjects (P = 0.03). Compared with the "no deficit" group, patients who demonstrated a new cognitive deficit 4 days postoperatively had larger plasma NOx at each perioperative time point (P < 0.05 for each time point). Serum S-100beta protein concentrations were similar in the 2 groups. In conclusion, preoperative (and postoperative) plasma concentrations of stable NO products (but not S-100beta) are associated with early POCD. The former represents a potential biochemical predictor of POCD.