Incentives for the Expansion of Day Surgery

Day Surgery Article
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Review Status	SR
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Incentives for the Expansion of Day Surgery

Lindsay Roberts, FRCS FRACS

Chairman, Australian Day Surgery Council, 1990 – 2000

President Elect, International Association For Ambulatory Surgery 1999

Introduction

Incentives for the Expansion of Day Surgery has been prepared by the National Day Surgery Committee as a stimulus for the expansion of day surgery in Australia. It will be widely distributed to the medical profession, organisations involved in the delivery of health care, Government and other interested parties.

The Committee has sought the support of the Hon. Brian Howe, Minister for Health, Housing and Community Services, for the initiatives addressed in the Paper.

Day surgery will only expand to reach its potential if there is energetic support from all those involved in the delivery of health care, especially procedural services.

History

Day surgery his been carried out in Australia for many decades, but until relatively recently it was uncoordinated and integrated with overnight stay hospital procedures.

In the United States, highly organised sophisticated day surgery services rapidly developed following the construction of Surgicentre in Phoenix, Arizona, 1974, by Dr Wallace and Dr Reed, Australia has been slow to react and it was not until 1982 that the first modern sophisticated freestanding day surgery centre was established – Dandenong Surgicentre (Dr George Tippett). Three further free-standing day surgery centres had been established by 1985. However since then they have steadily increased in number. Private Hospitals, and to a lesser extent public hospitals, have also encompassed the day surgery principle by developing day surgery units within their hospitals.

The extent of day surgery in Australia has also lagged behind. In the United States it is recorded that forty per cent of surgical procedures are carried out as day surgery and in some centres higher figures are quoted.

In Australia statistics are not readily available, but it is generally accepted that only approximately twenty to twenty five per cent of procedures are carried out as day surgery.

In 1980 a combined initiative of the Australian Association of Surgeons and the Royal Australasian College of Surgeons resulted in the establishment of a Working Party on day surgery and the first manual of Standards “Report and Recommendations on Day Surgery” was published in 1981. A revised edition was published in 1987.

In 1985 the Working Party was formalised as the National Day Surgery Facility Standards Committee, a quadripartite committee with representatives of the Royal Australasian College of Surgeons, Faculty of Anaesthetists of the Royal Australasian College of Surgeons, the Australian Association of Surgeons and the Australian Society of Anaesthetists. In 1988, prompted by the expansion of day surgery and a necessity to address aspects of day surgery other than standards, the Committee changed its name to the National Day Surgery committee.

During 1990 two important Expanded Groups were formed – Speciality group and Medico/Economic Group and as such the National Day Surgery Committee is the most informed advisory body on Day Surgery in Australia.

Principles

The National Day Surgery Committee recognises that day surgery in Australia has not reached its full potential and is considering incentives for its expansion.

The Committee also appreciates that day surgery should not be considered in isolation but must be integrated with other health care procedural services, office based and overnight hospital admission.

With the expansion of day surgery, which might ultimately extend to approximately fifty percent of procedural services, certain fundamental principles are recorded.

• The Committee considers that office based procedures (Type C procedures) might be defined as those procedures which are suitable to be carried out in General or Specialist medical practitioners surgeries and seldom require the use of hospital or registered freestanding day surgery facility operating theatres to ensure patient safety and high quality of medical service.
• The Committee strongly believes that the expansion of day surgery should occur by the inclusion of suitable procedures currently treated as overnight stay hospital patients, not those deemed appropriate as office based procedures.
• An appropriate system of health insurance rebates must be developed to stimulate day surgery. The consequent cost saving will significantly assist in the availability of high quality health care.

Preamble

Although the following comments are directed to day surgery and endoscopy, the observation could equally apply to day medicine, psychiatric and obstetric services.

The many advantages of day surgery are well documented and the high standard of care, safety and efficiency of this service to patients has been established. Before considering specific incentives to stimulate its expansion in Australia, a brief general overview of day surgery as it affects those involved is worthwhile.

The quality of care to, and safety of, patients is as high in day surgery as ovenight(s) stay hospital services and there are very few disadvantages, with the most important proviso that selection of patients must remain the responsibility of the advising surgeon and/or anaesthetist. This has been recognised and recorded by the Federal Minister for Health, Housing and Community Services the Hon. B.L. Howe M.P. (speech to Victorian Committee, AAS, August 1990).

The more minor day surgery procedures, amongst which are some of those most frequently carried out, are suitable for office based operating theatres, incorporated in general and specialists consulting rooms. These are included in the list of Type C procedures with a provision that patients are eligible for overnight and day only rebates where the advising medical practitioner certifies that admission is necessary for medical or some other appropriate reason(s). It is important that these procedures continue to be carried out as office based procedures, not as day only or overnight(s) stay services, and a proper level of remuneration (and rebates) is essential to achieve this end. The overall financial and economic advantages of office based services are obvious, particularly to health insurance funds and Government.

The majority of day surgery procedures are carried out in specific centres or units which may be freestanding or associated with hospitals, private and public. Again, the financial and economic advantages are obvious. Although costs are significantly higher than office based services they are, nevertheless, much less costly than ovenight(s) stay hospital services. Free-standing day surgery (endoscopy) centres are less costly as their services are provided during normal weekday working hours and do not provide twenty four hour/seven days per week services, as is required in hospitals. The great majority of freestanding centres are in the private sector (there are a few physically and administratively independent day only centres in public hospitals). It has been stated that approximately ninety per cent of hospitals provide highly organised day surgery services, and some of these have independent day surgery units.

The financial advantage of day surgery in private hospitals has been the subject of debate, as income is reduced where patients do not occupy overnight beds. This is offset, however, by the high cost of overnight, weekend and holiday services, which are not incurred where patients are treated in day surgery. There is potential for further advantage by increased through put of patients.

The advantages of day surgery to health insurance funds, in particular hospital insurance, is unquestioned. There is obviously a considerable saving where patients are treated without overnight admission and the extension of day surgery services could only assist in containing health (hospital) insurance contributions. Maximum saving, of course, is achieved where patients are treated in consulting room surgeries and every stimulus should be provided to maintain, and extend, these services.

Although day surgery includes a wide spectrum of specific procedures, it is more applicable to some than others. Paediatric surgery is particularly adaptable to day surgery and it has been stated that approximately two thirds of all elective surgery on infants and children can be carried out on a day surgery basis. Paediatric patients differ from all other specialities in that procedures can rarely be carried out under local anaesthetic or without anaesthesia, and this has particular relevance to Type C procedures. In practice, virtually all paediatric procedures are carried out in day surgery centres or hospitals.

Plastic surgery and ophthalmology also have a majority of procedures which are suitable for day surgery however in many instances these procedures are still carried out on an inpatient basis, sometimes involving several nights admission. General surgery includes a wide range of procedures, some of which overlap with speciality groups, and many of these procedures currently treated by overnight(s) admission are suitable for day surgery.

Other specialties, such as neurosurgery and cardiothoracie surgery, have little scope for day surgery.

To a very large extent it is the attitude of the individual surgeons which determines the scope of day surgery, rather than the procedure itself. What is not generally appreciated is the necessity for modification of technique, both operative and anaesthetic to achieve the change from overnight(s) stay surgery to day surgery.

In summary, day surgery is dominated by advantages with few disadvantages, and has the potential to provide high quality, safe, cost effective service for approximately fifty per cent of procedures.

Specific Incentives

Education

It was agreed that there should be a much greater emphasis placed on an ongoing education programme focusing on the expansion of day surgery. It was noted that the (then) Federal Department of Community Services and Health had previously offered $100,000 to the Royal Australasian College of Surgeons for day surgery education programmes, which was declined at the time. The Committee considers that the Department should be asked to renew that offer and that the funds be devoted to the education of three main groups – the medical profession, hospital operators and the general public.

Medical Profession

– particularly surgeons and anaesthetists – to inform them of the cost effectiveness of day surgery for many procedures and patients. The Committee believes that most emphasis should be placed on education of surgeons and anaesthetists.

The Federal Government should be invited to be a major participant in the planned National Day Surgery Committee Seminar.

Hospital Operators

– to reassure them that an increase in day surgery will not necessarily adversely affect their viability

General Public

– to point out to them the safety and social advantages of day surgery.

Financial

The provision of day surgery services, whether office based, in free-standing centres or hospitals requires greater professional commitment by surgeons and anaesthetists compared to overnight(s) stay services where back-up medical and nursing support is provided, both pre and post-operatively. This especially applies to the early post-operative management of patients, particularly those having more major procedures (Bands 3 and 4), where changes of dressings, removal of drainage tubes and other minor services may be required.

The provision of a financial incentive in the form of a higher rebate to patients again applying to more major procedures, as an incentive for their treatment in day surgery rather than overnight(s) stay surgery, deserves consideration.

Having regard to the above, the following specific financial incentives are recommended:

• Increased procedural rebate for Type C procedures which reflects the additional cost of performing procedures in doctors’ rooms.
• Increased procedural rebate for Bands 3 and 4 procedures, subject to a twelve month trial of nominated procedures (Appendix A).
• Payment of a post-operative consultation rebate for the following services: removal of drainage tube or pack, aspiration or drainage of haematoma (not requiring anaesthesia) or urgent after hours consultation. These appear to be covered by the “Not Normal Aftercare” provision to Bands 3 and 4 procedures, including the above mentioned trial (Appendix B).
• Provision of an appropriate home support service rebate, for nominated procedures, may need to be considered. Such a rebate should be linked with the supplementary hospital or procedural rebate and not part of the basic hospital insurance table.

Conclusions

• Day surgery provides a high quality, safe procedural service for appropriately selected patients and is more cost effective than overnight stay hospital services for these patients.
• At present, only twenty to twenty five per cent of procedures are carried out in day surgery and it is considered that this can be expanded to approximately fifty per cent of procedural services.
• The National Day Surgery Committee strongly believes that the extension of day surgery should occur by the inclusion of suitable procedures currently treated as overnight(s) stay hospital patients, not those deemed appropriate as office based procedures.
• The National Day Surgery Committee considers that incentives should be provided for the expansion of day to achieve its potential.
• As a most fundamental principle, the choice of patients considered suitable for day surgery, whether this is carried out in office based surgeries, freestanding day centres or hospitals, must remain the responsibility of advising surgeons and anaesthetists.
• The National Day Surgery Committee, with its two Expanded Groups, is the most informed advisory body on day surgery in Australia.

Appendix A – Specific Financial Incentives: Trial

On advice from members of the Committee, including Specialty Group representatives, the following procedures have been recommended for inclusion in a trial to assess the effectiveness of an increased procedure rebate to encourage transfer of procedures from overnight(s) stay to day stay surgery.

It is considered that five or six procedures should be selected from this list if the Trial is accepted in principle.

• Item 30342
  Breast, Excision of Cyst, fibroadenoma other local lesion or segmental resection for any other lesion.
• Item 30346
  Breast, excision of Cyst, fibroadenoma or other local lesion or segmental resection for any other reason, where frozen section biopsy is performed or where specimen radiography is used.
• Item 30592
  Femoral or inguinal hernia or infantile hydrocoele, repair of not covered by Items 30595, 30624 or 30625.
• Item 30617
  Umbilical, epigastric or linea alba hernia, repair of, in a person ten years of age or older.
• Item 30676
  Pilonidal Sinus or Cyst or Sacral Sinuis or Cyst, excision of in a person ten years of age or older.
• Item 32503
  Varicose Veins, multiple ligations with or without local stripping or excision, including sub-fascial ligation of one or more perforating veins through separate incisions – One Leg – not associated with Item 32506, 32509 or 32530 on the same leg.
• Item 32506
  Varicose Veins, high ligation with complete or partial stripping or excision of long or short saphenous vein or its major tributaries, with multiple ligations, local stripping or excision of minor veins with or without sclerotherapy of minor veins one leg.
• Item 36812
  Cystoscopy with urethroscopy or urethral dilation not associated with any other urological endoscopic procedure on the lower urinary tract except Item 7327.
• Item 36815
  Cystoscopy, with or without urethroscopy, for the treatment of penile warts or uretheral warts, not associated with Item 30189
• Item 36818
  Cystoscopy with uretetic catheterisation including flouroscopic imaging of the uninary tract, unilateral or bilateral not associated with Item 36824 or 36830.
• Item 36821
  Cystoscopy with one or more of: ureteric dilation, insertion of ureteric stent, or brush biopsy of ureter or renal pelvis, unilateral, not associated with Items 36824 or 36830.
• Item 36824
  Cystoscopy with ureteric catheterisation, unilateral or bilateral, not associated with items 36818 or 36821.
• Item 36836
  Cystoscopy, with biopsy of bladder, not associated with Items 36812, 36830, 36839, 36845, 36848, 36854, 37203, 37206 or 37215.
• Item 35627
  Hysteroscopy with dilation of cervix under general anaesthesia.
• Item 35630
  Hysteroscopy with endometrial biopsy or suction curettage, or both.
• Item 35633
  Hysteroscopy with uterine adhesiolysis or polypectomy or tubal catherisation or removal of IUD which cannot be removed by other means, one or more of.
• Item 42698 / 42701
  Lens extraction and artificial lens insertion.
• Item 42833
  Squint, operation for, on one or both eyes, the operation involving a total of one or two muscles.
• Item 45659
  Lop ear, bat ear or similar deformity, correction of.

Appendix B – Respondents Presenting to Hospital

The following data was compiled by the University of Newcastle, Commonwealth Department of Health and provides valuable information concerning the frequency of early postoperative services following day surgery procedures.

Respondents presenting to a hospital Casualty or Outpatients in the seven day postoperative period, by hospital

Hospital	Nil Visits	1 Visit	2 Visits	3 Visits	Unknown	Total
Albury	56 (87.5)	1 (1.6)			7 (10.9)	64 (14.3)
Armidale	19 (86.4)	1 (4.6)			2 (9.1)	22 (4.9)
Nepean	39 (92.9)	1 (2.4)			2 (4.8)	42 (9.4)
RNS	75 (94.9)	3 (3.8)			1 (1.3)	79 (17.6)
Ryde	65 (90.3)	3 (4.2)			4 (5.6)	72 (16.1)
Sydney	50 (89.3)	2 (3.6)		1 (1.8)	3 (5.4)	56 (12.5)
Syd Eye	46 (73.0)	5 (7.9)	4 (6.4)	1 (1.6)	7 (11.1)	63 (14.1)
Westmead	47 (94.0)	0			3 (6.0)	50 (11.2)
Total	397 (88.6)	16 (3.6)	4 (0.9)	2 (0.5)	29 (6.5)	448 (100.0)

(figures are in percent)

Reference: Evaluation of Medical Day Surgery Initiative in New South Wales. (February 1991. Centre for Clinical Epidermiology and Bio-Statistics University of Newcastle. Commonwealth Department of Health)

National Day Surgery Committee

• Australian Association of Surgeons
• Royal Australasian College of Surgeons
• Australian & New Zealand College of Anaesthetists
• Royal Australian College of Obstetricians & Gynaecologists
• Otolaryngological Society of Australia
• Royal Australian College of Ophthalmologists
• Neurosurgical Society of Australasia
• Australian Society of Plastic Surgeons
• Australian & New Zealand Association of Urological Surgeons
• Australian Orthopaedic Association
• Australian Association of Paediatric Surgeons
• Australian Dental Association
• Australian Medical Association
• Australian Private Hospitals Association
• Australian Health Insurance Association
• Health Insurance Commission (Medibank Private)
• Australian Hospital Association
• Australian Association of Day Surgery Centres
• Gastroenterology Society of Australia