Ambulatory Surgery in the UK Status, Financing and Non-elective work

Transcription

1 Ambulatory Surgery in the UK Status, Financing and Non-elective work Dr Mark Skues, Editor in Chief, Ambulatory Surgery Past President, British Association of Day Surgery

2 Overview In the United Kingdom Status of Day Surgery Best Practice Tariffs for Ambulatory Surgery Emergency Day Surgery

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4 The Hospital

5 Where I work

6 Jubilee Day Surgery Centre Protected Areas Areas Undergoing Refurbishment Area of expansion RaceTrack Ward Areas Car Park Area Post Op recovery Endoscopy LA Theatre/Consultation rooms Existing Theatres Staff Change Courtyard Endoscopy Patient Male and Female Change and waiting rooms Endoscopy Reception Staff Rest Seminar Admin/offices Admin/offices

7 New Plan Additional en-suites New Extension Ward Recovery Racetrack Extension to Post Op Recovery Staff Change 3 Consultation Rooms Staff Hub Racetrack 4th Operating Theatre Staff Change Staff Offices Trolley Bay Staff Rest Room Seminar Room

8 Jubilee Day Surgery Centre 5 operating theatres; (1 LA) 10 bedded first stage recovery (+4) 40 ward beds and recliners (+14) 9 Pre-assessment /pre-op review rooms (+3) Cost: M 2.3

9 Is this justified? National performance

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13 What s made the difference? Change in attitude of clinicians Advances in surgical and anaesthetic techniques Continued national cost constraints British Association of Day Surgery

14 British Association of Day Surgery Established in Council members from all disciplines 5 Co-opted Trainee and Lay Members Active website ( Annual Meeting (June) Contribute to the national agenda on Day Surgery

15 BADS books / booklets

16 The BADS Procedure Directory

17 The BADS Procedure Directory Provides appropriate surgical codes for 200+ procedures Offers guidelines on length of stay for these procedures Procedure Room, Day case, One night stay, Two nights+ Gives contemporaneous insight into state of play for Day Surgery with the Dataset publication

18 BADS Directory of Procedures

19 BADS Dataset

20 International Evidence Base Day Surgery is a more cost-efficient option for surgical care than inpatient management Reimbursement mechanisms for Day Surgery are variable or non-existent in many IAAS member countries

21 The Day Surgery Pathway Out-patient review Diagnostics Admission on the Day GP Referral Pre-operative Assessment Listing/Booking Nurse Review Home Support Clinician Review Discharge Post-op Advice Recovery Operative Care

22 The Day Surgery Pathway- Constraints Abnormal? Out-patient review Diagnostics DNA Admission on the Day GP Referral Pre-operative Assessment Listing/Booking Nurse Review Home Support Criteria Liberal/Conservative Phone/ Re-Admission Timely Cancellation Cancellation Clinician Review Discharge Post-op Advice Recovery Operative Care Criteria TTOs Sick Note Overnight Admission Surgery/Anaesthesia Staffing/Capacity/Use

23 Wouldn t it be nice if? The Day Surgery pathway was financially incentivised? One payment for all the pathway? Day Surgery patients earn more than inpatients for the same operation?

24 Payment by Results From patient notes to pound notes

25 Payment by Results Submission of Operative Procedure Co-morbidities/Complications Elective or Emergency Coding of operation using Health Resource Group code Payment made of a fixed tariff

26 Payment by Results Operative Procedure coded by OPCS code codes (version 4.8) Codes to route of access and site Laparoscopic cholecystectomy: J183: Total cholecystectomy + Y752: Laparoscopic approach to abdominal cavity

27 HRG4+ coding J183+Y752 Code Description GA10H Laparoscopic Cholecystectomy, 19 years and over, with CC Score 4+ GA10J Laparoscopic Cholecystectomy, 19 years and over, with CC Score 1-3 GA10K Laparoscopic Cholecystectomy, 19 years and over, with CC Score 0

28 Comorbidities Old myocardial infarction Chronic ischaemic heart disease, unspecified Atrial fibrillation and flutter Chronic obstructive pulmonary disease, unspecified Insulin-dependent diabetes mellitus without complications Rheumatoid arthritis, unspecified Unspecified disorder of adult personality and behaviour

29 Complications Acute laryngopharyngitis Hypotension due to drugs Cardiac arrhythmia, unspecified Volume depletion Fluid overload Disorientation, unspecified

30 Payment by Results for England One tariff funds everything from intention to operate to home discharge Includes: GP Referral Home Support Out-patient review Pre-operative Assessment Diagnostics Listing/Bookin g Admission on the Day Nurse Review Clinician Review Pay: Surgeon/Anaesthetist/Theatre Staff/Ward nurses/admin Drugs/Equipment Consumables/Non consumables Environment Heat, Light, Water Pre and Post Op Care Discharge Post-op Advice Recovery Operative Care

31 Best Practice Tariffs 2009: Approach to BADS by the NHS PbR Team How do we provide appropriate payment for Day Surgery activity? Reduce tariff based on reduced cost? No... Enhance tariff as a financial incentive

32 Laparoscopic Cholecystectomy: Best Practice Tariff 2009: Day case: kr13650 In-patient: kr13650 For : Day case: kr16940 In-patient: kr13690

33 Best Practice Tariffs 2015 Breast Surgery: Mastectomy, Sentinel Node Biopsy, Axillary Clearance ENT: Tonsillectomy, Septoplasty, Mastoid Ops Orthopaedics: Dupuytren s, Subacromial decompression, Bunion ops Gynaecology: Female incontinence surgery, O/P Hysteroscopy/Sterilisation Urology: Resection of Prostate, O/P Cystoscopy General Surgery: Laparoscopic Cholecystectomy, Hernia Repair

34 Payment.. Daycase (kr) Inpatient (kr) Laparoscopic Cholecystectomy % Inguinal/Umbilical/Femoral Hernia Repair % Ops for urinary incontinence % Tonsillectomy (adult) % Mastectomy % TUR (Prostate) % Septoplasty % Tympanoplasty/Mastoid Ops % Dupuytren s Repair % 1 = 10 Krone Diff (%)

35 Daycase Rates for Laparoscopic Cholecystectomy in England Q Q Q Day case rate (%) English Hospitals

36 Day Case Lap Chole Rates: England 60% 50% 40% 30% 20% 10% 0%

37 What about other operations? 0% 10% 20% 30% 40% 50% 60% 70% 80% Hernia ops 0% 10% 20% 30% 40% 50% 60% Tonsillectomy 0% 2% 4% 6% 8% 10% 12% Mastectomy 0% 10% 20% 30% 40% 50% 60% 70% 80% Septoplasty 0% 20% 40% 60% 80% Dupuytren s 0% 10% 20% 30% 40% 50% 60% 70% 80% Hallux Valgus Surgery

38 How does this compare with other countries?

39 Norway vs England (2014) Procedure Norway England [2016] Cataract extraction +Intraocular lens 96% 97% [98%] Tonsillectomy 62% 50% [55%] Laparoscopic Cholecystectomy 26% 45% [53%] Partial excision of mammary gland 47% 69% [72%] Repair of Inguinal Hernia 60% 70% [75%] Mastectomy 11% 8% [11%]

40 From April more Ambulatory Procedures Gynaecology: Anterior colporrhaphy, Posterior colporrhaphy, Lap Therapeutic Procedures, Oophorectomy/Salpingectomy Orthopaedics: Anterior Cruciate Ligament Repair Urology: Optical urethrotomy, Ureteroscopic extraction of calculus, Insertion of ureteric prosthesis, endoscopic destruction lesion of bladder ENT: Nasal Polypectomy General Surgery: Repair of other abdominal hernia, Excision/biopsy of lymph nodes for diagnosis

41 From April more Ambulatory Procedures (Contd) Medical: Renal Biopsy, Liver Biopsy, Bone Marrow Biopsy Ophthalmology: Dacryocysto-rhinostomy + Tube Vascular/Interventional Radiology: Transluminal procedures on femoral artery, Creation of AV fistula for dialysis

42 Why these procedures? Incentivisation based upon: Volume of procedures (>2000) Daycase rate <90% Variation of global rates (Less than 0.9 of BADS rate) Interhospital variation of >15% between median and 95 th percentile

43 Daycase Inguinal Hernia Repair, England, Jan-March >15% 70 % Daycase Hospitals

44 Has it worked? An evaluation of the BPT programme by the University of Manchester and the University of Nottingham found this BPT had been successful in increasing the proportion of activity seen on a day case basis. Adding to the scope of this BPT will create an incentive for providers to move more activity into day cases National Tariff Proposals

45 Has it worked (2)? Day case Lap Chole rates: We found that the price change led to an almost six percentage point increase in the daycase rate and an 11 percentage point increase in the planned daycase rate. Health Economics 2016;25:56-70

46 In Conclusion England is the only country (worldwide) to have incentivised Ambulatory Surgery; The evidence is that daycase rates have increased with implementation of BPT;

47 Day Surgery Day surgery is the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day. Day Surgery: Development and Practice. IAAS 2006.

48 Emergency Surgery Unselected Unplanned Unscheduled Day or Night

49 A new domain of care? 8988 children reported All treated as outpatients These included: Birth fracture of skull, Pyloric stenosis Mastoid empyema British Medical Journal 1909;2:753-4

50 Overview A new domain of care? Classification of emergency ambulatory surgery Which procedures? Which patients?

51 Classification of Emergency Surgery Immediate Immediate life, limb or organ-saving intervention (within minutes) Urgent Intervention for acute onset or deterioration of potential life-threatening conditions (within hours) Expedited Patient requiring early treatment where the condition is not an immediate threat to life (within days) Elective Intervention planned or booked in advance of routine admission (planned)

52 Emergency Day Surgery - Expedited True Emergency Day Surgery - unplanned admission to discharge Planned Emergency Day Surgery - interval emergency procedure Day Surgery on the Emergency Pathway - same-day discharge after operation

53 Emergency Day Surgery True Emergency Day Surgery Planned Emergency Day of Surgery Discharge Admission Admission Admission Diagnosis Diagnosis Investigations Surgery Discharge Diagnosis Discharge Readmission Surgery Surgery Discharge Discharge

54 Emergency Ambulatory Pathways True Emergency Day Surgery Complete pathway within one calendar day Emergency admission Diagnosis Operation Discharge Day Surgery on Emergency Pathway Discharge on same day as operation Home & Planned Readmission Operation Discharge Planned Emergency Day Surgery

55 Minor emergency procedure required Planned Emergency Day Surgery Pre-operative assessment by surgical team Home with fasting instructions Coordinator assigns theatre slot Patient advised time and place of admission Emergency procedure performed as scheduled Patient discharged on day of surgery

56 Planned Emergency Day Surgery Patient Criteria Exclude systemic sepsis before temporary discharge Caution with diabetic patients (Type 1) Exclude patients with major co-morbidities Ensure oral analgesia is adequate Proposed surgery is suitable for day case

57 100 consecutive patients referred with superficial abscesses

58 90 patients with abscesses Unplanned overnight admission rate 5.5% Traditional pathway 5.7 times longer than day case pathway

59 Day case group: 70% successfully treated as daycase Bed usage: 19 nights for daycase 86 nights for inpatient British Journal of Surgery 2002;89:423-7.

60 Ambulatory Surgery 2015;21.4: Emergency peri-anal abcess surgery - Day case rate Day Case Procedure (%) Data Average 2SD limits 3SD limits Total Procedures Source: HES

61 M Skues. National Dataset 2015

62 Perianal abscess Drainage % Emergency n % 30% 20% Daycase rate (%) Elective Daycase % % Year 0% HES Data

63 One Day Abscess Management Moran N, Skues M. Journal of One Day Surgery 2015;25.3:A21

64 Which procedures? True Emergency Day Surgery Emergency admission Diagnosis Operation Discharge Timely? Optimisation Access to operating theatre

65 Which procedures? Emergency admission Diagnosis Operation Discharge Day Surgery on Emergency Pathway And what else? MUA Fractures + Fixation Retained Products of Conception Superficial abscesses Superficial trauma Hand trauma

66 Open Appendicectomy... between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus. Experience with Early Operative Interference in Cases of Disease of the Vermiform Appendix. New York Medical Journal; 1889;50: Charles McBurney Surgeon-in-Chief Roosevelt Hospital New York

67 Laparoscopic Appendicectomy 13 September 1980 Kurt Semm Prof Obstetrics & Gynaecology University of Kiel At the request of co-workers, Kurt Semm had to undergo a brain scan because colleagues suspected that only a person with brain damage would perform laparoscopic surgery.

68 39 of 52 (75%) laparoscopic appendectomies were done as day-care procedures Day-care laparoscopic appendectomies. Brosseuk DT, Bathe OF. Can J Surg 1999;42: (56%) children went home in <24 hours following laparoscopic appendectomy Laparoscopic appendectomy in children can be done as a fast-track or same-day surgery. Grewal H, Sweat J, Vazquez WD. JSLS 2004;8(2):151-4 The majority of the patients (n=66, 64%) were discharged within 24 h. Day case emergency laparoscopic appendicectomy. Gilliam AD, Anand R, Horgan LF, Attwood SE. Surg Endosc 2008;22: (78.3%) were discharged on the day of surgery Routine same-day discharge after acute or interval appendectomy in children. Alkhoury F. Et al. Arch Surg. 2012;147(5):443-6

69 Int J Surg 2014;12: year retrospective review with 13 studies 1152 adults 312 (27%) discharged within 12 hours 614 (53%) discharged within 24 hours

70 The Challenge in Appendicectomy Patient Perception Continuing Sepsis Continuing pain Pathology - ruptured appendix - non-ruptured appendix - normal appendix

71 Laparoscopic Salpingostomy for Ectopic Pregnancy Abstract Seventy-nine ampullary tubal ectopic pregnancies were managed using laparoscopic linear salpingostomy. All patients were discharged within 24 hours of the procedure. It would appear from our observations that a skilled laparoscopist can remove a small tubal pregnancy in this manner with minimal complications. DeCherney AH, Diamond MP. Obstet Gynecol 1987;70(6):

72 Hot Cholecystectomy Abstract Review over 20 years Statistically significant reductions in mortality, bile duct leaks, bile duct injuries, length of hospital stay and blood loss with early Lap Chole Early LC clearly superior to delayed LC in acute cholecystitis. Cao AM, Eslick GD, Cox MR. Surg Endoscopy 2016;30(3):

73 Emergency Ambulatory Pathways Emergency admission Diagnosis Operation Discharge Day Surgery on Emergency Pathway Laparoscopic appendicectomy Laparoscopic salpingostomy Acute laparoscopic cholecystectomy

74 Management strategies for Emergency day cases Planned Emergencies Low volume Beds allocated in emergency ward or day surgery unit Theatre slot on day list, emergency list or other elective list with unplanned cancellation High volume Beds allocated on the day unit Planned operating lists for predictable emergency day cases Large catchment area

75 Regional referral centre for hand trauma Population 4 million 21 referring accident units Referral protocols Telephone appointment for next day Patient travels to regional centre Regional or local anaesthesia Results : 101 patients treated in 4 months. One unplanned overnight admission Reduction in : carve-out of elective workload patient delays inflammation, oedema and infection of the wound

76 In summary

77 Ambulatory Surgery in the UK Status, Financing and Non-elective work Dr Mark Skues, Editor in Chief, Ambulatory Surgery Past President, British Association of Day Surgery