The recent evolution of health care in response primarily to socioeconomic factors has been spectacular, and the process is by no means complete. The most striking result to date is the emergence of ambulatory surgery as the predominant mode for the delivery of surgical health care. Just a few years ago, it was estimated that more than 40% of all operative procedures would be performed in the outpatient setting. By 2000, however, 70% of operative procedures were already being performed on an outpatient basis. In 1996, an estimated 31.5 million procedures were performed during 20.8 million ambulatory surgical visits.94 The majority (84%) of these visits still took place in hospitals, however, with the remainder in freestanding units.94 Although procedures such as endoscopies and lens extraction and insertion were predominant at this time, there were also many breast biopsies, herniorrhaphies, and orthopedic procedures.
The explosive growth of ambulatory surgery was initiated by economic factors, but it has had some positive effects on patient care, for the following reasons:
1. Development of new technology. Newer techniques, such as laparoscopic surgery, minimize the need for hospitalization and decrease the pain and suffering that patients must endure. It is not yet clear, however, whether such developments will inevitably lead to a reduction in total health care costs. One study reported that the cholecystectomy rate increased from
I.35 per 1,000 enrollees in an HMO in 1988 to 2.15 per 1,000 in 1990 and that the total cost for cholecystectomies rose by
II.4% despite a unit cost savings of 25.1%.95The authors suggested that these results might be attributable to changing indications for gallbladder operations; however, it is much more likely that a significant number of patients suffering from gallbladder dysfunction who were reluctant to undergo an open procedure are now willing to accept the lesser discomfort and inconvenience characteristic of a laparoscopic procedure. What the appropriate cholecystectomy rate may be is a question for the future to answer; in the meantime, many patients are living more comfortably, having had the dysfunctional organ removed. The situation is similar in the treatment of GERD. Repairs to the esophagogastric junction can now be done without a long and difficult postoperative course. In addition, there have been major advances in anesthetic techniques and postoperative management of pain and PONV.
2. Cost savings achieved by Medicare and other payors. In 1987, Medicare approved over 200 procedures as suitable for ASCs. Currently, more than 1,200 procedures are so designated, with more procedures being approved every year. The endorsement of cost-efficient delivery systems by employers and the reduction of employee benefits by insurers are encouraging employees (as both consumers and patients) to be more cost-conscious. When patients are involved in the actual cost of medical care, they tend to accept more efficient modes of delivery.This is even more likely to be the case when they are at risk for the cost of care.
3. Physician concern.The emergence of the concept of managed care has exerted a strong influence on physician involvement in ambulatory surgery. Concerns over the safety of major surgical procedures being performed in the outpatient setting have largely been removed, and surgeons are becoming more aggressive. Clearly, surgeons have benefited from the ease and convenience of outpatient surgery, especially with respect to scheduling and protection from cancellations due to emergencies. Equally clearly, however, they will now have to be more vigilant, given that outpatient surgical facilities tend to be less well monitored and supervised.
4. Patient awareness of quality assurance. Today's patients (or consumers) are more medically knowledgeable than ever before and more concerned with actively seeking out institutions that deliver high-quality and cost-efficient care. Consumers are highly sensitive to the issue of quality, but their definitions of this attribute are not always based on the same criteria that surgeons use. To patients, quality is a combination of effectiveness, safety, cost, convenience, and comfort.
Economic benefits aside, the major issue in the movement of surgical activities out of the hospital and into a more convenient and economical environment is how best to ensure that patients continue to receive safe, high-quality care. This consideration must in all circumstances be the primary issue underlying the planning of elective surgery. More and more, third-party payors expect surgical care to be provided to their clients (patients, to us) in a cost-effective environment. On the whole, this is not a bad thing. If, however, they also expect that surgical care can be provided just as cost-effectively to diabetic patients, morbidly obese patients, and patients with serious cardiac or respiratory disease, there is a real danger that patients' welfare could be compromised. Accordingly, it is crucial that all third parties who are not directly involved in the care of the patient permit the surgeon and the anesthesiologist to exercise sound medical judgment in regard to what type of care is needed and where such care can best be delivered. Surgeons must not delegate their responsibility for safeguarding their patients' well-being.
The ACS has issued several statements on ambulatory surgery.96 In their 1983 statement, the ACS approved "the concept that certain procedures may be performed in an ambulatory surgical facility" but emphasized that "a prime concern about ambulatory surgery is assurance of quality" and that "a discussion between patient and surgeon about performance of the procedure on an ambulatory basis should result in a mutually agreeable decision."96 More than two decades later, this is still the position of the ACS. The College is continually evaluating evolving medical technology, both inpatient and outpatient.
Outpatient surgery would seem to have an obvious advantage over inpatient surgery with respect to cost savings, especially if the main focus of the comparison is the high charges for 1 or more days of inpatient care. Such a comparison may be misleading insofar as it suggests that the entire cost of inpatient care can be saved when the procedure is done on an outpatient basis. The hospital inpatient charge reflects the costs of a number of functions associated with early convalescence in the hospital, including nursing, diet, and housekeeping; some of these costs are also associated with immediate postoperative care in the outpatient recovery area and consequently will be reflected in the outpatient facility's bill as well.The comparison may also be misleading insofar as it ignores the inherent costs of outpatient surgery. In some cases, medical personnel perform functions that do not appear on the bill, such as follow-up care, care by phone, and home visits to evaluate recovery, as well as dressing changes and other services similar to those provided by family members or friends. The costs associated with buying or renting durable medical equipment (e.g., beds and commodes), preparing meals, and various other activities must also be taken into account. Clearly, there are avenues for development in the postoperative setting that might raise expenses for outpatient surgery, but certainly not to the level of an inpatient stay.
It is to be hoped that new Medicare and state regulations mandating evaluation of quality of care in outpatient surgical facilities will provide definitive statistics for determining actual cost savings. Cost data must be analyzed thoroughly if we are to assess the true contribution of outpatient surgery to cost containment. As medicine advances into the 21st century, the changes in patient care have been and will continue to be nothing but spectacular, and one can only speculate what is to come. If this century brings about the same level of innovation that was experienced in the 20th century, the future for surgery and the surgical patient is bright, exciting, and to be greatly anticipated.
1. Margolese RG, Lasry JF: Ambulatory surgery for breast cancer patients. Ann Surg Oncol 7:181,
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