Cost- and Budget-Impact-Analysis of an Increase in Day Surgery for Selected Indications

Research areas: High tech medicine, Health economics

Duration: April 2014 - May 2014
Publication: LBI-HTA Projektbericht Nr. 71: https://eprints.aihta.at/1035

Language: German

Background:
Compared with countries like the USA, UK or Scandinavia, in Austria day surgery is not very common. The reasons are shorter waiting lists, comparably high inpatient capacities and different financial incentives in the Austrian health care system. If a treatment in a day surgery setting is as safe and effective as inpatient care, a high volume of inpatient treatments constitutes an inefficient use of resources. In addition, the defined aim of the recent Austrian health care reform to reduce cost increases in health care - especially in the inpatient sector - requires the identification of rationalisation potentials.

Aims of the Project:
The aim of the project is to compare costs of inpatient and day surgery and to conduct a budget-impact-analysis from the hospital providers’ perspective for a scenario of increased day surgery in those interventions that were considered as safe both in an inpatient and outpatient setting in a recently published evidence analysis of the Ludwig Boltzmann Institute [1]. Beside the presentation of the current state of affairs, several future scenarios will be calculated.
The evaluation will be limited for a defined number of operations, prioritised on the basis specific criteria (see methods).

Research Objectives:
• What is the current situation in terms of out- and inpatient surgery in Austria and in the federal states for the selected interventions?
• What are the direct medical costs of the selected interventions in a day surgical setting compared with inpatient surgery taking into account possible unexpected (re)admissions?
• What is the budget impact of increased provision of day surgery for the selected interventions from the hospital providers’ perspective taking into account demographical changes?

Methods:
A) Excursus: selection of interventions (see also attachment)
• Pre-selection of interventions according to frequency and safety:
  o Interventions that are registered as day surgery options in the Austrian hospital benefit catalogue and that were carried out more than 10,000 times in 2011,
  o Interventions out of the 15 most frequent operations in 2011, which are carried out in day surgery setting  internationally,
  o Evidence on safety of the selected interventions[1].
• Prioritisation of the preselected surgical interventions by the following criteria (based on the external manual of the LBI-HTA [2]:
  o Frequency of the intervention,
  o Point value of the intervention according to the hospital benefit catalogue,
  o Multiplication of the intervention frequency with the relevant point value (as indicator for costs),
  o Interventions with a total point of value of more than 30 million.
• The following interventions have been identified for a detailed analysis:
  o BF 020 cataract operation,
  o EK 050 vein ligitation (stripping),
  o HM 110 laparoscopic cholecystectomy,
  o LM 080 repair of inguinal hernia,
  o NF 020 arthroscopic operations of the knee.
• The „Gesundheit Österreich GmbH“ has already conducted a budget-impact-analysis for increasing day surgery of cataract operation [3], thus we will focus only on the remaining four interventions
   B) Detailed analysis:
• Description of the out- and inpatient characteristics of the selected interventions: development over time, federal differences and political objectives, comparison with international data,
• Analysis of direct medical costs for out- and inpatient service performances based on data of public hospitals,
• Budget-impact-analysis for the increase of day surgery from the hospital providers’ perspective (using the report by Gesundheit Österreich GmbH: „Verlagerung von Kararaktoperationen in Tageskliniken“ as a starting point):
  o Calculation for a short time horizon until 2016
  o Rough estimate for a time horizon until 2020
  o Presentation of the results for the federal states and for Austria overall,
  o Sensitivity analysis for uncertain parameters (development, demography, ratio of day surgery and costs) to calculate the „best case scenario“ and „worst case scenario“ for the selected time horizons,
  o In accordance with methodical standards of a budget-impact-analysis, results will not be discounted.
• Data sources:
  o costs: data from the „Dokumentations- und Informationssystems für Analysen im Gesundheitswesen (DIAG)“, interpreted by the federal health organisations (Landesgesundheitsfonds) in coordination with the Ludwig Boltzmann Institute (LBI-HTA),
  o data for development / prognosis of selected indications and demographic data (population, inflation, etc.): reports by Statistik Austria, WHO, OECD and IASO,
  o data for unexpected admissions, readmissions and visits in the emergency rooms: previous assessment of the LBI-HTA [1], data from hospitals and federal health organisations, national/international records.

Time shedule/ mile stones:
May-July 2013:  collection of data in accordance with the federal health organisations and calculation
June-October 2013:  writing report
End of October 2013: review, final report

Literature:

1. Fischer, S. and I. Zechmeister-Koss, Tageschirurgie:Systematischer Review. HTA-Projetbericht Nr. 64, 2012, Ludwig Boltzmann Institut für Health Technology Assessment: Wien.

2. Wild, C., et al., (Externes) Manual. Selbstverständnis und Arbeitsweise, 2006, Ludwig Boltzmann Institut für HTA: Wien.

3. Rosian-Schikuta, I., et al., Verlagerungen von Kataraktoperationen in Tageskliniken: Evidenz, Ist-Stand, Budgetauswirkung, 2013, Gesundheit Österreich GmbH: Wien. p. 46.

Atttachment: selection of interventions

Intervention / performance incl. code	Frequency Intervention	Rank frequency	Point value of intervention	Frequency x point value	Day surgical performances(portion of total performances in %)	Day surgery safe?
Ophthalmology	b  BF020 Cataract operation	79,147	1	1,252 (MEL15.05)	99.1 Mio.	37,671 (47.6%)	yes
b  BA010 Correction of eyelid	11,999	10	1,108 (MEL15.01)	13.2 Mio.	5,149 (39.7%)	Not clear (not assessed)
Neck, Nose and Ears	b  CB010 Paracentesis	12,360	8	932-1,493 (MEL04.04)	11.5-18.4 Mio.	4,35 (34.3%)	No clear evidence
Operations in head and neck area	b  FA010 Adenotomy	b       13,279	6	932-1,493 (MEL04.04)	b       12.3-19.8 Mio.	b       2,898 (21.8%)	b       yes
Gynaecology / Urology	b  JK030 Curettage	35,440	2	1,153-3,107 (MEL13.07)	40.8-110.1 Mio.	11,125 (31.4%)	No clear evidence
General surgery	b  HH 040/ HH 050 Appendectomy	12,673	12	2,226-3,471 (MEL06.06)	28.2-43.9 Mio.	253 (0.02%)*	No clear evidence
b  EK050 Vein ligation (stripping)	17,745	4	1,916-4,585 (MEL09.03)	34-81.3 Mio.	1,562 (8,8%)	Yes
b  HM 110 Laparoscopic Cholecystectomy	16,315	5	3,149-6,677 (MEL05.05)	51.3-108.9 Mio.	816 (0.05%)*	Yes
b  LM080 Repair inguinal-or femoral hernia (open)	12,152	9	2,226-3,471 (MEL06.06)	27-42.1 Mio.	231 (1.9%)	Yes
b  LM100 Repair ventral hernia (open)	10,080	13	2,226-3,471 (MEL06.06)	22.4-35 Mio.	251 (2.5%)	Not clear (not assessed)
Orthopaedics	b  NF020 Arthroscopic operations of the knee	33,258	3	1,607-7,173 (MEL 14.21)	53.4-238.6 Mio.	2,751 (8.3%)	yes
b  NZ010 Removal of implanted bone devices	11,993	11	1,583-2,198 (MEL14.23)	19 -26.4 Mio.	3,018 (25.2%)	No clear evidence
b  AJ070 Decompression of nervus medianus (open)	12,984	7	3,314 (MEL02.02)	43 Mio.	5,149 (39.7%)	No clear evidence

MEL: medical single performance in hospital benefit catalogue; * performance not in hospital benefit catalogue for day surgery defined, match number of zero day inpatient stays; Colors:

Missing evidence for safety

Frequent intervention, performed in several countries

Intervention with ? 30 Mio total points of value/year

Evidence for safety in day surgery