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                                            • Minimum Volume Standards in Day and Ambulatory Surgery

                                            Minimum Volume Standards in Day and Ambulatory Surgery

                                            Lb04-fortschrittsbegriff
                                            Research area: Health economics

                                            Project leaders: Christoph Strohmaier

                                            Project team: Christoph Strohmaier

                                            Duration: April 2019 -November 2019
                                            Suggested by: The Main Association of Austrian Social Insurance Institutions (HVB)
                                            Language: English (with German summary)

                                            Background:
                                            Many surgical interventions that were previously conducted in the in-patient setting can be now dealt within the ambulatory care. The British Association of Day Surgery (BADS) currently lists around 200 procedures across all surgical specialities that can be performed as day surgeries. Such day surgeries are defined as a patient being admitted to hospital for a planned procedure and discharged home the same calendar day. In Austria, surgical interventions are listed in the catalogue of outpatient hospital services.

                                            Reasons for this shift are manifold: organizational, ethical, economic, and medical. The aim is to improve the pathway of care, while efficiently allocating the resources where they are needed. Day surgeries allow patients to choose their own surrounding to convalesce and they are associated with shorter waiting times and lower risks of surgery cancellation. Also, day surgeries tend to reduce the rates of hospital-acquired infection and venous thromboembolism. However, defining conditions on how to implement day surgeries appropriately and quality assurance in the move towards day surgeries are key.

                                            Aim:
                                            The aim of this project is to provide decision support for the context of day surgery by identifying the evidence and relevance of minimum volume standards (MVS)[1] as a criterion of quality assurance in the day surgery and ambulatory setting.

                                            Research Questions:

                                            1. What is the evidence in the literature on MVS as a quality assurance criterion for day surgeries or ambulatory feasible surgeries[2]?
                                              1. For which day surgeries and ambulatory feasible surgeries are MVS defined?
                                              2. How is the regulatory framework with respect to MVS for the identified surgical interventions shaped? According to which determinants and criteria are MVS defined?
                                              3. Are there any differences in outcomes for day surgery procedures with defined MVS and (comparable) ambulatory procedures without MVS and can they be identified?
                                            2. How can the evidence of MVS in the Austrian clinical context be evaluated – based on perspectives of clinicians?

                                            PICO: (Inclusion criteria)

                                            Population

                                            Patients eligible for DS, e.g.: according to anaesthetic classifications (ÖGARI), type of anaesthetic possibilities (local, mask), according to ASA classifications or general state respectively. The appropriate population will be identified in the course of the literature analysis on the detected, specific day surgery interventions/indications.

                                            Key words: day surgery, same day surgery, ambulatory care, day-care hospital, zero-day hospital stays

                                            Intervention

                                            Identified surgical interventions from the international literature in the day surgery/ambulatory setting in combination with implemented minimum volume standards

                                            Comparators

                                            Same or comparable surgical interventions (in the ambulatory setting) without implemented minimum volume standards

                                            Outcomes

                                            Dependent on the found indications/interventions, general health related outcomes such as morbidity, mortality, quality of life, functional outcomes such as functionality in everyday life, at the work place or satisfaction are to be taken into account here. Also, day surgery specific outcomes are to be considered such as rates of hospital-acquired infection, rates of venous thromboembolism etc.

                                            Setting

                                            Ambulatory care/Day-care hospital/Zero-day hospital stays

                                            Study type

                                            No study limitations

                                            Publication period

                                            2000-2019

                                            Languages

                                            German/English

                                            Methods:

                                            Systematic Review of minimum volume standards in day surgery

                                            To answer research question one, we will systematically review the current literature in five databases (Medline via Ovid, PubMed, Embase, The Cochrane Library, CRD) with the aim of gathering all available evidence on the topic of minimum volume standards with respect to day surgery.

                                            Additionally, a hand search on websites of national and international professional societies and a review of current international and national guidelines with respect to pathways of care will be performed.

                                            The data on the identified surgical indications/interventions or interventions groups respectively will be extracted from the literature, systematically depicted and categorized. Possible categories are year of the source document, health care context (country, health care system, surgery setting), indications, interventions, outcome, relevance and characteristics of minimum volume standards. As a second step we will shortly discuss further quality assurance measures that are identified in the literature search and depict them in a compact overview. These measures and criterions can be categorized in sub-categories associated with the process, structure and outcome quality and are implemented over the perioperative period, such as patient selection, pre- and postsurgical standards, patient information, anaesthetic management etc.

                                            Qualitative expert interviews

                                            In the course of writing the report clinicians will be consulted to include the clinical perspective throughout the project and to contrast the identified evidence of MVS to the Austrian context.

                                            Time schedule: Completion until November 2019

                                            Period

                                            Task

                                            April/May/June

                                            Scoping and clarifying of the research question

                                            June

                                            Literature search, hand search, and contacting of interview participants

                                            July

                                            Literature selection and analysis, data extraction, preparation of the interviews

                                            July - September

                                            Drafting of the report, conducting of interviews, interview transcription and analyses

                                            October

                                            Internal review and external review

                                            November

                                            Finalizing, layout

                                            References:

                                            List of day surgeries:

                                            Bundesministerium Arbeit, Soziales, Gesundheit und Konsumentenschutz. (2018). LKF-Katalog für den spitalsambulaten Bereich. https://www.sozialministerium.at/site/Gesundheit/Gesundheitssystem/Krankenanstalten/LKF_Modell_2018/Kataloge

                                            BADS. (2015). BADS Directory of procedures 5th Edition. https://daysurgeryuk.net/en/shop/publications/bads-directory-of-procedures-5th-edition/

                                            Minimum Volme Standards and Quality assurance in day surgeries:

                                            GKV-Spitzenverbände, DKG and KBV. Qualitätssicherungsvereinbarung nach § 115b SGB V Vereinbarung von Qualitätssicherungsmaßnahmen bei ambulanten Operationen und stationsersetzenden Eingriffen einschließlich der notwendigen Anästhesien gemäß § 115b Abs. 1 Satz 1 Nr. 3 SGB V. 2019. Available from: https://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/krankenhaeuser/ambulante_krankenhausleistungen/ambulantes_operieren/aop_vertrag/KH_AOP_QS-Vereinbarung_115_b_Abs_1_011006.pdf.

                                            Bauer H, Honselmann K, C: Minimum Volume Standards in Surgery - Are We There Yet. Visc Med 2017;33:106-116. doi: 10.1159/000456041

                                            IQTIG (2017): Methodische Grundlagen V1.1. Stand: 15. April 2019. Berlin: Institut für Qualitätssicherung und Transparenz im Gesundheitswesen. URL: https://iqtig.org/dateien/dasiqtig/grundlagen/IQTIG_Methodische-Grundlagen-V1.1_barrierefrei_2019-04-15.pdf

                                            de Cruppé, W., Malik, M., & Geraedts, M. (2015). Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis. BMC health services research, 15, 279. doi:10.1186/s12913-015-0944-7

                                            Huo, Y. R., Phan, K., Morris, D. L., & Liauw, W. (2017). Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. Journal of gastrointestinal oncology, 8(3), 534–546. doi:10.21037/jgo.2017.01.25

                                            Daniel J Quemby, Mary E Stocker. (2014). Day surgery development and practice: key factors for a successful pathway, Continuing Education in Anaesthesia Critical Care & Pain. Volume 14, Issue 6, Pages 256–261, https://doi.org/10.1093/bjaceaccp/mkt066

                                            Rajala M. et al. (2016). The Quality of Patient Education in Day Surgery by Adult Patients. Journal of PeriAnesthesia Nursing , Volume 33 , Issue 2 , 177 - 187

                                            Nunes, J.S., Gomes, R., Povo, A., Alves, E.C. (2018). Quality Indicators in Ambulatory Surgery: A Literature Review Comparing Portuguese and International Systems. Acta Med Port 2018 Jul-Aug;31(7-8):425-430, https://doi.org/10.20344/amp.10416

                                            Economics and ethics:

                                            Torjuul, K., Nordam, A., & Sørlie, V. (2005). Ethical challenges in surgery as narrated by practicing surgeons. BMC medical ethics, 6, E2. doi:10.1186/1472-6939-6-2

                                            Moore FD. Ethical Problems Special to Surgery: Surgical Teaching, Surgical Innovation, and the Surgeon in Managed Care. (200) Arch Surg. 135(1):14–16. doi:10.1001/archsurg.135.1.14

                                            Basques, B. A., Bitterman, A., Campbell, K. J., Haughom, B. D., Lin, J., & Lee, S. (2016). Influence of Surgeon Volume on Inpatient Complications, Cost, and Length of Stay Following Total Ankle Arthroplasty. Foot & Ankle International, 37(10), 1046–1051. https://doi.org/10.1177/1071100716664871

                                            Al-Qurayshi Z., R. Robins, J. Buell, E. Kandil, (2016) Surgeon volume impact on outcomes and cost of adrenal surgeries, European Journal of Surgical Oncology (EJSO), Volume 42, Issue 10, Pages 1483-1490, ISSN 0748-7983, https://doi.org/10.1016/j.ejso.2016.06.392.

                                            Al-Qurayshi Z, Robins R, Hauch A, Randolph GW, Kandil E. Association of Surgeon Volume With Outcomes and Cost Savings Following Thyroidectomy: A National Forecast. JAMA Otolaryngol Head Neck Surg. 2016;142(1):32–39. doi:10.1001/jamaoto.2015.2503


                                            [1] Other used terms in the English speaking literature besides minimum volume standards are volume-outcome relationship, surgeon volumes, surgical volumes, hospital volumes, case load etc. In the German speaking context “Frequenzregelung, Mindestmengen oder Mindestfallzahlen” are commonly used.

                                            [2] This is with regard to MVS that are transferable to the Austrian health care system: spitalsambulante, tagesklinische or in the course of a 0-Tagesauftenthalt conducted surgery

                                             

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