Minimum Volume Standards in Day and Ambulatory Surgery

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)

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

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 5^th 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