Economic aspects of day care after operations for hernia or varicose veins

Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes

PURPOSE

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery.

METHODS

This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

RESULTS

A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021-22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58-0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74-0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04-1.40, p = 0.015).

CONCLUSIONS

For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Patient satisfaction after ambulatory inguinal hernia repair in Hong Kong

Ambulatory surgery was introduced to Asia in the 1990s. Acceptance of ambulatory surgery by oriental patients remains largely unknown. A telephone survey was conducted to evaluate the level of patient satisfaction following ambulatory inguinal hernia repair. A total of 157 patients (61%) completed the telephone survey. More than 90% of the respondents expressed satisfaction with regard to the pre-operative, operative and post-operative service. The majority of the respondents (>80%) preferred to undergo day surgery again in case of hernia recurrence. Our findings prove that ambulatory surgery has a high level of acceptance in Chinese patients and supports the expansion of a day surgery service in Hong Kong.

The Trent Regional Day Case Commission. An initiative to investigate the constraints to the extension of the use of day surgery

In 1989, Trent Regional Health Authority set up a Commission to enquire into the organization of day case surgery and encourage its use. Improved methods for measuring and comparing day surgical activity were developed using routine data sources. These revealed even greater variation between hospitals and specialties in the amount of day surgery performed than did the usual analyses. Arrangements for day surgery differed considerably between specialties. Few theatres, beds, or surgeons' sessions were dedicated to day surgery, but general surgery and gynaecology used dedicated facilities more than other specialties such as ENT and ophthalmology. The Commission visited each hospital and found that day case facilities, organization and resources were poor in many of them. It was able to make specific recommendations for improvements. Day case surgery increased substantially over the period that the Commission operated, most hospitals reported that it had influenced changes in day surgery and that it had been useful, especially for local managers. Schemes to increase day surgery were funded. Highlights two elements for managing change: the need for good information about a problem, and the need to extend ownership of the issue throughout the organization.

The role of economic evaluation in setting priorities for elective surgery

Problems with waiting lists have long affected the National Health Service. The priority given by clinicians to the elective surgery conditions usually found on waiting lists is low, but the publicity surrounding the waiting lists ensures that the priority accorded elective surgery in the political arena is much higher. Waiting list initiatives have provided additional resources for the purpose of reducing the number of patients waiting for elective surgery. It is suggested that economic evaluation should form one of a package of tools used by those setting priorities within elective surgery, but that the evidence provided by previously conducted economic evaluations of elective surgery is not of sufficient quality for purchasing authorities to use as a basis for priority setting.

An economic evaluation of daycare in the management of hypertension in pregnancy

OBJECTIVE

To evaluate the efficiency of daycare in the management of hypertension in pregnancy compared with inpatient management with prior domiciliary visits.

DESIGN

Comparative study.

SETTING

Two maternity teaching hospitals, Glasgow Royal Maternity Hospital which has an established daycare unit and Aberdeen Maternity Hospital with no daycare unit.

MAIN OUTCOME MEASURES

Pregnancy outcomes in terms of maternal hypertensive complications, gestation at delivery, mode of delivery, birthweight, Apgar scores, admission rates and length of admission to special care baby unit.

RESULTS

There was no significant difference in any of the measured pregnancy outcomes between the two hospitals. The average cost of treating a women with mild hypertension was 154.91 pounds in Glasgow and 136.59 pounds in Aberdeen. The average cost of treating women with a single episode of hypertension and women with a past history of hypertension was 88.65 pounds and 214.12 pounds in Glasgow and 31.18 pounds and 28.28 pounds in Aberdeen, respectively. If these two groups are excluded, the average cost of treating women with mild hypertension was 172.32 pounds in Glasgow and 201.13 pounds in Aberdeen. The majority of women were willing to attend daycare five times per week to avoid admission.

CONCLUSION

Daycare management of hypertension in pregnancy is more efficient than inpatient care with prior domiciliary visits for most women, but less efficient for women with transient or previous hypertension. It is very acceptable to women. Domiciliary checking of women with hypertension found at outpatient clinics would reduce resource use.

Discharge criteria in day surgery

Criteria are necessary to guide the nurse's clinical decision in determining when a patient is ready for discharge following day surgery. On the basis of a literature search and a descriptive research study of the recovery and welfare of patients following day surgery, seven categories are proposed for guiding the nurse's decision making. The seven categories are mental state, mobility, pain, eating and drinking, elimination, information and social factors. Mental state examines recovery from the effects of the premedication (if used) and anaesthetic on mental abilities, and the related problems of headache and muzzyheadedness. Mobility examines mobilization and the related problems of dizziness or faintness. Pain considers postoperative pain. Eating and drinking considers oral intake and the related problems of nausea and vomiting. Elimination considers voiding and the related problem of urine retention. Educational factors relate to the patient's need for predischarge information. Lastly, social factors consider the need for transportation and support within the home. Although there is not a proposed category for wound and cardiovascular complications, the literature review in this area is included in order to support this decision. The seven categories are subdivided into those criteria which are essential and those which are desirable. Meeting the essential criteria ensures patient safety. The desirable factors provide guidance for the nurse on additional factors which should be considered in relation to the quality of the patient's recovery and welfare. With these factors the nurse exercises his or her judgement in relation to the individual patient.

Screening and surveillance of pregnancy hypertension--an economic approach to the use of daycare

Frequent measurement of blood pressure is an accepted part of routine outpatient antenatal care. Women found to have mild hypertension may be further monitored for signs of progressive disease, while women with proteinuria or severe hypertension may be admitted for more intensive surveillance or treatment. In practice, the course and ultimate severity of this disorder are unpredictable and women with mild hypertension are frequently admitted. Recently, daycare has grown as an option for assessing women with hypertension as it offers the advantage of more extensive evaluation than is possible at an outpatient clinic and is widely assumed to be more cost-effective than conventional management. However, its use in obstetrics has not been subject to a formal economic appraisal. Such an evaluation is currently being carried out in two hospitals in Scotland, one of which uses daycare and inpatient admissions in the management of hypertension and one of which uses domiciliary midwife visits as well as hospital beds. Preliminary results suggest that the pregnancy outcome in terms of birthweight, gestation at delivery, admission to a special unit, etc., are the same in the two units for women with mild hypertension (diastolic 90-99 mmHg, no proteinuria). The costs per patient were less in the hospital with a daycare unit. These lower individual costs, however, do not mean that the overall costs to the health service are less in a hospital with daycare. This will depend on the average number of visits to daycare for women with mild hypertension, the proportion of hypertensive women receiving daycare, whether freed inpatient beds are closed or redeployed, and the capital costs of establishing a day unit. Data has also been collected on women's costs and views which will ultimately be presented and should play a part in any decision to implement or continue daycare.

Five years' experience of a gastroenterology day-case unit

An inpatient ward has been converted, at low cost, to a gastroenterology day-case unit, which includes a purpose-built endoscopy room and a day-case area. The presence of a day-case ward permits the nursing establishment to be sufficiently flexible to cover the endoscopy room fully, and the hours are suitable for married nurses with families. Patients remain on the same trolley throughout the procedure so that portering delays are avoided, and a good flow system operated by the unit's staff enables endoscopies to be carried out at the rate of one every ten to fifteen minutes. Admissions rose from 1900 to 2700 per year (an average of 12 X 5 admissions per working day, theoretical bed occupancy = 140%). Cost per patient is about half the estimated cost without a day-case unit. The increasing numbers of routine upper gastrointestinal endoscopies are mirrored by a halving of barium-meal examinations.

Postoperative analgesia for day-case herniorrhaphy patients. A comparison of cryoanalgesia, paravertebral blockade and oral analgesia

Patients were admitted as day-cases for inguinal herniorrhaphy under epidural anaesthesia and chlormethiazole sedation. The patients were given oral analgesia, and in addition, some were given either a paravertebral block with a dextran/bupivacaine mixture or cryoanalgesia of the ilio-inguinal nerve for postoperative pain relief. These anaesthetic and analgesic techniques are discussed in relation to day-case herniorrhaphy.

Cost and efficacy of the substitution of ambulatory for inpatient care

The substitution of ambulatory for inpatient care has become a common cost-containment proposal; it assumes that an equivalent or better clinical outcome at lower cost will result. However, when criteria for measuring cost and efficacy are appropriately defined, there is little published information available that support this assumption. Only four of 134 relevant papers that we analyzed provided enough data on both cost and efficacy to allow statistically valid conclusions. Two of these four demonstrated that potential savings would be accompanied by a slightly poorer clinical outcome; two showed ambulatory care to be as effective as inpatient care and less costly. Future study should include both appropriate calculations of costs and properly controlled measurements of clinical outcome. Indirect costs cannot be ignored in such calculations if the total costs of illness, not simply payments to the health industry, are to be reduced.