Advantages of and barriers to day surgery in Hong Kong
Day or ambulatory surgery is the practice of admitting carefully selected patients into hospital for a planned, nonemergency surgical procedure that requires full operating theatre facilities and discharging them within hours after that surgery. In an interview with MIMS Doctor, Dr Regina Choi, Specialist in Anaesthesiology in private practice in Hong Kong, discussed the advantages of day surgery, the need for careful patient selection, and existing barriers to this growing practice.
“The number of day surgeries performed in Hong Kong has been growing over the past 15–20 years as a result of both new, less invasive surgical techniques and the development of short-acting anaesthetics,” said Choi.
According to Hong Kong Hospital Authority list for key performance index, at least 18 surgical procedures are considered suitable for same-day dismissal in Hong Kong. They are: myringotomy, reduction of nasal fracture, resection of nasal septum, tonsillectomy, ovarian cystectomy, squint correction, arthroscopy, ganglion excision, carpal tunnel release, implant removal, anal surgery, circumcision, breast lump excision, inguinal hernia repair, laparoscopic cholecystectomy, transurethral resection of bladder tumour, unilateral thyroidectomy, and varicose vein ligation and stripping. “The list is not exhaustive and other procedures can be performed as day surgery as well, depending on the surgeons’ and anaesthetists’ expertise and individual medical centres’ capabilities,” noted Choi.
Advantages of day surgery
Compared with inpatient surgery, day surgery allows an increased throughput of patients and reductions in staff and hospital costs. Other benefits include the release of inpatient facilities for more complex and urgent cases, and less disruption to patients’ daily routines, with reduced absence from work or fewer problems providing care for others. “Importantly, the prevalence of surgical site infections following day surgery is low, regardless of the surgical procedure,” added Choi. [J Hosp Infect 2019;101:196-209]
“Unsurprisingly, many studies have reported high satisfaction with day surgery from patients and parents of young children,” noted Choi. [J Laryngol Otol 1999;113:1072-1075; Middle East J Anaesthesiol 2006;18:1113-1121; J Indian Assoc Pediatr Surg 2017;22: 226-231]
A telephone survey of 157 patients who underwent ambulatory inguinal hernia repair in Hong Kong reported >90 percent satisfaction with preoperative, operative and postoperative service. The majority of respondents (>80 percent) preferred day surgery again in case of hernia recurrence. [Ambul Surg 2000;8:115-118]
Patient satisfaction is generally ensured by good postoperative pain control, short waiting time before surgery, courteous staff and a friendly environment, avoiding rushing patients upon discharge, and a telephone follow-up the day after surgery. [International Association for Ambulatory Surgery, Policy Brief, 2007; Anaesthesia 2002;57:270-275]
Careful patient selection
“Not all patients are suitable for day surgery,” said Choi. “The selection process should be individualized, taking into account the patient’s overall physical condition, and should not be solely based on age, weight or anaesthetic risk. The main consideration is whether pre- and/or postoperative hospitalization would improve patient management or outcome; if not, the patient should undergo day surgery.”
Availability of social support should play a part in patient selection, as patients undergoing day surgery may require support from a responsible, physically able adult who can take care of them overnight (or longer for more invasive procedures). It is usually recommended that patients undergo day surgery at a facility within an hour’s journey of their home to ensure an easy return for emergency medical care in case of need. [International Association for Ambulatory Surgery, Policy Brief, 2007]
Patients also need to be well informed about what to expect of day surgery and in the postoperative period, so as to prepare them psychologically, reduce anxiety, minimize risks in the postoperative period, and improve overall satisfaction with the day-surgery experience.
“Day surgery is particularly appropriate for children, as it allows quicker return to a familiar home environment, thus reducing stress to both the children and their parents,” said Choi. “However, there are additional requirements associated with paediatric day surgery.”
The UK’s Royal College of Anaesthetists recommends that ex-preterm neonates should not be considered for day surgery unless medically fit and >60 weeks postconceptual age. “In Hong Kong, as of 2017, the age threshold for paediatric day surgery is >52 weeks postconception,” noted Chan. A staff member with advanced paediatric life support qualification or an anaesthetist with paediatric competencies should be immediately available, and infants with a history of chronic lung disease or apnoea should be managed in a centre equipped with facilities for postoperative ventilation. [Royal College of Anaesthetists, Guidelines for the Provision of Paediatric Anaesthesia Services 2020; rcoa.ac.uk/gpas/chapter-10]
Overcoming barriers to day surgery
“While the number of day surgeries performed in Hong Kong is growing, it varies widely between hospitals,” said Choi. “The main barrier to greater acceptance is the existing risk-adverse mindset, although day surgery is very safe when all the recommended guidelines are followed.”
At <0.1 percent, the incidence of death and major morbidity directly associated with day surgery is extremely low. [Curr Opin Anaesthesiol 2006;19:622-629] Rates of unplanned return visits to hospital and readmissions within 30 days directly related to day surgical procedures range from 0.28 percent to 1.5 percent. [J Clin Anesth 2002;14:349-353; Ann Surg 1999;230:721-727; Anesth Analg 1997;84:319-324] A retrospective study of return hospital visits and morbidity within 60 days of 18,736 day surgical procedures in Denmark found 117 (0.6 percent) complications definitely or likely related to day surgery. [Acta Anaesthesiol Scand 2006;50:911-919]
“Another hurdle to day surgery is that some insurance reimbursement plans may be more advantageous for hospitals or surgeons if patients are hospitalized for ≥24 hours, or some patients may be obliged to pay a percentage or even the full fee for day surgery by their private health insurance plans as opposed to full reimbursement for regular hospitalization,” highlighted Choi. “However, as insurers become more aware of the cost reduction implications, the trend in insurance coverage is shifting towards more favourable day surgery reimbursement for recognized procedures.”
“To facilitate the shift towards day surgeries for suitable procedures, patient and continued medical education are important. In addition, a change in reimbursement schedules can further promote day surgery,” concluded Choi.