Transcript Outpatient Surgery Centers Draw Cases Away from Hospitals

Outpatient Surgery Centers Draw
Cases Away from Hospitals,
Impact Resident Training Volume
Kyle Dunning, MD*
Eric Liedtke DO*
Lori Toedter, PhD†
Chand Rohatgi, MD FASC*
*Department of Surgery, Easton Hospital, Easton, PA
†Department of Psychology, Moravian College,
Bethlehem, PA
Background
The first independent Ambulatory Surgery
Center (ASC) was established in Phoenix,
Arizona in 1970.
Today, over 4,000 ASCs span all fifty
states and account for over six million
procedures per year.
Currently, over 50% of colonoscopy
services in the United States are
performed in ASC’s.
Purpose
Ambulatory surgery centers (ASC’s) are
increasing in both number and surgical
volume
Impact on reimbursement, patient safety,
and surgical productivity and efficiency
Shift toward outpatient surgery in nonhospital settings is concerning with respect
to resident training
Hypothesis
Due to the expansion of local surgery centers,
hospital-based outpatient procedures would
decline and, in turn, negatively affect case loads
for our surgical residents.
Methods
Performed a retrospective review

Reviewed cases commonly performed in ASCs
Hernias, breast biopsies, endoscopies, etc.

Double-armed evaluation
Analyzed data from two separate sources to perform
independent evaluations
1. Reviewed resident reported data by year
2. Reviewed facility reported data per state reporting
agency
Resident reported data and hospital reported statistics are
not directly comparable (reported by academic year and
hospital data by calendar year)
Study Design
Resident reported data arm

Reviewed case log data (July 2004–June 2007)
Tallied by academic year
PGY1 – PGY3 resident data evaluated (n=30)
ACGME electronic case log system

Compared by procedure on yearly intervals
Tabulated each procedure by number performed
Evaluated for statistically significant increase or
decrease
Results: Resident reported data
Statistically significant decline in :
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Hemorrhoidectomies
carpal tunnel releases
excision of skin lesions
breast biopsies
skin grafts
Study Design
State reported data arm

Outpatient Market Share State Data from the
state of Pennsylvania
Data tallied by Pennsylvania Health Care Cost
Containment Council (PHC4)
Analyzed data between 2001-2006 by calendar year
Included our institution and four local ASCs that
participated in voluntary reporting
Compared hospital outpatient procedures vs. the four
ASCs individually and in total
Calculated specified procedures as a percentage of
total hospital volume to account for any errors from
fluctuating volume
Results: State reported data
2003 vs. 2005 there was a significant decrease for
some specific procedures:
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colonoscopy (p<.0001);
inguinal/femoral hernia (p=.04);
excision of skin lesion (p=.0022)
incision/drainage (p<.0001).
No significant differences were noted for carpal tunnel
release, endoscopy, hemorrhoidectomy, lumpectomy or
skin graft.
Trend toward significant decrease each year from 2001
to 2006, however could not complete calculations due to
some missing intervals
Results: State reported data
The total number of cases for both inpatient and
outpatient surgeries between 2003 and 2005
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ASC’s reported a combined total of 9,089 cases in 2003
compared with 12,832 cases in 2005 for a 41.2%
increase in volume
Our institution increased 6% (11,587 to 12,279)
While the total volume increased by 6%, there was a 4%
decrease in selected cases1 performed between these two
years. (p<.0001)2.
The selected cases represented 29.9% of all the hospital cases
in 2003, compared to 28.5%, 27.2% and 27.5% in 2004 through
2006.
1
Pre-selected cases for this study
Goodness-of-Fit test
2Chi-square
Pennsylvania Health Care Cost Containment Council (PHC4)
Discussion
Operative case numbers as a measure of surgical
training


Is it an effective measurement?
How many to be certified; competent; proficient?
Today, outpatient procedures constitute the bulk of
all surgeries
Residents are losing exposure to more basic cases
that serve as building block for surgical skills

May be less prepared for more challenging procedures
The “80-hour work week”
Confounding Variables
Compliance and accuracy of resident reported data
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Varies among residents
Only available for past 4 years
Voluntary reporting to State agency
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Some centers have gaps in certain years
Not all centers reporting in area
Academic vs. Calendar year data
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Allowed two separate analysis of same hypothesis
Study area is not isolated
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Patients may have gone to other hospitals
Also may have had procedure performed in non-reporting
ASCs
Pennsylvania Health Care Cost Containment Council (PHC4)
Conclusions
Based on our results, ASCs have significantly
impacted certain cases available to our
residents
More data will be collected and prospectively
followed in the years to come
Surgical residency directors must look to
include access to ASCs in the their residency
programs to assure the highest quality training
References
Ambulatory Surgery Center Association
http://www.ascassociation.org/advocacy/AmbulatorySurgeryCentersPositiveTrend
HealthCare.pdf
Frakes JT. Ambulatory endoscopy centers: what the interviewing fellow needs to
know. Gastrointest Endosc 2005; 62: 112-113.
Ferguson CM, Kellogg KC, et al. Effect of Work-hour Reforms on Operative Case
Volume of Surgical Residents. J Am Coll Surg 2005;62(5):535-538.
Pennsylvania Health Care Cost Containment Council (PHC4)
http://www.phc4.org/default.htm
Carlin AM, Gasevic E, Shepard A. Effect of the 80-hour work week on resident
operative experience in general surgery. Am J Surg 2007; 193:326-330.
Smale BF, Reber HA, Terry BE, Silver D. The creation of a surgical endoscopy
training program-Is there sufficient clinical material? Surg 1983; 94:180-185.
Spencer AU, Teitelbaum DH. Impact of Work-Hour Restrictions on Residents’
Operative Volume on a Subspecialty Surgical Service. J Am Coll Surg
2005;200:670-676.