Outpatient operations: The focus is on the patient

A large proportion of the most frequently performed inpatient operations in Germany can be carried out on an outpatient basis without any disadvantages for the patient. There would be advantages for the patient, the doctor and the payers. The patient would benefit from a full course of treatment with the same trusted doctor, reduced downtime and recovery at home. The doctor could specialize in certain outpatient operations and thus gain a competitive advantage. Health insurance companies would have the opportunity to achieve cost savings because outpatient operations are significantly cheaper than inpatient operations. For example, an inguinal hernia operation carried out on an inpatient basis costs a statutory health insurance company around 2,252 euros; the same operation carried out on an outpatient basis costs less than half (around 1,069 euros). The cost of a cataract operation is around 1,458 euros as an inpatient and only around 903 euros as an outpatient. A study by Oberender and Partner from 2010 shows potential savings in the area of outpatient operations of 25 million to 515 million euros in Germany. Cost savings of this magnitude should be taken into account by politicians, especially given the current dramatic financial situation of the health insurance companies.

>> Despite these clear advantages, the rate of outpatient operations in Germany is relatively low compared to other countries. In relation to all operations, with a share of 37%, it is well below the international average (see Fig. 1). Industrialized countries such as Canada (87%), Denmark, Sweden and Norway (55%, 50% and 48%) as well as Australia (41%) and Scotland (39%) have much higher proportions of outpatient operations. Possible factors for this could be a lack of information for patients and a lack of transparency about the quality of the services offered on an outpatient basis.
The Bavarian Association of Statutory Health Insurance Physicians (KVB), in cooperation with the Ludwig Maximilian University of Munich (LMU) and the Federal Association for Outpatient Surgery (BAO), has therefore prepared a scientific evaluation of the process and result quality of selected outpatient operations. The aim of the project was to create transparency regarding the quality of care for outpatient operations as well as a meaningful database for further projects. Two topic blocks were analyzed: patient satisfaction and the postoperative patient course.
Method description patient satisfaction
The study of patient satisfaction was based on the quality assurance instrument AQS1 from the Institute for Quality Assurance Systems medicaltex and was carried out for four selected outpatient operations as part of a pilot study:
• Closure of a hernia inguinalis (inguinal hernia)
• Submucosal resection and plastic reconstruction of the nasal septum (nasal septum)
• Excision and destruction of diseased tissue of the uterus (myoma on the uterus)
• Arthroscopic refixation and plastic of the capsular ligament apparatus of the shoulder joint (shoulder joint)

These outpatient operations were selected by a team of experts based on the following criteria:
• The services fall under so-called ward-replacing services of category 2 services according to the catalog of outpatient operations according to §115b SGB V
• The services show high savings compared to the inpatient area
• The services should be able to be provided by as many specialist groups as possible

The focus of the quality assurance instrument AQS1 was a patient survey in which patients voluntarily rated the processes in the practice and any postoperative complications that occurred. Many dimensions of patient satisfaction mentioned in the literature (Neugebauer/Porst 2001) were also asked in this patient questionnaire, for example the evaluation of medical care, the politeness of the people surrounding the patient, the process organization and administration, the evaluation of the information and explanation as well the overall satisfaction.
The pilot study was carried out between July 1, 2008 and December 31, 2008. All outpatient surgeons in Bavaria who performed one or more of the four selected outpatient operations were eligible to participate. The medical participation rate, i.e. the proportion of participating doctors out of potentially participating doctors, was 45.3%.
The patient questionnaire was given to the patient including a addressed postage-paid envelope with the request that they fill it out within the first two weeks postoperatively and send it directly to medicaltex in the enclosed postage-paid envelope. In addition, the anesthesiologist and the surgeon documented their intraoperative and immediate postoperative performance on the physician questionnaire.
Patient satisfaction
During the study period, 1,910 patients were surveyed about the four selected outpatient operations. The average age was 46.9 years; Of the 1,910 patients, 1,073 patients were male and 834 were female. The response rate for the patient questionnaires was 43.1%.

Overall satisfaction with outpatient surgery:
A total of 97.5% patients rated the procedure as “very good” or “good”. The overall evaluation of the intervention received a grade of 1.4 on a scale of 1 (very good) to 5 (very bad).

When asked about the information provided by the surgeon, 90.8% of the patients said that they found the information about the risks and benefits of the surgical procedure “very good” or “good”. According to the patients, 88.9% of patients were able to dispel their fear of anesthesia “very well” or “well” by the anesthesiologist. Furthermore, 87.7% of the patients rated the information about further treatment after the operation as “very good” or “good” (Figs. 2 and 3).
In the topic block of practice equipment and service (see Figure 4), 93.9% of patients rated the organization and appointment planning, 95.3% the equipment of the practice and 97.2% the friendliness and helpfulness of the practice and practice team as “very good” or “good”.
95.5% of patients, 93.5% of patients over 65 years of age and 95.5% of single patients would - if necessary - undergo another outpatient operation. Thus, there are no significant differences in willingness to undergo repeat outpatient surgery depending on whether or not the patient is single or older than 65 years.
Complaints/postoperative adverse events:
In addition to overall satisfaction, doctor and patient questionnaires were used to record possible adverse events during the operation, complaints in the recovery room and complaints at home.
Few intraoperative adverse events occurred in the documented outpatient operations. As shown in Table 1, extension of planned surgery had to be performed in 1.0% of cases; Bleeding occurred in 0.9% of outpatient operations. Nerve lesions, technical/instrumental complications, other complications or cancellation of the operation occurred in 0.2% of outpatient operations.
The three most common complaints identified in the recovery room were cardiovascular complaints in 6.4% of documented outpatient operations, respiratory tract complaints (2.3%) and technical problems (2.2%). These complaints in the recovery room only range in severity from 1 to 2 and are therefore classified as not serious (Table 2).
The patients also rated any complaints they may have experienced at home on an 11-point scale (see Figure 5). The majority (average 81.2%) of the possible complaints were rated as “not at all” to “a little”. The wound pain up to the 3rd day after the operation, sleep problems (9.1%), circulatory problems (7.7%) and wound pain after the 3rd day after the operation (7.6%) were “moderate” to “unbearable” at 13.9%. .
Home care:
Another important aspect for the patient is adequate care at home. This not only includes care at home, but also the supply of medication or the ability to call the doctor. The results show that 94,9% of the patients surveyed felt at home after surgery that their surgeon/anesthetist was available to them at all times. 94.9% of patients overall and 93.9% of patients over 65 years of age stated that they felt they received adequate care at home. In particular, 97.5% of the patients felt adequately supplied with medication on the day of surgery and 96.9% of the patients at home.
Postoperative patient course
Estimates of the frequency of complaints or complications based on patient information can lead to an underestimation of complaints or the frequency of complications. This can be attributed to the fact that the willingness to take part in the voluntary survey is negatively influenced by the occurrence of severe symptoms and complications. Therefore, in addition to patient satisfaction, inpatient and outpatient billing data were examined to determine possible postoperative adverse events and to validate patient information about complaints.
Method description postoperative patient course:
When analyzing the postoperative patient course, the cohort of patients on whom one of the selected outpatient operations was performed in the period 2008/03 and 2008/04 was taken into account. Additionally, data from the quarters of 2007/03 and 2007/04 were used as a control group. For the first time, inpatient and outpatient billing data could be combined for the analysis. Data from the inpatient area were provided by the participating health insurance companies (AOK Bayern, Vereinigte IKK, BKK Audi, BKK Faber Castell, SBK, BKK mobil oil, mhplus BKK).
A team of specialists was founded to analyze the post-operative treatments. The specialist experts (Dr. med. Winfried Goertzen, Dr. med. Axel Neumann and Dr. med. Ulrich Schwiersch) are outpatient surgeons from the relevant fields of general surgery, otolaryngology and gynecology and regularly carry out the corresponding selected outpatient operations. In the outpatient data, the specialist experts analyzed those treatments that were carried out 72 hours after the outpatient operation. On the one hand, it was taken into account that most surgery-related complications occur 72 hours after an operation and, on the other hand, the selected period allowed inaccuracies in the allocation of adverse events based on the fee schedule position (GOPs) to be limited.
For the inpatient data, the team of experts examined the treatments that occurred 30 days after the outpatient operation. The observation period could be extended here because the ICD-10 diagnoses, which can be recorded on a daily basis, can provide precise information about the respective treatment. The task of the subject expert analysis was to identify those services that indicated a postoperative adverse event.
Results of the postoperative patient course:
The results show low postoperative adverse events in inpatient and outpatient settings. On average, a postoperative adverse event occurred in 5.9% cases, which led to outpatient treatment 72 hours after the outpatient operation. Treatments related to an adverse event in the inpatient setting 30 days after outpatient surgery were necessary in an average of 1.1% cases. Figure 6 shows the relative frequencies separately for the outpatient operations considered.
Conclusion
In this article, patient satisfaction and the postoperative course of patients in selected outpatient operations were analyzed, whereby, on the one hand, a combined doctor and patient survey was carried out to determine the quality of treatment and patient satisfaction and, on the other hand, outpatient and inpatient billing data were merged and examined.
Patient satisfaction was measured using patient information without the direct involvement of the service providers. Publication of the results - for example through quarterly evaluation reports for the participating doctors - leads to constructive discussions in practice and quality improvements within the framework of internal quality management. However, estimates based on patient information can lead to an underestimation of the frequency of complaints or complications. This would be the case if participation in the survey was negatively influenced by the occurrence of complaints and complications. When examining billing data, however, possible data problems must be taken into account, particularly inaccuracies in the allocation of adverse events based on fee schedule items. Here – as far as possible – a prospective change to the data structure would be desirable.
Therefore, the combination of both aspects appears to be a sensible and holistic approach to creating transparency with regard to the quality of care in outpatient operations. The results indicate a high process and result quality in outpatient operations. <<