{
Characteristics, Clinical & Cost
Effectiveness Assessment of a
Community Ambulatory Surgery
Center Compared with a Public
Hospital
Kesner D1, Shapira C2, Kaufman L1, Milman U3.
1. Zvulun medical center 2. Carmel medical center
Disclaimer
This study was funded by : Gertner Institute
for Epidemiology and Health Policy Research
Background
Healthcare costs and new technologies enabled shift to
outpatients’ facilities.
Zvulun Medical Center has 3 active ambulatory operating
theaters for the last 10 years.
Similar ambulatory operations are also done at Carmel hospital,
a public hospital [owned by Clalit].
The quality, adequacy and cost of both systems was not
{
QUALITY
ADEQUACY (Age, Demographic characteristics, Medical History, Operative Risk).
SATISFACTION COST
FLOW CHART
eligible for research (n=3315) patients recruitment Excluded=190,6%) cohortn=3125,94% CARMEL ZVULUN
distribution according to site research group 2 (n=1095,33%) research group 1 (n=2030,61%) were treated (n=1095,33%) were treated (n=2030,61%) dropped (n=0) dropped (n=0)
first follow up (one month after surgery)
participated in research (n=1030,31%)
participated in research (n=1941,59%)
dropped(lost contact) (n=50,1.5%) dropped(lost contact) (n=75,2%) refusal to continue (n=140,4%) refusal to continue (n=14,0.4%)
second follow up (6 month after surgery) participated in research (n=976,29%) participated in research (n=1837,55%)
Dropped (lost contact) (n=44,1%)
Dropped (lost contact) (n=94,3%)
refusal to continue
(n=2,0.06%) refusal to continue (n=5,0.2%) death (n=8,0.2%) death (n=5,0.2%)
data analysis
data that was analyzed (n=976,29%)
data that was analyzed (n=1837,55%)
were taken off the analysis (n=0,0%)
were taken off the analysis (n=0,0%)
the percentage of the participants - 85% in all the sample & at every site separately
the percentage in the chart were calculated from n=3315 patients who arrived for surgery
Hysteroscopy
Children Hernia
Adult Hernia
Cataract
Adenoidectomy
Tube Insertion
Trigger Finger
Carpal Tunnel
Operations that were
sampled
There were no major differences in terms
of:
Basic demographic characterizations
Complications
]
Immediate or late]
Waiting period to operation
Local anesthesia was used in 71% of the
CAS operations compared with 50% in
hospital.
Most of the patients who were operated
in the CAS and in the hospital will prefer
the same site again.
CAS patients lost slightly more days from
receiving explanations about the operation before the procedure CARMEL ZVULUN % n % n 4% 42 2% 45 day of surgery 8% 75 7% 134 > one week before op .
6% 55
11% 208
one-two weeks before op .
29% 283
28% 516
two weeks-two month before
12% 115
20% 364
two month -six month before
13% 129
7% 136
six month -1 year before
3% 27 3% 62 < 1 year 7% 72% 6% 112 recurrent operation 18% 177 14% 253
did not receive explanation
Cost Analysis – The players
The ministry of Health (MOH) – the
primary insurer of all the Israeli population.
The HMO’s - contractors of the MOH;
actual providers of healthcare.
The Hospitals – private, owned by
MOH or by HMO's); Each with its
economic interests – despite the fact the most are, by definition, a non profit organizations
Cost Analysis – a New
player?
In to this field of giants, the
Community Ambulatory Medical Center was introduced as a new provider of, what is traditionally
considered, hospital merchandise.
We have shown that the Ambulatory
medical center is not inferior in terms of quality but, is it cost effective?
Cost Analysis – The Rules
The official price - published by the
Ministry of Health. Is the basis for pricing of health care products, including surgical procedures.
The financial policy in the public
health system, that is based upon capping, is the basis for the actual cost.
Cost Analysis – Mind the Gap
The difference in salaries, overhead andother factors make the difference in the actual cost.
It should be noted that the cost of the
procedures in the ambulatory center is the actual cost, and it is lower by about 20% than in hospital.
20% difference may result in a
Conclusions
The low complications rate suggests that patient's
selection for ambulatory operation or hospital was
appropriate
.
Community Ambulatory Service operations contribute
to a better use of resources considering the lower cost
Who gave the explanation
CARMEL
ZVULUN
% n % n 2% 13 4% 63family practitioner
96% 694 75% 1118surgeon
1% 9 9% 142nurse
1% 6 12% 174other
χ²=152.3, p <.001surgery site preference by patients surgery site
ZVULUN CARMEL
n % N %
if could choose what ambulatory 1627 89% 753 77% would you prefer hospital 139 8% 220 23% ambulatory or hospital no difference 47 3% 0 0%
surgery? doesn't know 24 1% 3 0%
if ambulatory community 1626 89% 142 15% in the community hospital 138 8% 189 81% or the hospital no difference 49 3% 37 4%
doesn't know 24 1% 7 1%
85% would prefer ambulatory surgery(89% from zvulun,77% from carmel)
carmel zvulun ² X % n % n 9.8 ** 39% 381 45% 830 male gender 61% 594 55% 1006 female 6.7 ns 67% 657 63% 1151 Jewish religion 6% 60 7% 119 Christian 20% 192 24% 432 Muslim 7% 64 7% 122 Druze 0% 3% 0% 4 other 14.0 ** 12% 120 11% 197 < 18 age 14% 133 12% 225 18-40 19% 186 17% 310 41-55 23% 223 29% 539 56-70 32% 311 31% 565 > 71 31.1 *** 7% 58 4% 61 no formal education education 21% 171 23% 367 < 8 years 43% 356 48% 777 high school 17% 142 14% 227 first degree 13% 104 11% 174 second degree + ** p<.01,***p<.001 Surgery site
DOCTOR VISIT AFTER THE OPERATION SURGERY SITE ZVULUN CARMEL n % n % family no visit 847 46% 396 41% pratitioner 1 visit 496 27% 316 32% 2-3 visits 425 23% 223 23% 4+ visits 69 4% 41 4% surgeon no visits 611 33% 508 52% 1 visit 570 31% 302 31% 2-3 visits 571 31% 141 14% 4+ visits 85 5% 25 3%
CARMEL PATIENTS WENT MORE TO FAMILY PRACTITIONER ZVULUN PATIENTS WENT MORE TO THE SURGEON
