Ambulatory anesthesia practices in Spain

Ambulatory Anesthesia Practices in Spain F. Gilsanz and G. Blanc

I N RECENT YEARS health care expenditure has soared in Europe, in part because an in-

creasingly older population has created a higher demand for health services to treat chronic dis- eases. In addition, the rapid pace of social change, improved living standards, and longer life expectancy have led to a greater demand for surgical operations. All governments, whatever their political ideology, are seeking new ways of financing their health care services or evaluating cost containment programs because the constant increase in the resources allocated to health care has been insufficient to alleviate the problems generated by a greater and more costly demand.

It is clear that the current economic situation requires greater levels of efficacy and efficiency. Optimal use of resources requires that new for- mulas be devised to meet the demand without compromising the quality of medical care, slow- ing down technological progress, or stopping re- search.

Major ambulatory surgery (MAS) represents an alternative to traditional surgery requiring hospitalization. It arose as a response to rising health care costs and as a way to achieve greater efficacy in the use of hospital resources. Its de- velopment was made possible through new diag- nostic and therapeutic techniques, minimally in- vasive surgery, and new anesthetic drugs.

There is still confusion in Spain regm'cting the terminology to be used in this area and lack of agreement about the most appropriate definition for this medical subspecialty.

The most widely known term is m a j o r a m b u l a - tory surgery , which is used to distinguish this type of surgery from what is traditionally known as a mbu la to ry surgery (usually identified with minor surgery). Novel anesthetic drugs, mini- mally aggressive surgical techniques, and im- proved postoperative care have made it possible to perform surgical procedures traditionally re- quiring hospitalization on an ambulatory basis.

On the other hand, the need to provide specific facilities for these procedures has Ied to the cre- ation of specific surgical units known as Day Surgery Hospitals, in which ambulatory surgical procedures or day-case surgery is performed.

The period of growth and consolidation of am- bulatory surgery was in the 1980s, at which time the term major ambulatory surgery became estab- lished.

The introduction of MAS has been slow in Spain. In recent years, through the initiative of individual practitioners, some isolated programs have been perforated, each one having its own peculiarities in terms of program design, hospital stay, and postdischarge follow-up. The first MAS programs were not started in Spain until the end of the eighties and beginning of the nineties. The first Major Ambulatory Surgery Unit was created in 1988 as part of the Toledo Hospital Center. The Major Ambulatory Surgery Unit of the Hos- pital of Viladecans (Barcelona) was established in 1990. A private Major Ambulatory Surgery Unit was created in Madrid in 1992.

1992 was an emblematic year for MAS in Spain. The first Congress on MAS was held in Barcelona in February 1992. Later in the same year, the Spanish Society of Major Ambulatory Surgery and Short Inpatient Stay was founded. It is from this time on when the development of MAS began to be promoted in Spain.

TYPES OF SURGICAL PROCEDURES

The way MAS was initially introduced in Spain differed in several aspects from its intro- duction in other countries such as the United States or the United Kingdom. When health care systems such as the American or British systems introduce changes in the way their services are provided, they generally begin with the less com- plex diagnostic or therapeutic procedures that previously required hospitalization, making them ambulatory procedures. Of the total procedures performed in 1985 in the United Kingdom, i5%

From the Department of Anesthesiology, Hospital de la Princesa, Madrid, Spain.

Address reprint requests to F. Gilsang, Servicio Anestesia- Reanimacion, Hospital de la Princesa, Diego de Leon 62, 28006 Madrid, Spain.

Copyright �9 1997 by W.B. Saunders Company 0277-0326/97/1603 000755.00/0

Seminars in Anesthesia, Vol 16, No 3 {September), 1997: pp 20%212 209

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Table 1. Surgical Procedures Included in the British Report of 1990

Inguinal hemiorrhaphy Extirpation of benign breast tumors Excision or dilation of anal fissures Varicose vein surgery of lower extremities Hemorrhoidectomy Uncomplicated and fistulae surgery Excision of pilonidal sinus Treatment of hallux valgus Release and excision of sheaths arid/or tendons

(Dupuytren's contracture, carpal lunnel syndrome, ganglion) Diagnostic and therapeutic arthroscopy Osteosynthesis removal Cataract surgery Lacrimal cyst incision and drainage Strabismus surgery Phimosis Orchidopexy Tonsillectomy, adenoidectomy Uterine dilatation and curettage

were gastroscopies, 5% uterine dilatation and cu- rettage, 4% excisions of skin lesions, and 4% sigmoidoscopies. These are procedures that gen- erally do not require hospitalization or special- ized care and would be treated on an outpatient basis in most units. In 1990 the British Audit Commission established a list of the procedures considered appropriate for treatment in day-case surgical units.

When Spanish hospitals started their ambula- tory surgery programs, they began with the surgi- cal procedures included in the British Report of 1990. These are listed in Table 1.1

ELECTIVE SURGICAL PROCEDURES

The use of MAS in Spain has been spreading since the beginning of this decade, although more slowly than would be desired, mainly through the efforts of practitioners and incentives pro- vided by the public health administration in the last 3 years.

In 1993 the Spanish Ministry of Health pub- lished "Guidefines on the Organization and Management of Ambulatory Surgery, ' '2 and in 1994 the Directorate General for Health Planning surveyed Spanish hospitals to assess the current status of ambulatory surgery in Spain. 3

A total of 611 hospitals included in the Na- tional Listing of Hospitals were surveyed, with a total capacity of 139,322 beds.

GILSANZ A N D BLANC

Survey responses were received from 212 hos- pitals (35% of those surveyed), with the highest response rate corresponding to hospitals belong- ing to the INSALUD (hospitals from the public hospital network administered by the national government and not by autonomous community governments).

There was a total of 78 hospitals (37% of re- sponders) performing MAS. Forty of those hos- pitals had less than 200 beds and 18 hospitals had more than 500 beds. The largest percentage of hospitals performing MAS belonged to the Social Security System.

Twenty-four percent (19) of the hospitals per- forming MAS had a specific program for this purpose. The remaining hospitals offered either specific surgical services or health professionals.

The most frequently performed MAS proce- dures were (1) tonsillectomy and/or adenoidec- tomy (2) cataract surgery, (3) phimosis, and (4) inguinal heruiorrhaphy.

The responses to the question, How is MAS provided?, are outlined in Table 2. 3

The survey did not find any Type IV MAS units, the usual case being that these procedures are performed as an additional service without a specific unit.

Of the 78 hospitals performing MAS, in only 27% are there specific protocols for these proce- dures; 40% have some type of protocol and 28% are not aware of the use of a specific protocol. The areas most frequently covered in these proto- cols were preanesthetic assessment (42 hospi- tals), preoperative preparation (40 hospitals), pa- tient selection (36 hospitals), informed consent (34 hospitals), postdischarge follow-up (33 hos- pitals), selection of surgical procedures (31 hos- pitals), and anesthetic technique (31 hospitals).

The survey covered a total of at least 27,536 MAS procedures performed in 1993.

MAS procedures performed in hospitals in

Table 2. How Is MAS Provided?: Responses of 611 Hospilals Included in Ihe National Listing of Hospitals

As a service without a specific unit 42~/o Type I unit (shares all resources) 22% Type II unit

(shares resources but has its own organization) 19% Type fll unit (specific facilities for the unit} 15% Type IV unit (independent facilities and organization) 0%

AMBULATORY ANESTHESIA IN SPAIN

1994 accounted for 4.87% of the total surgical procedures performed and 7.04% of those requir- ing hospitalization. Ambulatory procedures were 35.63% of all surgical procedures.

In 1993 Colomer et al4 published the indexes of substitution (weight of these surgical proce- dures as a percentage of total surgical proce- dures) for the Hospital of Viladecans where they found an overall rate of 27.1%, whereas the rates for specific procedures were: cataracts (51.6%), tonsillectomy and adenoidectomy (36.2%), in- guinal hernia (29.1%), carpal tunnel decompres- sion (56.7%), phimosis (52.1%), and arthroscopy (86.2%). The index of substitution for hernias in this same hospital 2 years tater was 38%. The Ministry of Health perfoixned a study in 1993 to determine the impact of the development of MAS on two procedures, hernia and cataract surgery. In the case of hernia surgery, 34 hospitals had performed 10,707 surgical procedures, 1,832 of which were on an ambulatory basis (index of substitution 17.11%). In the case of cataract sur- gery, 34 hospitals performed 13,009 surgical pro- cedures, 2,003 of which were on an ambulatory basis (index of substitution 16.93%).

According to a study by the INSALUD on surgical procedures that may be considered ac- ceptable candidates for outpatient surgery and covering the period from the second semester of 1995 to the first semester of 1996, a total of 96,755 potentially ambulatory surgical proce- dures were performed. The mean hospital stay was 4.03 days. I f we eliminate those conditions having more than one diagnosis (mean diagnoses per patient 3.06; a total of 34,939 cases) there were 46,934 potential cases for MAS. Of these surgical procedures 32.66% were included under contract programs, which are an agreement be- tween the National Health Service and hospitals on the number and type of patients that will be operated on per year by each hospital department. This would mean a saving of 200,332 hospital- izations. At present, only 34.38% of total surgical procedures are performed on an ambulatory ba- sis, with hernia and cataract surgery being the most common procedures.

Ambulatory surgery activity remained con- stant in Spain until 1993. In the last 4 years, soaring health care costs and lengthy waiting lists have caused changes in the management of health services. The public health administration

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Table 3. The Amount Paid in Thousands of Pesetas for the Conditions Considered as MAS by the INSALUD

Tonsillectomy 31 Cataracts 127 Varicose vein surgery 97 Phimosis 39 Unilateral herniorrhaphy 85 Bilateral herniorrhaphy 111 Hallux valgus 67 Lacrimal cyst drainage 31 Arthroscopy 108 Hemorrhoid surgery 71 Uterine dilation and curettage 46 Excision of pilonidal sinus 46 Extirpation of breast tumor 70 Re~ease of sheaths 51 Orehidopexy 62

has begun to promote the use of this type of surgery and has included MAS under contract programs. In 1990, MAS procedures were the exception in Spain, whereas more than 62,000 MAS procedures are expected to be performed in 1997.

Starting in 1996, MAS procedures performed in public hospitals were remunerated on a per procedure basis to encourage increased use of this type of surgery. The amount paid in thou- sands of pesetas for the conditions considered as MAS by the INSALUD are Iisted in Table 3.

MAS is the leading program of all contract programs for 1997. The INSALUD has centered its actions for specialized care on the reduction of waiting lists for elective surgery. For this pur- pose, in its statement of objectives for this year, it has forecast a 15% increase with respect to the estimated 54,684 MAS procedures performed in 1996. To achieve this goal, it is planned that each Major Ambulatory Surgery Unit have an output of not less than 2,800 procedures per year, which means an average of 12 procedures per day. In addition, the previously stated remuneration rates are being updated and the number of procedures included will be increased (A. Navarro, INSA- LUD Provincial Director, personal communica- tion, November 1996).

ANESIHETIC TECHNIQUES, EQUIPMENT, AND POSTOPERATIVE SIDE EFFECTS

The anesthetic techniques used in our center since the creation of the Major Ambulatory Sur- gery Unit in 1994 are general anesthesia

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(59.46%), monitored anesthesia cure (MAC; 23.16%), and local or regional anesthesia (17.36%).

The most commonly used drugs are propofol for induction and MAC; midazolam for preopera tive sedation; mivacurium, atracurium, and vec- uronium as muscular relaxants; isoflurane or desflurane for maintenance during general anes thesia (sevoflurane is not commercially available in Spain at present); fentalayl for intranperative analgesia; ketorolac for postoperative analgesia; metamizole (pyrazolon derivative) in the event of intolerance to ketorolac; lidocaine for spinal anesthesia; and bupivacalne, lidocaine, or mepiv acaine for plexus and peripheral nerve blocks and surgical wound infiltration.

The operating room equipment used is the same as for inpatient surgery and hacludes a sphygmomanometer, electrocardiogram, pulse oximeter and capnograph, respiratory parameter monitoring, inhalational anesthetic concentration monitoring, and muscle relaxation monitoring.

General anesthesia has the largest percentage (9.37) of admissions, followed by local or re gional anesthesia (8.80%) and local anesthesia and sedation (5.03%).

The most frequent reasons for admission were vomiting (27.39%), dizziness (21.91%), poor pa tient selection (20.54%), pain (9,58%), hemor rhage (8.21%), and urinary retention (5.47%).

Routine prophylaxis for pulmonary aspiration is not recommended, and neither is routine use of prophylactic antiemetics, f f nausea or vomiting appears postoperatively, we use metoclopramide as the drug of first choice. The use of the drug ondansetron is restricted in our hospital because

GILSANZ AND BLANC

of its high cost. Low-dose dropefidol is used ex- tensively.

For treatment of postoperative pain, surgical wound infiltration with the anesthetics bupiva- caine or lidocaine is used when feasible. Analge- sia is provided according to a protocol using non- steroidal anti-inflammatory drugs (ketorolac, metamizole, acetaminophen-codeine).

FUTURE PERSPECTIVE FOR AMBULATORY SURGERY IN SPAIN

There seems to be a bright future for MAS in Spain i f we consider the growth seen in this modality of surgery, the number of units created in recent years, and the support of the public health administration.

However, it will take many years for Spain to reach the levels attained in the United States and the United Kingdom, where it is estimated that between 60% to 80% of surgical operations will be performed on an ambulatory basis by the year 2000. However, i f the growth rate of recent years is maintained, as much as 40% to 45% of surgical operations could be performed on an ambulatory basis by the end of this century.

REFERENCES 1. Audit Commission: A short cut to better services, in

Day Surgery in England and Wales. London, UK, HMSO, 1990

2. Ministerio de SatlJdad y Consumo: Cirugla Mayor Am- bulatoria. Gula de Organizacidn y Funcionamiento. Madrid, Spain, Ministerio de Sanidad y Consumo, 1993

3. Sevilla F: Situacion especial de la ciraga ambulatoria en Espafia. 11 Cotlgresso Nacional de Cirugia Ambulatofia, Sevi/la, Octubre 1995

4. Colomer J, Alonso A, Serra A, Moreu F. AmbaIatory surgery: The need for indexes of substitution. Ambulatory Surgery 1:22-24, 1993