Ambulatory surgery
Over the past few decades, the number of surgical procedures carried out on a same-day basis has increased markedly in OECD countries. Advances in medical technologies – in particular, the diffusion of less invasive surgical interventions – and better anaesthetics have made this development possible. These innovations have improved patient safety and health outcomes. Further, by shortening the treatment episode, ambulatory surgery can save important resources without any adverse effects on quality of care. It also frees up capacity within hospitals to focus on more complex cases or to reduce waiting lists. However, the impact of the rise in same-day surgery on overall health spending may not be straightforward, since the reduction in unit costs (compared to inpatient surgery) may be offset by overall growth in the volume of procedures performed. Any additional costs related to post-acute care and community health services following the interventions also need to be considered.
Cataract surgeries and tonsillectomies provide good examples of high-volume surgeries that are now mainly carried out on a same-day basis in many OECD countries.
Ambulatory surgery accounts for 90% or more of all cataract surgeries in around three-quarters of OECD countries with available data (Figure 5.29). In several countries, nearly all cataract surgeries are performed as day cases; however, the rate is relatively low in Lithuania and Mexico, with fewer than 65% of surgeries performed as ambulatory cases. Ambulatory surgery is also low in accession countries Bulgaria and Romania, comprising under 50% of surgeries. While low rates may be explained in part by limitations in the data coverage of outpatient activities in or outside hospital, it may also reflect higher reimbursement for inpatient stays or constraints on the development of day surgery.
Tonsillectomies are one of the most frequent surgical procedures performed on children – usually those suffering from repeated or chronic infections of the tonsils, breathing problems or obstructive sleep apnoea due to large tonsils. Although the operation is performed under general anaesthesia, it is now carried out predominantly as ambulatory surgery in 12 of 31 OECD countries with comparable data, with children returning home the same day (Figure 5.30). However, the proportion of day cases is not as high as for cataract surgery, at 40% of tonsillectomies versus 94% of cataract surgeries on average across OECD countries with available data. Day tonsillectomy rates are relatively high in Iceland and Costa Rica (over 90% of cases) but remain lower than 10% of cases in six OECD countries, as well as in accession countries Bulgaria and Romania. In Slovenia, Hungary, the Czech Republic and Austria, practically no tonsillectomies are performed as day cases. These large differences in the share of ambulatory surgery may reflect variations in the perceived risks of post-operative complications, or simply clinical traditions of keeping children in hospital for at least one night after the operation.
The number of cataract surgeries and tonsillectomies performed as ambulatory cases has grown significantly over time in many countries, including Austria, Hungary, France and the United Kingdom (Figure 5.31 and Figure 5.32). In Austria, the share of cataract surgeries performed as day cases increased from only 46% in 2011 to 91% in 2021; in Hungary, it increased from 35% to 77%. The share of tonsillectomies performed as ambulatory cases almost doubled between 2011 and 2021 in Sweden (45% to 80%) and the United Kingdom (39% to 70%). The share of same-day surgeries was largely unaffected by the pandemic, with similar shares in 2021 and 2019 for most OECD countries, for both cataract surgeries and tonsillectomies.
Financial incentives can also affect the extent to which minor surgery is conducted on a same-day basis. In Denmark and France, diagnostic-related group systems have been adjusted to incentivise ambulatory surgery. In the United Kingdom, a financial incentive is awarded for selected surgical procedures if the patient is managed on a day-case basis (OECD, 2017[1]).
Cataract surgery consists of removing the lens of the eye because of the presence of cataracts partially or completely clouding the lens, and replacing it with an artificial lens. It is mainly performed on elderly people. Tonsillectomy consists of removing the tonsils – glands at the back of the throat. It is mainly performed on children.
The data for several countries do not include outpatient cases in hospital or outside hospital (patients who are not formally admitted and discharged), leading to some underestimation. In Costa Rica, Mexico, New Zealand, Portugal and the United Kingdom, the data only include cataract surgeries carried out in public or publicly funded hospitals, excluding any procedures performed in private hospitals.
References
[1] OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://doi.org/10.1787/9789264266414-en.
Source: OECD Health Statistics 2023.
Source: OECD Health Statistics 2023.
Source: OECD Health Statistics 2023.
Source: OECD Health Statistics 2023.