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My Turn
The Inpatient-Outpatient Gap
Terrance Yemen
Publish Date: June 9, 2008
Fifteen to 20 years ago, when the concept of sending otherwise healthy patients home just a few hours after surgery really took hold, most of us did not foresee the tremendous advances in anesthesia and surgical techniques that now allow us to perform significant outpatient procedures even on patients with controlled systemic disease. Now that surgeons perform four of every five procedures in the outpatient setting, however, ASCs have hit the wall.

Despite pre-emptive, multimodal analgesia and minimally invasive surgical techniques, we cannot move most, if any, of the remaining 20 percent of surgical patients over to the outpatient setting. In a good number of these cases, postoperative pain is the sole barrier to doing so. It is crucial to control pain during the first 24 post-op hours to maximize recovery. For some patients (particularly orthopedic), this cannot be achieved safely without ongoing, professional intervention.

The problem is not just that these patients must stay overnight. The problem is that those of us who operate out of freestanding ASCs have no choice but to send most patients who require overnight pain management - no matter what level of medical care they otherwise need - to large, expensive tertiary care hospitals for their surgeries and overnight stays. In many cases, this is pure overkill. Currently, insurers - including Medicare and Medicaid - do not allow premeditated admission of outpatients into the inpatient setting, and 31 states specifically prohibit this practice of "planned admits." As a result, patients are either outpatients or inpatients, and there is no middle ground.

Here in Virginia (a state that prohibits planned admits), we are challenging this antiquated regulation with a proposed pilot project that would let us send patients who need overnight pain management to a ?step-down' facility. This pain management facility would be staffed with several nurses, and an anesthesiologist would be available around the clock. It could operate out of a local hotel, the nearby hospice-care facility or within the ASC. Such a concept does not raise patient safety concerns, as the nursing home industry has already fully established this model of care.

We can care for a whole range of patients in this way - including those who undergo joint replacements, fracture repairs, osteotomies; hand procedures; tendon releases, club foot repairs and other significant congenital corrections; fairly extensive cosmetic surgeries like facelifts; and gynecologic and general surgeries. Currently, up to 40 percent of cholecystectomy patients remain in the hospital overnight due to pain, but the ability to care for them in a step-down pain management facility could bring the "outpatient" success rate for this procedure up to nearly 100 percent.

Arguably, this model could render cheaper and better care. Although the monetary savings are hospital-specific, our cost analysis projects a savings of between $300 and $500 per patient. Additionally, the nosocomial infection rate would likely be extremely low, and the environment would be comfortable for the patient and conducive to family visits.

Already, the proposal has caused controversy. Yet, we cannot halt the evolution of patient care on the basis of hospitals' competitive concerns. I believe that, five years from now, we will wonder what took us so long to bridge the gap between inpatient and outpatient surgery.

Dr. Yemen ([email protected]) is the Medical Director of the Virginia Ambulatory Surgical Institute and Associate Professor of Anesthesiology and Pediatrics and Director of Pediatric Anesthesia with the University of Virginia.