For previous generations, undergoing surgery and going into hospital were absolutely inseparable. In the majority of cases, an operation also meant at the very minimum an overnight stay in a hospital as an inpatient.
Indeed, being admitted for a procedure depended as much on the availability of a hospital bed as it did on the surgeon’s schedule.
Things have changed dramatically. Since the start of the century, outpatient care in general, and for surgical services in particular, has grown at a relentless rate. Whereas once admission to hospital was the default for most interventional and acute medicine, the growth of walk-in clinics and single-day surgery has flipped the situation on its head.
Before the COVID-19 pandemic struck, it was predicted that the volume of procedures being carried out at so-called Ambulatory Surgical Centers (ASCs) worldwide would rise to 60%, eclipsing the 40% of operations still taking place in traditional hospital settings.
This is a phenomenal transformation in healthcare provision. Yet there is every reason to believe that the rise of ASCs is far from finished.
The reasons why ambulatory care has come so far — cost efficiencies, convenience for the patient, easing the pressure on critically over-stretched hospital services — are more relevant today than they have ever been. As global healthcare services are forced to pivot to new operational structures at speed in the wake of the COVID-19 pandemic, it would be no surprise if the ambulatory model went on to overtake hospitals as the global default.
There are certainly very convincing arguments in its favor.
The development of ambulatory surgery
Ambulatory care is defined as the provision of acute or preventative personal healthcare on an outpatient basis. We might call it ‘walk in, walk out’ healthcare, because of the tendency for it to focus on high volume, routine treatments where the emphasis is on making the patient journey as short as possible, even to the extent of not requiring an appointment.
Ambulatory services have developed across the full span of healthcare in a wide variety of settings — private and public clinics, doctor’s surgeries, specialist referral centers, even dedicated ‘walk-in’ units based on hospital campuses.
The range of surgical procedures handled at ASCs is growing all the time, with some of the most common worldwide including cataract removal, sclerotherapy (varicose vein treatment), hip and knee arthroplasty, vasectomy and certain laparoscopic procedures like cholecystectomy (gall bladder removal).
While some of these more straightforward procedures have been widely available on a ‘walk-in’ or ‘short stay’ basis for several decades now, it is the ability of ASCs to nowadays handle major surgery such as hip and knee replacements plus a wide range of urological, gynecological and general surgical procedures that has transformed the impact of ambulatory surgery.
Technology has had a key role to play, with the development and widespread availability of increasingly sophisticated minimally invasive techniques lowering the risks of complications. Compared to open surgery, patients undergoing a laparoscopic procedure recover much faster and require less intensive aftercare. When this reaches the point where a patient can be sent home the same day they undergo a procedure, the costs associated with postoperative care on a hospital ward are drastically reduced.
Research already suggests that ASCs can deliver up to 60% cost savings compared to surgery carried out in a traditional hospital setting. In the US alone, where 23 million procedures are carried out in ASCs, that equates to a $40bn saving for the healthcare system.
A new model for healthcare
The ambulatory / outpatient model will never be suitable for all forms of surgery, nor for all patients. Some procedures are so inherently complex, lengthy and debilitating that it’s hard to foresee a time when patients won’t require a period of carefully monitored postoperative convalescence in a hospital environment. The same applies to patients with complex comorbidities, for whom even relatively simple procedures carry heightened risks. And as populations age, the number of people falling in this bracket increases.
But growing, ageing populations is one reason why we can expect ASCs to take on an increasingly prominent role. The greater the demands being placed on health services grows, the less the centralized model that hospitals have come to represent looks fit for purpose. All around the world, the biggest challenges facing providers are shortages of hospital beds, and the cost of increasing hospital capacity.
By decentralizing healthcare administration, by pushing services out of the creaking hospital hubs and into community-based networks of smaller, specialized, mutually complementary provider settings, the sector can respond to changing demographics, drastically reduce costs and provide a better patient experience.
In this model, ASCs form part of a bigger whole that also includes minor injury units and walk-in clinics, with the overall aim being to take as much strain off hospitals as possible so they can focus on what they were originally designed to do — provide care for the more vulnerable and in need.
Due to the cost savings involved, ambulatory care has also been linked to having a significant impact on raising public health levels amongst poorer populations in developing countries.
Outpatient services in a post-COVID world
The need to relieve the pressure on hospitals has been sharply underlined by the COVID-19 pandemic. As capacity in emergency wards and ICUs worldwide has been pushed to its limits trying to deal with COVID patients, the knock-on effect of this has been the cancellation of large volumes of elective procedures and the disruption of essential services, not to mention large numbers of patients choosing to stay away from emergency units because of concerns over catching the virus.
Now we know that the pandemic is not going to be tackled in a few months, authorities cannot afford to keep elective surgery shut down for too much longer without serious repercussions for public health. ASCs are ideally placed to take some of the burden off hospitals, if they are allowed to do so and with the right kind of collaboration in terms of making the required equipment and expertise available.
If and when the role of ASCs is broadened to enable a return to something like normal surgical services for however long it takes to get the pandemic under control, we can expect that to represent a ‘new normal’ in provision. After all, as well as offering cost benefits, ASCs are often more conveniently placed for patients, they put an emphasis on recovery in their own home rather than on a ward and, crucially, their smaller size makes infection control easier to manage.
As much as any other benefit right now, decentralizing surgical services via ASCs offers a way to provide the procedures people need while following what we know works in terms of halting suppression of the virus.