Siow Matthew, Cuff Germaine, Popovic Jovan, Bosco Joseph
Bull Hosp Jt Dis (2013). 2017 May;75(3):201-206.
The value proposition of surgery at freestanding ambulatory surgery centers (FSASCs) in terms of efficiency, safety, and patient satisfaction is well established and has led to increased FSASC utilization. However, there are comorbid conditions that disqualify certain patients from surgery at FSASCs. Understanding the percentage of patients whose comorbid conditions exclude them from FSASCs is important for the proper planning and utilization of operating room assets. We aim to understand the percentage of excluded patients, and we predict that certain procedures have higher rates of disqualification due to the types of patients who undergo them.
We reviewed the records of 4,242 consecutive patients undergoing outpatient orthopaedic surgeries in our hospital system from July 2015 to February 2016. Patient characteristics, comorbidities, and procedures performed were included in our database. We analyzed each case and determined eligibility for surgery at our FSASC based on established comorbidity exclusionary guidelines. Chi-square and t-tests were used to establish statistical significance.
Of 4,242 patients, 878 (20.7%) were ineligible for surgery at our FSASC based on accepted exclusionary guidelines. The average body mass index (BMI) of FSASC-eligible patients was 27.37, compared to 31.68 for FSASC-ineligible patients (p < 0.001). The majority, 85.6% (543/634), of American Society of Anesthesiologists (ASA) class 3 patients were FSASC-ineligible. The most common reasons for excluding patients from surgery at our FSASC were morbid obesity (25.4% of ineligible cases), untreated obstructive sleep apnea (22.1%), age less than 13 (19.6%), and coronary artery disease with prior intervention (13.3%). When stratifying by procedure, the operations most likely to be FSASC-ineligible were contracture releases (39.13% ineligible, p = 0.03), trigger finger releases (36.14%, p < 0.001), carpal tunnel releases (30.63%, p = 0.009), tumor resections (38.89%, p = 0.056), rotator cuff repairs (25.47%, p = 0.078), and subacromial decompressions (30.23%, p = 0.12), primarily because these patients have more comorbidity (ASA 2.20 vs. 1.88, p < 0.001).
Roughly 1 in 5 patients is ineligible for surgery at a freestanding ASC due to disqualifying comorbidities. Although FSASCs offer cost effective care that satisfies patients, we must understand that certain patients cannot have their surgeries at these venues. In addition, we must use additional caution when scheduling certain procedures at a FSASC. Therefore, as the number and complexity of the surgeries performed at FSASCs increase, we must better understand the factors that make patients better candidates for surgery in a hospital setting, thus minimizing transfers and readmissions and maximizing the value proposition of FSASCs.
独立门诊手术中心（FSASC）在效率、安全性和患者满意度方面的价值主张已得到充分确立，并导致FSASC的利用率有所提高。然而，存在一些合并症会使某些患者不符合在FSASC进行手术的条件。了解因合并症而被排除在FSASC手术之外的患者比例，对于手术室资产的合理规划和利用非常重要。我们旨在了解被排除患者的比例，并预测某些手术由于接受这些手术的患者类型而被取消资格的比例更高。
我们回顾了2015年7月至2016年2月在我们医院系统中连续接受门诊骨科手术的4242例患者的记录。患者特征、合并症和所进行的手术均纳入我们的数据库。我们分析了每个病例，并根据既定的合并症排除指南确定在我们的FSASC进行手术的资格。使用卡方检验和t检验来确定统计学意义。
在4242例患者中，根据公认的排除指南，有878例（20.7%）不符合在我们的FSASC进行手术的条件。符合FSASC手术条件的患者平均体重指数（BMI）为27.37，而不符合FSASC手术条件的患者为31.68（p<0.001）。美国麻醉医师协会（ASA）3级患者中的大多数，即85.6%（543/634）不符合FSASC手术条件。将患者排除在我们的FSASC手术之外的最常见原因是病态肥胖（占不合格病例的25.4%）、未经治疗的阻塞性睡眠呼吸暂停（22.1%）、年龄小于13岁（19.6%）以及有过干预的冠状动脉疾病（13.3%）。按手术分层时，最有可能不符合FSASC手术条件的手术是挛缩松解术（不合格率为39.13%，p = 0.03）、扳机指松解术（36.14%，p<0.001）、腕管松解术（30.63%，p = 0.009）、肿瘤切除术（38.89%，p = 0.056）、肩袖修复术（25.47%，p = 0.078）和肩峰下减压术（30.23%，p = 0.12），主要是因为这些患者有更多的合并症（ASA 2.20对1.88，p<0.001）。
由于合并症不合格，大约五分之一的患者不符合在独立门诊手术中心进行手术的条件。虽然FSASC提供具有成本效益且令患者满意的护理，但我们必须明白，某些患者不能在这些场所进行手术。此外，我们在安排FSASC的某些手术时必须格外谨慎。因此，随着在FSASC进行的手术数量和复杂性增加，我们必须更好地了解使患者更适合在医院环境中进行手术的因素，从而最大限度地减少转诊和再入院，并最大限度地提高FSASC的价值主张。
