Outpatient Surgery Centers Draw Outpatient Surgery Centers Draw Cases Away from Hospitals, Cases Away from Hospitals,

Impact Resident Training VolumeImpact Resident Training Volume

Kyle Dunning, MD*Kyle Dunning, MD*Eric Liedtke DO*Eric Liedtke DO*

Lori Toedter, PhD†Lori Toedter, PhD†Chand Rohatgi, MD FASC*Chand Rohatgi, MD FASC*

*Department of Surgery, Easton Hospital, Easton, PA*Department of Surgery, Easton Hospital, Easton, PA††Department of Psychology, Moravian College, Department of Psychology, Moravian College,

Bethlehem, PABethlehem, PA

BackgroundBackground

The first independent Ambulatory Surgery The first independent Ambulatory Surgery Center (ASC) was established in Phoenix, Center (ASC) was established in Phoenix, Arizona in 1970. Arizona in 1970.

Today, over 4,000 ASCs span all fifty Today, over 4,000 ASCs span all fifty states and account for over six million states and account for over six million procedures per year. procedures per year.

Currently, over 50% of colonoscopy Currently, over 50% of colonoscopy services in the United States are services in the United States are performed in ASC’s. performed in ASC’s.

PurposePurpose

Ambulatory surgery centers (ASC’s) are Ambulatory surgery centers (ASC’s) are increasing in both number and surgical increasing in both number and surgical volumevolume

Impact on reimbursement, patient safety, Impact on reimbursement, patient safety, and surgical productivity and efficiencyand surgical productivity and efficiency

Shift toward outpatient surgery in non-Shift toward outpatient surgery in non-hospital settings is concerning with respect hospital settings is concerning with respect to resident trainingto resident training

HypothesisHypothesisDue to the expansion of local surgery centers, Due to the expansion of local surgery centers, hospital-based outpatient procedures would hospital-based outpatient procedures would decline and, in turn, negatively affect case loads decline and, in turn, negatively affect case loads for our surgical residents.for our surgical residents.

MethodsMethodsPerformed a retrospective reviewPerformed a retrospective review Reviewed cases commonly performed in ASCsReviewed cases commonly performed in ASCs

Hernias, breast biopsies, endoscopies, etc.Hernias, breast biopsies, endoscopies, etc. Double-armed evaluationDouble-armed evaluation

Analyzed data from two separate sources to perform Analyzed data from two separate sources to perform independent evaluationsindependent evaluations

1. Reviewed resident reported data by year1. Reviewed resident reported data by year2. Reviewed facility reported data per state reporting 2. Reviewed facility reported data per state reporting agencyagency

Resident reported data and hospital reported statistics are Resident reported data and hospital reported statistics are not directly comparable (reported by academic year and not directly comparable (reported by academic year and

hospital data by calendar year)hospital data by calendar year)

Study DesignStudy DesignResident reported data armResident reported data arm Reviewed case log data (July 2004–June 2007)Reviewed case log data (July 2004–June 2007)

Tallied by academic yearTallied by academic year

PGY1 – PGY3 resident data evaluated (n=30)PGY1 – PGY3 resident data evaluated (n=30)

ACGME electronic case log systemACGME electronic case log system Compared by procedure on yearly intervalsCompared by procedure on yearly intervals

Tabulated each procedure by number performedTabulated each procedure by number performed

Evaluated for statistically significant increase or Evaluated for statistically significant increase or decreasedecrease

Results: Results: Resident reported dataResident reported dataStatistically significant decline in :Statistically significant decline in : HemorrhoidectomiesHemorrhoidectomies carpal tunnel releasescarpal tunnel releases excision of skin lesions excision of skin lesions breast biopsiesbreast biopsies skin graftsskin grafts

Study DesignStudy DesignState reported data armState reported data arm Outpatient Market Share State Data from the Outpatient Market Share State Data from the

state of Pennsylvania state of Pennsylvania Data tallied by Pennsylvania Health Care Cost Data tallied by Pennsylvania Health Care Cost Containment Council (PHC4) Containment Council (PHC4) Analyzed data between 2001-2006 by calendar year Analyzed data between 2001-2006 by calendar year Included our institution and four local ASCs that Included our institution and four local ASCs that participated in voluntary reportingparticipated in voluntary reportingCompared hospital outpatient procedures vs. the four Compared hospital outpatient procedures vs. the four ASCs individually and in totalASCs individually and in totalCalculated specified procedures as a percentage of Calculated specified procedures as a percentage of total hospital volume to account for any errors from total hospital volume to account for any errors from fluctuating volumefluctuating volume

Results: Results: State reported dataState reported data2003 vs. 2005 there was a significant decrease for 2003 vs. 2005 there was a significant decrease for some specific procedures:some specific procedures: colonoscopy (p<.0001); colonoscopy (p<.0001); inguinal/femoral hernia (p=.04); inguinal/femoral hernia (p=.04); excision of skin lesion (p=.0022) excision of skin lesion (p=.0022) incision/drainage (p<.0001). incision/drainage (p<.0001). No significant differences were noted for carpal tunnel No significant differences were noted for carpal tunnel

release, endoscopy, hemorrhoidectomy, lumpectomy or release, endoscopy, hemorrhoidectomy, lumpectomy or skin graft.skin graft.

Trend toward significant decrease each year from 2001 Trend toward significant decrease each year from 2001 to 2006, however could not complete calculations due to to 2006, however could not complete calculations due to some missing intervalssome missing intervals

Results: Results: State reported dataState reported dataThe total number of cases for both inpatient and The total number of cases for both inpatient and outpatient surgeries between 2003 and 2005 outpatient surgeries between 2003 and 2005 ASC’s reported a combined total of 9,089 cases in 2003 ASC’s reported a combined total of 9,089 cases in 2003

compared with 12,832 cases in 2005 for a compared with 12,832 cases in 2005 for a 41.2%41.2% increase in volume increase in volume 

Our institution increased 6% (11,587 to 12,279) Our institution increased 6% (11,587 to 12,279) While the total volume increased by 6%, there was a 4% While the total volume increased by 6%, there was a 4% decrease in selected casesdecrease in selected cases11 performed between these two performed between these two years. (p<.0001)years. (p<.0001)22. . The selected cases represented 29.9% of all the hospital cases The selected cases represented 29.9% of all the hospital cases in 2003, compared to 28.5%, 27.2% and 27.5% in 2004 through in 2003, compared to 28.5%, 27.2% and 27.5% in 2004 through 2006. 2006.

11 Pre-selected Pre-selected cases for this study cases for this study 22Chi-Chi-square Goodness-of-Fit test square Goodness-of-Fit test

Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)

DiscussionDiscussionOperative case numbers as a measure of surgical Operative case numbers as a measure of surgical training training Is it an effective measurement?Is it an effective measurement? How many to be certified; competent; proficient?How many to be certified; competent; proficient?

Today, outpatient procedures constitute the bulk of Today, outpatient procedures constitute the bulk of all surgeries all surgeries

Residents are losing exposure to more basic cases Residents are losing exposure to more basic cases that serve as building block for surgical skills that serve as building block for surgical skills May be less prepared for more challenging procedures May be less prepared for more challenging procedures

The “80-hour work week” The “80-hour work week”

Confounding VariablesConfounding VariablesCompliance and accuracy of resident reported dataCompliance and accuracy of resident reported data Varies among residentsVaries among residents Only available for past 4 yearsOnly available for past 4 years

Voluntary reporting to State agencyVoluntary reporting to State agency Some centers have gaps in certain yearsSome centers have gaps in certain years Not all centers reporting in areaNot all centers reporting in area

Academic vs. Calendar year dataAcademic vs. Calendar year data Allowed two separate analysis of same hypothesisAllowed two separate analysis of same hypothesis

Study area is not isolated Study area is not isolated Patients may have gone to other hospitalsPatients may have gone to other hospitals Also may have had procedure performed in non-reporting Also may have had procedure performed in non-reporting

ASCsASCs

Pennsylvania Health Care Cost Containment Council (PHC4)Pennsylvania Health Care Cost Containment Council (PHC4)

ConclusionsConclusionsBased on our results, ASCs have significantly Based on our results, ASCs have significantly impacted certain cases available to our impacted certain cases available to our residentsresidents

More data will be collected and prospectively More data will be collected and prospectively followed in the years to comefollowed in the years to come

Surgical residency directors must look to Surgical residency directors must look to include access to ASCs in the their residency include access to ASCs in the their residency programs to assure the highest quality trainingprograms to assure the highest quality training

ReferencesReferencesAmbulatory Surgery Center Association Ambulatory Surgery Center Association http://www.ascassociation.org/advocacy/AmbulatorySurgeryCentersPositiveTrendhttp://www.ascassociation.org/advocacy/AmbulatorySurgeryCentersPositiveTrendHealthCare.pdfHealthCare.pdf

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Pennsylvania Health Care Cost Containment Council (PHC4) Pennsylvania Health Care Cost Containment Council (PHC4) http://www.phc4.org/default.htmhttp://www.phc4.org/default.htm

Carlin AM, Gasevic E, Shepard A. Effect of the 80-hour work week on resident Carlin AM, Gasevic E, Shepard A. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007; 193:326-330.operative experience in general surgery. Am J Surg 2007; 193:326-330.

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