By AMY KRAMBECK, MD
The trend toward less invasive procedures, shifting from inpatient to outpatient, has changed the face of surgery. Industry-changing leaps in technology and surgical techniques have allowed us to achieve our treatment goals with smaller incisions, laparoscopy and other “closed” procedures, less bleeding, less pain, and lower complication rates. As a result, patients who used to require days of recovery in the hospital for many common surgeries can now recuperate in their own homes.
Outpatient procedures grew from about 50% to 67% of hospitals’ total surgeries between 1994 and 2016,1,2 and outpatient volume is expected to grow another 15% by 2028,3 with advantages for patients, surgeons, insurers, and hospitals. In my hospital, where bed space is at a premium, my colleagues and I were able to make a significant impact by switching minimally invasive surgery for enlarged prostate, also called benign prostatic hyperplasia (BPH), from inpatient to outpatient.
New Opportunity with an Advanced Technology
BPH affects about half of men in their 50s, with the prevalence increasing with age to include about 90% of men 80 and older.4 As a result, BPH surgery makes up a significant portion of urological procedures in any hospital.
I have been performing BPH surgery for 11 years. There are several options, including transurethral resection of the prostate (TURP) and suprapubic prostatectomy, both of which require hospital stays and bladder irrigation with a catheter due to bleeding. Another less frequently utilized surgical option for BPH is holmium laser enucleation of the prostate (HoLEP). HoLEP causes fewer complications and requires shorter hospitalization.5 Specifically, its postoperative morbidity is the lowest among BPH surgeries.5,6,7 HoLEP has the least bleeding, shortest catheter time, and low rates of urinary tract infection, plus patients are less likely to require additional treatment for BPH as they age compared to other available therapies.5,6,7
Last year, my colleagues and I began using a Lumenis 120-watt holmium laser with MOSES Technology that modulates the laser pulse, building on HoLEP’s advantages in a procedure called MOSES laser enucleation of the prostate (MoLEP). Simultaneously cutting and cauterizing in a very controlled fashion, MoLEP improves hemostasis and significantly reduces surgical time and anesthesia use. With these advantages and very little bleeding after surgery, we found that patients did not need prolonged irrigation in the hospital. We began to feel comfortable with the idea of discharging patients after MoLEP surgery – a change we knew would make a major impact at our hospital because BPH surgery is so common.
Making the Outpatient Change
Historically, my hospital had been through many surgical advances and transitions to the outpatient model. The move must be made with caution each time. Although we were highly confident in patients’ ability to safely leave the hospital after MoLEP, we needed to track the success of this approach and identify any areas for improvement. Thus, we spent several months collecting baseline data on MoLEP patients who stayed at the hospital overnight.
Reviewing everything that happened inside the hospital, we saw no reason to keep patients after surgery unless they had acute comorbidities. Even patients with very large prostates or those taking blood thinners could safely recuperate at home.
Eight months ago, we began releasing patients the day of MoLEP surgery and tracking the outcomes. To date, no MoLEP outpatients have come into the ER with complications. We are beginning to see positive trends in the data, including better bladder voiding the day after surgery, which we think may be traced to patients’ tendency to get up and move around at home and the absence of narcotics in at-home recovery. We have found that patients who discharge home are more likely to successfully urinate on their own after the catheter is removed the next day than patients that stay in the hospital overnight.
Since we started performing MoLEP, I have discharged over 100 patients home the same day. We are keeping some patients overnight – specifically those with significant medical comorbidities, concurrent other procedures, or those who do not meet discharge requirements.
The Effect on Our Hospital
The hospital has responded favorably to the same-day discharge. Our level I trauma center runs near capacity, so it helps that by discharging healthy MoLEP patients home, we are freeing up hospital beds for more acute patients. The change has led us to review our outcomes with other surgical procedures and take steps to shorten hospital stays. My colleagues and I will continue to explore less invasive surgical techniques that may allow more patients to recover at home while we focus on more acute cases in the hospital.
Amy E. Krambeck, MD, is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis.
I view this as a positive trend but I wonder what impact it’s had on the inpatient occupancy rate not just at your hospital but on hospitals more broadly across the country. I’m also curious about how many of these outpatient surgical procedures can be safely performed at ambulatory surgical centers instead of hospital outpatient departments because insurers claim that ASC’s can do these operations for as much as 50% less cost than hospitals. The main reason for the ASC’s significant cost advantage is that hospitals must operate around the clock seven days a week and ASC’s don’t. The bottom line from a payer perspective is that the more care we can drive out of hospitals and into much less expensive facilities, the better as long as patient safety and the quality of outcomes aren’t compromised.
Thanks for Advice all.