Ambulatory Surgery gynecology, what developments?
Ambulatory Surgery includes surgical procedures and / or programmed explorations (…) and made in the technical conditions requiring mandatory safety of an operating room under anesthesia mode variable, and followed by a prolonged postoperative monitoring, permitting, without increased risk, leaving the patient on the day of admission. ”
Recovery is defined by the Caisse Nationale de l’Assurance Maladie in a paper published in 2003, which assesses the benefits of this type of surgery: how many and benefits of this kind of care, there are satisfying patients (90% of patients were satisfied), the decrease in the number of nosocomial infections (divided by 6) and lower costs including the removal of nights in the hospital. Many of our neighbors have understood: for example, 78% of all surgical procedures are performed in outpatient departments in Denmark, 67% in the Netherlands, 60% in Britain, compared with 30% in France. French Bridging the delay has become a priority of the health insurance, but in doing so, really given the means to the institutions to comply with this objective?
In gynecology, thanks to technological progress and thanks also to technology medical devices that offer an alternative to major surgery, experts estimate that nearly 50% the number of surgical procedures that could be carried out in outpatient departments. Yet, for economic or administrative, few institutions, public or private, that emphasize today this type of intervention. Professor Hervé Fernandez, chief of gynecology - obstetrics at the hospital Antoine Béclère, in Clamart, explains the reasons for the french paradox.
Professor Fernandez, what are the gynecological surgeries can be performed in outpatient departments?
Pr Hervé Fernandez: Gynecology, nearly half of all interventions can be carried out in outpatient departments, including:
Interventions for urinary incontinence, whatever technique;
Any uterine surgery by utéroscopie, either sterilization, the treatment of fibroids, treatments by thermocoagulation of the endometrium;
By cœlioscopie, all surgeries treatment or removal of ovarian ablation tubal, repairing the tubes, as part of a fertility treatment.
All of this is perfectly conceivable with a care in outpatient departments.
If outpatient surgery is technically feasible and medically, why is it not used more often?
Pr H. F. : First there reasons relating to the coercion of organization. Indeed, if we follow the directive of 1992, which set the legal framework for the implementation of outpatient surgery, it is supposed to move towards the establishment of an independent and operating independent of beds, attributed exclusively for ambulatory. However, the tool to operate is the same and that the surgery should be carried out according to the classical mode or outpatient care, and the hospital did not always have the means to finance a dual equipment. As a result, operations, whatever the mode support, are often carried out in the same block. And for good would require us to have beds reserved for the patient, even within individual services, which is not the case today.
The administration tells us, the priority is the patient. Either, except that it does nothing to ensure that the patient could be developed. The hospitals do not have the funds to make the necessary investments to the reception of patients.
However, the outpatient is practiced in the private sector is that it must be profitable…
Pr H. F. : True, it is practiced in the private sector. But first, we practice a lot on specialties like ophthalmology, ENT, dermatology, it is less often the case for urology, gynecology or surgery visceral. It’s a shame.
As for the so-called minimally surgery, made possible by the emergence of medical devices (such as bandages support uréthral, or the balloons that are used to treat by thermocoagulation the méno-métrorragies), we must distinguish two cases :
If the device is tipsé, that is repaid by Social Security, private hospitals are well placed to carry out interventions. This applies to the treatment of urinary incontinence by laying strips of support. The strip is tipsées, the clinic is reimbursed directly by the hardware and Social Security bill intervention, according to the tariff schedule, the patient who will, in turn, reimbursed.
If the device is not tipsé, the clinic can obtain reimbursement and the intervention will not be effected. This is the case for the treatment of endometrial by thermocoagulation. The different techniques that exist on the market are not tipsées. However, the purchase of up to approximately 400 euros for a speech in which the rate is set at 200 euros under the nomenclature. The practice is not profitable and privately not propose this kind of intervention.
Instead, it will be possible for the patient to take advantage of this technique has many advantages (which the intervention will take no more than ten minutes, can go home that evening and to return to work after 48 hours) in the audience. But for us, another problem arises. If I decide to do a treatment of the endometrium by using a medical device allowing thermocoagulation, such as the purchase of equipment is not provided for in my budget, and nowhere in the T2A, I will have to deduct the amount necessary in buying my overall budget. And since we can not do everything, I am going to do, for example, less surgical incontinence of urine. Whether tipsé or not, the hospital must pay on its overall budget. In a speech to sterilization, if I use a technique which is minimally to put a spring in the mistaken by hysteroscopy-a simple, painless, reversible and without anesthesia, ideal for the patient), the operation cost me 900 euros, while it is charged 210 euros. And it is the hospital that finances the difference, or 690 euros. It is in a square the circle. Besides, in the hospital, no medical device is repaid to the institution.
The arrival of the T2A changed nothing because we stubbornly ignore the reality of the practice and medical progress, and even more, according to my calculations, as a result of the application of T2A, my service, which carries 50% of its outpatient care, will lose 30% of its resources.
What should be done, specifically, to improve things?
Prof. H. F. : There is a need for the administration includes the arrival of these techniques, and it has everything to gain because their use would allow an increase in outpatient treatment, and generate significant savings in hospital stays. Should charging acts performed in ambulatory or at least aligned with acts performed with a care classic. Should the T2A takes into account the real costs, including those of the public hospital. Should we, public hospitals, will not have to pay for practice this method of surgery. Because regardless of the fact that the restrictions that we suffer are very damaging to our patients, there is another risk, perhaps even more serious, because very harmful if the public hospital is no longer able to take care surgery minimally outpatient care, it means it will no longer be able to assume its full role to training future doctors.
And the authorities would do well to rethink the conditions for the practice of ambulatory in France if they do not want to jeopardize the future of medicine and surgery in France.
Ambulatory Surgery stats:
94% of surgeries in the United States
78% in Denmark
67% in the Netherlands
60% in the UK
30% in France (according to data from 1997)
Today in France:
84% of outpatient interventions are in the private
The outpatient represents 5% of the activity of public hospital sector
30% in private
Ambulatory Surgery Lowers health insurance costs during the hospital stay without causing additional expenses before and after hospitalization. For example, a patient treated in outpatient surgery consumes less acts of biology, less than radiology, pharmacy less and less specialized consultations that during his stay in hospital when it is complete. Dr. Gilles Bontemps had encrypted, in a report to the National Health Insurance Fund, the savings generated by this mode of care to 30 and even 51% in some of the speeches.
Yet not all means are not implemented today to encourage schools to develop ambulatory.
Some examples:
Unlike what’s happening at our neighbors, ambulatory surgery is less well paid than in France conventional surgery. Thus, public institutions have to tap into their overall allocation to bridge the gap between the actual cost of surgery and the amount actually paid (the purchase of medical devices remaining borne entirely by the public). Finally, schools are asked to submit to additional organizational constraints, without compensation and sometimes even at the cost of a drain on their budget!
Some medical devices, which have proved their worth and propose alternatives to surgery heavy that lends itself well to the patient are not reimbursed and thus little or no use in the private sector, hence the need to reconnect with more technology classical sometimes requiring hospitalization.
The overall allocation of the hospital does not always invest in a second operating room and beds dedicated to the patient.
Patients are not aware of this type of alternative because when the physical conditions are not met to be able to use it, so we do not offer them a choice.
