BMJ 2015;350:h2918 doi: 10.1136/bmj.h2918 (Published 2 June 2015)
Page 1 of 2
Editorials
EDITORIALS China’s overuse of inpatient treatment and routine preoperative testing Moving to day case management of most ocular surgery in China is possible 1
Yizhi Liu professor , Nathan Congdon professor 14 glaucoma fellow
123
1
, Weirong Chen professor , Yuzhen Jiang
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China; 2Orbis International, New York, USA ; 3Queen’s University Belfast, Belfast, UK; 4Moorfields Eye Hospital, London, UK 1
China’s medical system is undergoing substantial reforms to improve access, efficiency, and quality of care.1 These changes have prompted recent suggestions in The BMJ on how efficiency could be further improved. Recommended reforms include reducing unnecessary use of intravenous fluid, currently estimated at eight bottles per capita annually,2 and restricting self medication with antibiotics for conditions such as flu, reported by a quarter of respondents in a recent survey by the China Food and Drug Administration.3
Another opportunity for improved efficiency is to stop admitting patients to hospital for non-invasive surgical care, which is common practice in China. Taking ophthalmology as an example, a tertiary public eye hospital in China typically has between 100 and 500 beds. By contrast, Moorfields Eye Hospital in London, one of the largest eye care facilities in the developed world, has closed all of its inpatient beds. This striking difference reflects the fact that routine eye operations such as cataract extraction are overwhelmingly performed as day case surgeries in Europe and the United States, whereas most ophthalmic operations require overnight hospital stays in China. The benefits of day surgery for cataract extraction were first reported 30 years ago in the United Kingdom4 and 20 years ago in China.5 Additionally, a wide range of preoperative testing is standard practice before cataract surgery in China, including hepatitis B and HIV serology, chest radiography, and electrocardiography. Trial evidence suggests that this testing does not reduce morbidity associated with such surgery.6
Barriers to day case surgery
The example of ophthalmology is particularly important: cataract extraction remains the most commonly performed elective surgery in the UK,7 and probably the world. However, the situation is similar for other non-invasive surgical specialties in China. There are several possible explanations for this. Firstly, many patients and physicians apparently believe that testing
and perioperative hospital stays are associated with greater safety. Perhaps high levels of mistrust between physicians and patients in China8 motivate both sides to opt for inpatient treatment as less likely to give rise to misgivings. However, a Cochrane review of day case cataract surgery found evidence of cost savings but no negative effect on outcomes.9 Another important factor is that reimbursement for surgical procedures under most of China’s government health insurance schemes, even laser treatment of diabetic eye disease, still requires inpatient treatment in many areas.10 Government hospitals, still the majority of providers in China, may be slower than their private counterparts to embrace more entrepreneurial approaches such as day operations, particularly because their low surgical output means there is little pressure to increase efficiency by adopting such reforms.
With support from local regulatory bodies, a pilot project aimed at moving to day case management of most ocular surgery is being carried out at Zhongshan Ophthalmic Centre in Guangzhou, one of China’s largest eye care facilities. The effect on output has been substantial: the number of operations rose by 120%, from 7150 in 2011 to 15 766 when day case surgery was introduced in 2012, and last year 63% of 19 810 operations were done on an outpatient basis. Our experience suggests that hospital admission may be a barrier to uptake of cataract surgery. This is an important concern given China’s relatively low rate of cataract surgery of 915/million population/year, far below that of less developed neighbours Vietnam (2000/million/year) and India (5000/ million/year).11 Even greater efficiencies remain to be realised. We estimate that discontinuing routine echocardiography, chest radiography, and blood testing just for cataract patients could save £69 (€97; $106) per patient annually, a total of £1.4m at our facility alone and £41.4m on 600 000 cases11 nationally. Further studies are needed to evaluate the safety, patient acceptability, and cost effectiveness of day case surgery in other specialties in China. Such data will guide policy makers in reducing cost and
Correspondence to: Y Liu [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2918 doi: 10.1136/bmj.h2918 (Published 2 June 2015)
Page 2 of 2
EDITORIALS
improving efficiency through implementing day case protocols for appropriate procedures. Competing interests: We have read and understood BMJ policy on declaration of interests and declare NC is supported by a Thousand Man Plan grant from the Chinese government. YJ is supported by British Council for the Prevention of Blindness and University College London overseas research scholarship. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3
Parry J. Nine in 10 Chinese are covered by medical insurance, but access to treatments remains a problem. BMJ 2012;344:e248. Yuan S. China should reduce the overuse of intravenous infusion. BMJ 2014;348:g1262. Fang Y. China should curb non-prescription use of antibiotics in the community. BMJ 2014;348:g4233.
For personal use only: See rights and reprints http://www.bmj.com/permissions
4 5 6 7 8 9 10 11
Day-case cataract surgery. Lancet 1983;2:383-4. Li S, Liu Y, Yang W, Li H, Lin Z. Outpatient intraocular lens implantation [in Chinese]. Yan Ke Xue Bao 1991;7:70-3. Schein OD, Katz J, Bass EB, et al. The value of routine pre-operative testing before cataract surgery. N Engl J Med 2000;342:168-75. Hospital Episode Statistics. Main procedures and interventions: 2000-2008. www.hesonline. nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=215 2009. Zhang X, Sleeboom-Faulkner M. Tensions between medical professionals and patients in mainland China. Camb Q Healthcare Ethics 2011;20:458-65. Fedorowicz Z, Lawrence D, Gutierriez P, van Zuuren EJ. Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev 2011;7:CD004242. Li Y, Wu Q, Xu L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ 2012;90:664-71. Zhao JL. To promote “Vision 2020” initiative under the new situation in China [in Chinese]. Zhonghua Yan Ke Za Zhi 2011;47:769-72.
Cite this as: BMJ 2015;350:h2918 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS China’s overuse of inpatient treatment and routine preoperative testing Moving to day case management of most ocular surgery in China is possible 1
Yizhi Liu professor , Nathan Congdon professor 14 glaucoma fellow
123
1
, Weirong Chen professor , Yuzhen Jiang
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China; 2Orbis International, New York, USA ; 3Queen’s University Belfast, Belfast, UK; 4Moorfields Eye Hospital, London, UK 1
China’s medical system is undergoing substantial reforms to improve access, efficiency, and quality of care.1 These changes have prompted recent suggestions in The BMJ on how efficiency could be further improved. Recommended reforms include reducing unnecessary use of intravenous fluid, currently estimated at eight bottles per capita annually,2 and restricting self medication with antibiotics for conditions such as flu, reported by a quarter of respondents in a recent survey by the China Food and Drug Administration.3
Another opportunity for improved efficiency is to stop admitting patients to hospital for non-invasive surgical care, which is common practice in China. Taking ophthalmology as an example, a tertiary public eye hospital in China typically has between 100 and 500 beds. By contrast, Moorfields Eye Hospital in London, one of the largest eye care facilities in the developed world, has closed all of its inpatient beds. This striking difference reflects the fact that routine eye operations such as cataract extraction are overwhelmingly performed as day case surgeries in Europe and the United States, whereas most ophthalmic operations require overnight hospital stays in China. The benefits of day surgery for cataract extraction were first reported 30 years ago in the United Kingdom4 and 20 years ago in China.5 Additionally, a wide range of preoperative testing is standard practice before cataract surgery in China, including hepatitis B and HIV serology, chest radiography, and electrocardiography. Trial evidence suggests that this testing does not reduce morbidity associated with such surgery.6
Barriers to day case surgery
The example of ophthalmology is particularly important: cataract extraction remains the most commonly performed elective surgery in the UK,7 and probably the world. However, the situation is similar for other non-invasive surgical specialties in China. There are several possible explanations for this. Firstly, many patients and physicians apparently believe that testing
and perioperative hospital stays are associated with greater safety. Perhaps high levels of mistrust between physicians and patients in China8 motivate both sides to opt for inpatient treatment as less likely to give rise to misgivings. However, a Cochrane review of day case cataract surgery found evidence of cost savings but no negative effect on outcomes.9 Another important factor is that reimbursement for surgical procedures under most of China’s government health insurance schemes, even laser treatment of diabetic eye disease, still requires inpatient treatment in many areas.10 Government hospitals, still the majority of providers in China, may be slower than their private counterparts to embrace more entrepreneurial approaches such as day operations, particularly because their low surgical output means there is little pressure to increase efficiency by adopting such reforms.
With support from local regulatory bodies, a pilot project aimed at moving to day case management of most ocular surgery is being carried out at Zhongshan Ophthalmic Centre in Guangzhou, one of China’s largest eye care facilities. The effect on output has been substantial: the number of operations rose by 120%, from 7150 in 2011 to 15 766 when day case surgery was introduced in 2012, and last year 63% of 19 810 operations were done on an outpatient basis. Our experience suggests that hospital admission may be a barrier to uptake of cataract surgery. This is an important concern given China’s relatively low rate of cataract surgery of 915/million population/year, far below that of less developed neighbours Vietnam (2000/million/year) and India (5000/ million/year).11 Even greater efficiencies remain to be realised. We estimate that discontinuing routine echocardiography, chest radiography, and blood testing just for cataract patients could save £69 (€97; $106) per patient annually, a total of £1.4m at our facility alone and £41.4m on 600 000 cases11 nationally. Further studies are needed to evaluate the safety, patient acceptability, and cost effectiveness of day case surgery in other specialties in China. Such data will guide policy makers in reducing cost and
Correspondence to: Y Liu [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2918 doi: 10.1136/bmj.h2918 (Published 2 June 2015)
Page 2 of 2
EDITORIALS
improving efficiency through implementing day case protocols for appropriate procedures. Competing interests: We have read and understood BMJ policy on declaration of interests and declare NC is supported by a Thousand Man Plan grant from the Chinese government. YJ is supported by British Council for the Prevention of Blindness and University College London overseas research scholarship. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3
Parry J. Nine in 10 Chinese are covered by medical insurance, but access to treatments remains a problem. BMJ 2012;344:e248. Yuan S. China should reduce the overuse of intravenous infusion. BMJ 2014;348:g1262. Fang Y. China should curb non-prescription use of antibiotics in the community. BMJ 2014;348:g4233.
For personal use only: See rights and reprints http://www.bmj.com/permissions
4 5 6 7 8 9 10 11
Day-case cataract surgery. Lancet 1983;2:383-4. Li S, Liu Y, Yang W, Li H, Lin Z. Outpatient intraocular lens implantation [in Chinese]. Yan Ke Xue Bao 1991;7:70-3. Schein OD, Katz J, Bass EB, et al. The value of routine pre-operative testing before cataract surgery. N Engl J Med 2000;342:168-75. Hospital Episode Statistics. Main procedures and interventions: 2000-2008. www.hesonline. nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=215 2009. Zhang X, Sleeboom-Faulkner M. Tensions between medical professionals and patients in mainland China. Camb Q Healthcare Ethics 2011;20:458-65. Fedorowicz Z, Lawrence D, Gutierriez P, van Zuuren EJ. Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev 2011;7:CD004242. Li Y, Wu Q, Xu L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ 2012;90:664-71. Zhao JL. To promote “Vision 2020” initiative under the new situation in China [in Chinese]. Zhonghua Yan Ke Za Zhi 2011;47:769-72.
Cite this as: BMJ 2015;350:h2918 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
