Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A... Background: High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. Methods: In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. Results: The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Conclusion: Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies. Keywords: Day care, Inpatient, Cataract Background therapeutic regimen, patients prefer being hospitalized for A cataract is an opacity of the lens in the eyes, which several days for cataract surgery, while the concept of day can lead to blurry vision or blindness. Cataracts may be care cataract surgery is currently increasingly introduced classified into three categories: age-related cataracts, [2]. In the U.S. and Europe and America over 60% cases of metabolic cataracts, and cataracts secondary to other cataract surgeries are carried out as day care surgeries. Day causes. Age-related cataracts are the most common type surgery, a fast and safe therapeutic regimen [3], is a surgical in adults [1]. With a rapidly growing and aging population, procedure wherein hospitalization, surgery and discharge the incidence of cataracts is subsequently increasing. occur within 24 h after a short post-operative recovery. WHO estimated that there were 95 million people visually Ophthalmologic operations are short and quick, making impaired due to cataracts in 2014. According to the former them suitable for day surgery, which allows for a more ef- fective use of medical resources and reduction of average hospitalization days. It has been shown that inpatient care * Correspondence: fanwen1029@163.com for age-related cataract surgery may not only be cheaper, Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 2 of 5 but also as effective as inpatient treatment after the same which will guide the further application of day care or surgery [4]. inpatient care following cataract surgery. Cataracts are the leading cause of blindness and the second-leading cause of vision loss in China [5]. With the promotion of “Vision 2020-the Right to Sight” Methods propaganda, the rate of cataract surgury has increased in Data of patients who underwent cataract operations was China in recent years [6]. In the past ten years, it has pulled from the cataract operation HIS database of the made great progress in blindness prevention and treat- First Affiliated Hospital of Nanjing Medical University ment. In 2005, the number of cataract extractions was only from August 1, 2014 to December 31, 2016. There are no 572,000, at the rate of 440 cases per one million people, absolute contraindications for day surgery patients. Pa- per year. By 2014, the number of cataract extractions tients with stable chronic medical conditions are consid- reached 1.9 million cases, a rate of 1400 cases per one ered to be suitable for day surgery [15]. At the First million people, per year [7]. Despite this, some patients Affiliated Hospital of Nanjing Medical University, patients continue to avoid or refuse cataract surgery due to the chose day care or inpatient cataract surgery on a voluntary costs and fear of surgery [8]. Until now, the high inci- basis. During this period, all fee standards remained the dence of cataracts and low surgical rate is still a serious same, and there was no day care patient transferred to the public health problem. It is essential to develop day ordinary ward due to severe surgical complications. In this surgery cataract treatment programs due to the fact retrospective cohort study, inclusion and exclusion criteria that they use fewer hospital resources, are cheaper, and included: 1) Patients were at least age thirty with a stable more efficient than those procedures which result in or- state of health and were diagnosed with cataracts in one dinary hospitalization. or both eyes; 2) Patients with other ocular comorbidities In 2011, the International Association for Ambulatory that could affect the postoperative prognosis was ruled Surgery (IAAS) defined day surgery in the UK and out by fundus assessment; 3) Each patient underwent sur- Ireland as: the patient must be admitted and discharged on gery for only one eye; 4) All the patients were operated the same day, with day surgery as the intended manage- upon under topical anesthesia and were performed ment [9]. The rate of day care cataract surgery is almost cataract surgery by phacoemulsification combined with 100% in Denmark and nearly 0% in Austria [10]. In China, posterior chamber intraocular lens implantation.These day surgery has been implemented only in recent years, two groups were respectively termed as day care group later than other countries, but has been implemented in and inpatient group. The surgeons in the two groups Hong Kong since the 1990s [11]. China joined the IAAS were the same, all of whom were senior doctors with officially in May 2013, as the 22nd member. By October rich clinical experience, performing over 5000 cases of 2014, 28 municipal hospitals performed day surgeries, and phacoemulsification.The surgical processesfollowed from January to October 2014, the daily proportion of day standard procedures [1]. The length from the patient’s surgeries of the top 10 hospitals accounted for 76.9% of the registration to check-out was called hospitalization municipal hospitals in Shanghai [12]. Today, day surgery of time, and less than a day was counted as one day. The cataracts is more widely accepted morethan previously in costs consisted of the operation treatment fee, cost of China [13, 14]. The day care cataract surgery has been the intraocular lens, anesthesia fee, preoperative inspec- implemented by the Ophthalmology of the First Affiliated tion fee,cost of drugs, and expense of nursing care and Hospital of Nanjing Medical University since August 1, hospital bed. All the patients had ophthalmic examina- 2014, which was the first hospital implementing day sur- tions including BCVA testing, slit-lamp examination, gery in Jiangsu Province. and intraocular pressure at one day, one week, one month, China launched a government-run mandatory insurance and three months after surgery. BCVA was examined program, the Urban Employee Basic Medical Insurance on the basis of standard logarithmic visual acuity chart (UEBMI) at the end of 1998. Current and former em- (GB11533–2011). ployees of urban enterprises and institutions are insured Based on these two groups, we analyzed differences of with UEBMI. Rural populations are mainly insured by New gender, age, and preoperative Best Corrected Visual Acuity Rural Cooperative Medical Care. While the other medical (BCVA) between the two groups. Intraoperative posterior insurances include Urban Residents Basic Medical Insur- capsule rupture was also analyzed. Postoperative complica- ance (URBMI), Poverty Salvation Free Medical Care, Free tions including cornea edema and intraocular hypertension medical care. Meanwhile, some citizens pay for their med- the first day after surgery, and postoperative BCVA one ical care out-of-pocket or are covered by other medical month after surgery were analyzed. Meanwhile the differ- insurances. ences of the hospitalization time, total costs and payment In this study, we compared the differences between manners between the two groups were also analyzed. All day care and inpatient cataract surgery, the results of statistical analyses were assessed using a t-test and χ2test Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 3 of 5 by IBM SPSS Statistics 24, and P < 0.05 was considered to Table 2 Intraoperative and postoperative complications be statistically significant. Complications Number of participants (%) P Day care (total Inpatient (total n = 4151) n = 2509) Results + 291 (7.0%) 170 (6.8%) General information Posterior capsule rupture 0.715 A total of 2809 males (1724 in the day care group and 1085 in the inpatient group) and 3851 females (2427 in – 3860 (93.0%) 2339 (93.2%) the day care group and 1424 in the inpatient group) pa- + 466(11.2%) 281 (11.2%) tients were included in the current study. The average Cornea edema 0.973 age was 70.54 ± 11.5 in the day care group and 70.01 ± – 3685 (88.8%) 2228 (88.8%) 12.59 in the inpatient group. The average preoperative + 323 (7.8%) 205 (8.2%) BCVA was 3.82 ± 0.48 in the day care group and 3.80 ± Intraocular hypertension 0.569 0.50 in the inpatient group. Generally, there were no sig- nificant differences in gender (P = 0.170), age (P = 0.150), – 3828 (92.2%) 2304 (91.2%) or preoperative visual acuity (P = 0.062) between day n number of participants; + numbers of participants having complications; − numbers of participants not having complications; P > 0.05 shows no care patients and inpatients (Table 1). significant difference Complications and outcomes conclusion, day surgery of cataracts is more efficient and Posterior capsule rupture (PCR) as a intraoperative com- cost-effective than inpatient surgery. plication (P = 0.715) was noted in 291 cases in the day care group and in 170 cases in the inpatient group Medical insurances (Table 2). The main postoperative complications such as To minimize sampling error, the data of payment method cornea edema (P = 0.973) and intraocular hypertension for each patient who underwentcataract surgery within (P = 0.569) occurring the first day after surgery were two years was analyzed. There were over six methods with noted in both groups (Table 2). The average postoperative which to pay for total costs of the medical care. Two main BCVA was 4.84 ± 0.18 in the day care group and 4.86 ± methods were Urban Employees Basic Medical Insur- 0.84 in the inpatient group, with no significant difference ance (UEBMI) and Out-of-pocket Medical Care (OMC) (P = 0.290) between the two groups (Table 3). As afore- (details in Table 4). There was a significant difference mentioned, there were no significant differences in intra- in these main payment methods between these two groups operative complications, postoperative complications, and (P < 0.05). postoperative BCVA between the two groups. Discussion Hospitalization time and costs In our study, the clinical outcomes exhibited by the pa- The average hospitalization time was 1 ± 0 days for the tients of the day care group were nearly equivalent to those day care group and 4.40 ± 1.69 days for the inpatient of the inpatient group, underscoring the safety and effectiv- group. Those patients who chose the day care option for ity of cataract day surgery. The results also demonstrated cataract surgery were hospitalized for a much shorter that day care surgery shortened the patient’s hospitalization time (P < 0.001) than those who chose the inpatient pro- time, which according to the patients’ satisfaction investiga- cedure (Table 3). The average costs paid by patients in tions, resulted in a reduction of nervousness, anxiety, and the day care group were ¥6893.68 ± 1362.89. While the mental stress caused by the long-term hospital stay sub- average costs paid by inpatients were ¥7849.70 ± 1432.70, sequently reducing the operation burden and improving the total costs paid by patients in the day care group were patient satisfaction. Before the cataract surgery, patients less (P < 0.001) than those in inpatient group (Table 3). In were typically required to undergo general examinations Table 3 General information after the surgery Table 1 General information before the surgery Information Average ± SD P Information Day care (total n = 4151) Inpatient (total n = 2509) Day care (total Inpatient (total Gender Male 1724 1085 n = 4151) n = 2509) Female 2427 1424 Postoperative BCVA 4.84 ± 0.18 4.86 ± 0.84 0.290 Age 70.54 ± 11.51 70.01 ± 12.59 Hospitalization 1 ± 0 4.40 ± 1.69 < 0.001 time (days) Preoperative BCVA 3.82 ± 0.48 3.80 ± 0.50 Costs (¥) 6893.68 ± 1362.89 7849.70 ± 1432.70 < 0.001 The data of gender were presented as number of participants (%); the data of age and preoperative BCVA were presented as average ± SD Total n = 1000; P > 0.05 shows no significant difference Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 4 of 5 Table 4 Different payment manners for surgery expenses (UEBMI and OMC) to pay the expenses, and patients who chose UEBMI in the day care group were more than Payment manners Number of participants (%) P those in inpatient group, mainly because local residents Day care (total Inpatient (total n = 4151) n = 2509) with UEBMI preferred day care due to the aforementioned Urban employees basis 2029 (48.9%) 765 (30.5%) < 0.001 advantages. Patients who chose OMC in the inpatient medical insurance group were more than those in the day care group. For ex- Urban residents basic 73 (1.8%) 70 (2.8%) 0.006 ample, most non-Nanjing natives who had other medical medical insurance insurances at their registered permanent residence, chose New rural cooperative 3 (0.1%) 3 (0.1%) 0.533 inpatient for cataract surgery because they had to pay the medical care medical costs through OMC and apply for reimbursement Poverty salvation 0 (0%) 2 (0.1%) 0.069 back to the origin residence. Day care medical expenses Free medical care 197 (4.7%) 102 (4.1%) 0.214 not being reimbursed may be the reason why more OMC patients chose regular hospitalization and not day care Out-of-pocket medical care 1768 (42.6%) 1529 (60.9%) < 0.001 procedures. Others 81 (2.0%) 38 (1.5%) 0.200 In order to improve day surgery, the Guidelines on n number of participants; P > 0.05 shows no significant difference Comprehensive Reform Pilot of Urban Public Hospitals and tests, the expenses of which were included in the total announced by General Office of the State Council in May costs paid by inpatients and not included in the total costs 2015 (No.38 [2015] of the General Office of the State paid by day surgery patients. As these expenses were a Council) clarified that diagnosis and therapy technologies small part of the total cost, they were not the leading including day surgery should be gradually brought into cause of the the difference in cost between day care and the scope of medical insurance payments on the basis of intpatient procedures. At the same time, hospitalization normalizing day surgeries. In 2015, 20 day surgeries in- costs including ward bed expenses, nursing expenses, and cluding age-related cataract were brought into single dis- treatment expenses were significantly reduced due to the eases in Jiangsu province. Twenty-three day surgeries have shortened hospitalization time. Day surgery patients were been paid according to medical insurance since 2016, with discharged from hospital within 24 h, which had the dual the highest reimbursement rate reaching 85% in Jiangxi benefit of greatly reducing the total hospitalization costs province [18]. The Guidelines on Comprehensive Reform and accelerating the turnover of hospital beds, leaving Pilot of Urban Public Hospitals announced by General more hospital beds available for severe cases and subse- Office of the State Council on June 28, 2017 (No.55 quently greatly increasing the efficiency of bed utilization. [2017] of the General Office of the State Council) clarifies UEBMI was the first basic medical insurance established the importance of medical insurance payments for day during medical security system reform in China. With the surgeries again. In this study, we didn’t distinguish the principle of “wide coverage and low level”, it provides costs of differingartificial lenses, which made the results basic medical insurance for urban workers by combining less rigorous. In further studies, this could be improved by government subsidies and medical insurance premiums a larger sample size. payed by individuals and enterprises together (called In conclusion, our results confirm that cataract day “social pooling combined with personal accounts”). [16]. surgery is high-quality and low-cost. Medical insurance The government has also launched a project called Pov- payments for day surgery is need urgent improvement. erty Salvation For The Poor. Free medical service refers to Further optimization and reorganization of the medical a social security system implemented by China to cover service process is essential for day care wards of hospi- state staff and offers free medical treatment and preventive tals to form a high efficiency management and operation service provided by the medical and health departments system, making it convenient for patients to seek medical according to the regulations. Currently, one of the biggest treatment and reducing the economic burden patients ex- bottlenecks in the development of day surgery in China is perience. Along with the rapid economic development in the inability to manage the reimbursement. Some studies our country, the organization and effective use of medical showed that the reimbursement level of medical insurance resources is an urgent and immediate concern. was an important factor influencing patients’ choice of day surgery [17]. In many areas of China, day care procedures Conclusions are not reimbursed by the hospital, or only the expenses In this study, we compared the differences between day for the operation can be reimbursed, excluding the pre- care and inpatient cataract surgery, the results of which operative inspection expenses. Although some terms have confirm that day care cataract surgery is high-quality already been piloted, there is still no national standard for and low-cost. Given these results, it is recommendable payment, limiting the development of day surgeries in that the practice of day care cataract surgery be expanded China. Patients in this study mostly chose two methods in China. Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 5 of 5 Abbreviations 13. Wei Y, Liang Y, Wu Y, Chen M. Application of clinical pathway with day-care BCVA: Best Corrected Visual Acuity; IAAS: International Association for Ambulatory unit mode among patients with cataract. Chinese Health Quality Surgery; OMT: Out-of-Pocket Medical Treatment; PCR: Posterior capsule rupture; Management. 2016;23(4):55–7. UEBMI: Urban Employees Basic Medical Insurance; URBMI: Urban residents basic 14. Lin J, Fang X, Wu S. the management pattern carried out in a cataract medical insurance surgery day ward. Eye Sci. 2013;28(2):79–83. 15. Ng L, Mercerjones M. Day case surgery guidelines. Surgery (oxford). 2014;32(2):73–8. Funding 16. LinW,Liu GG,ChenG.The urban residentbasic medicalinsurance:a No funding was received by any of the authors for the writing of this manuscript. landmark reform towards universal coverage in China. Health Econ. 2009;(18):83–96. Availability of data and materials 17. Fang L, Cao J, Wang M, Du N, Yang L, Zhao R, Li G. Comparison research on All data generated or analyzed of this study are included in this published day surgery in different countries implementing different medical insurance article. Raw and processed data during the current study are available from system. Chinese Hospitals. 2014;18(10):78–80. the corresponding author upon reasonable request. 18. Yu L. Development and Prospect of day surgery in China. Chinese Hospital Management. 2016;36(6):16–8. Authors’ contributions MZ, STY and WF designed the research. MZ, JC and MLC performed all experiments and analyzed the data. MZ, JC and MLC prepared the manuscript. QHL and WF interpreted and edited the manuscript. All authors discussed the results and commented on the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the First Affiliated Hospital with Nanjing Medical University,Nanjing, China. Due to the retrospective nature of the study, informed consent was waived. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China. Department of Ophthalmology, The Fourth Affiliated Hospital of Nantong University, Yancheng, China. Received: 15 March 2018 Accepted: 25 May 2018 References 1. Liu YC, Wilkins M, Kim T, Malyugin B, Mehta JS. Cataracts. Lancet. 2017; 390(10094):600–12. 2. Ingram RM, Banerjee D, Traynar MJ, Thompson RK. Day-case cataract surgery. Br J Ophthalmol. 1983;67(5):278–81. 3. Nicoll JH. The surgery of infancy—I. Pediatr Anesth. 1998;8(3):248. 4. Hamed W, Fedorowicz Z. Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev. 2011;1:CD004242. 5. Wong TY, Zheng Y, Jonas JB, Flaxman SR, Keeffe JE, Leasher JL, Naidoo K, Pesudovs K, Price H, White RA. Prevalence and causes of vision loss in East Asia: 1990–2010. Br J Ophthalmol. 2014;98(5):599–604. 6. Zhao JL. Chinese ophthalmologists should firmly promote vision 2020 action. Practical Journal of Clinical Medicine. 2010;6:1-3. 7. Zhao J. Change to "prevention of the avoidable blindness and visual impairment" from "prevention of blindness". Zhonghua Yan Ke Za Zhi. 2015;51(7):481–3. 8. Wu M, Yip JLY, Kuper H. Rapid assessment of avoidable blindness in Kunming, China. Ophthalmology. 2008;115(6):969–74. 9. Britainireland AOAOG. Day case and short stay surgery: 2. Anaesthesia. 2011;66(5):417–34. 10. Mojonazzi SM, Mojon DS. The rate of outpatient cataract surgery in ten European countries: an analysis using data from the SHARE survey. Graefes Arch Clin Exp Ophthalmol. 2007;245(7):1041. 11. Hospital CCL. The development of day surgery in Hong Kong. Chinese Hospital Management. 1997(7):31–31. 12. Zhao R, Yang L, Zhang WW, Liu GH, Du N, Liu J, Jia TY, Zhang W. Assessment of the development of ambulatory surgery in shanghai municipal hospitals. Chinese Hospitals. 2015;4:7-10. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Ophthalmology Springer Journals

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital

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Abstract

Background: High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. Methods: In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. Results: The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Conclusion: Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies. Keywords: Day care, Inpatient, Cataract Background therapeutic regimen, patients prefer being hospitalized for A cataract is an opacity of the lens in the eyes, which several days for cataract surgery, while the concept of day can lead to blurry vision or blindness. Cataracts may be care cataract surgery is currently increasingly introduced classified into three categories: age-related cataracts, [2]. In the U.S. and Europe and America over 60% cases of metabolic cataracts, and cataracts secondary to other cataract surgeries are carried out as day care surgeries. Day causes. Age-related cataracts are the most common type surgery, a fast and safe therapeutic regimen [3], is a surgical in adults [1]. With a rapidly growing and aging population, procedure wherein hospitalization, surgery and discharge the incidence of cataracts is subsequently increasing. occur within 24 h after a short post-operative recovery. WHO estimated that there were 95 million people visually Ophthalmologic operations are short and quick, making impaired due to cataracts in 2014. According to the former them suitable for day surgery, which allows for a more ef- fective use of medical resources and reduction of average hospitalization days. It has been shown that inpatient care * Correspondence: fanwen1029@163.com for age-related cataract surgery may not only be cheaper, Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 2 of 5 but also as effective as inpatient treatment after the same which will guide the further application of day care or surgery [4]. inpatient care following cataract surgery. Cataracts are the leading cause of blindness and the second-leading cause of vision loss in China [5]. With the promotion of “Vision 2020-the Right to Sight” Methods propaganda, the rate of cataract surgury has increased in Data of patients who underwent cataract operations was China in recent years [6]. In the past ten years, it has pulled from the cataract operation HIS database of the made great progress in blindness prevention and treat- First Affiliated Hospital of Nanjing Medical University ment. In 2005, the number of cataract extractions was only from August 1, 2014 to December 31, 2016. There are no 572,000, at the rate of 440 cases per one million people, absolute contraindications for day surgery patients. Pa- per year. By 2014, the number of cataract extractions tients with stable chronic medical conditions are consid- reached 1.9 million cases, a rate of 1400 cases per one ered to be suitable for day surgery [15]. At the First million people, per year [7]. Despite this, some patients Affiliated Hospital of Nanjing Medical University, patients continue to avoid or refuse cataract surgery due to the chose day care or inpatient cataract surgery on a voluntary costs and fear of surgery [8]. Until now, the high inci- basis. During this period, all fee standards remained the dence of cataracts and low surgical rate is still a serious same, and there was no day care patient transferred to the public health problem. It is essential to develop day ordinary ward due to severe surgical complications. In this surgery cataract treatment programs due to the fact retrospective cohort study, inclusion and exclusion criteria that they use fewer hospital resources, are cheaper, and included: 1) Patients were at least age thirty with a stable more efficient than those procedures which result in or- state of health and were diagnosed with cataracts in one dinary hospitalization. or both eyes; 2) Patients with other ocular comorbidities In 2011, the International Association for Ambulatory that could affect the postoperative prognosis was ruled Surgery (IAAS) defined day surgery in the UK and out by fundus assessment; 3) Each patient underwent sur- Ireland as: the patient must be admitted and discharged on gery for only one eye; 4) All the patients were operated the same day, with day surgery as the intended manage- upon under topical anesthesia and were performed ment [9]. The rate of day care cataract surgery is almost cataract surgery by phacoemulsification combined with 100% in Denmark and nearly 0% in Austria [10]. In China, posterior chamber intraocular lens implantation.These day surgery has been implemented only in recent years, two groups were respectively termed as day care group later than other countries, but has been implemented in and inpatient group. The surgeons in the two groups Hong Kong since the 1990s [11]. China joined the IAAS were the same, all of whom were senior doctors with officially in May 2013, as the 22nd member. By October rich clinical experience, performing over 5000 cases of 2014, 28 municipal hospitals performed day surgeries, and phacoemulsification.The surgical processesfollowed from January to October 2014, the daily proportion of day standard procedures [1]. The length from the patient’s surgeries of the top 10 hospitals accounted for 76.9% of the registration to check-out was called hospitalization municipal hospitals in Shanghai [12]. Today, day surgery of time, and less than a day was counted as one day. The cataracts is more widely accepted morethan previously in costs consisted of the operation treatment fee, cost of China [13, 14]. The day care cataract surgery has been the intraocular lens, anesthesia fee, preoperative inspec- implemented by the Ophthalmology of the First Affiliated tion fee,cost of drugs, and expense of nursing care and Hospital of Nanjing Medical University since August 1, hospital bed. All the patients had ophthalmic examina- 2014, which was the first hospital implementing day sur- tions including BCVA testing, slit-lamp examination, gery in Jiangsu Province. and intraocular pressure at one day, one week, one month, China launched a government-run mandatory insurance and three months after surgery. BCVA was examined program, the Urban Employee Basic Medical Insurance on the basis of standard logarithmic visual acuity chart (UEBMI) at the end of 1998. Current and former em- (GB11533–2011). ployees of urban enterprises and institutions are insured Based on these two groups, we analyzed differences of with UEBMI. Rural populations are mainly insured by New gender, age, and preoperative Best Corrected Visual Acuity Rural Cooperative Medical Care. While the other medical (BCVA) between the two groups. Intraoperative posterior insurances include Urban Residents Basic Medical Insur- capsule rupture was also analyzed. Postoperative complica- ance (URBMI), Poverty Salvation Free Medical Care, Free tions including cornea edema and intraocular hypertension medical care. Meanwhile, some citizens pay for their med- the first day after surgery, and postoperative BCVA one ical care out-of-pocket or are covered by other medical month after surgery were analyzed. Meanwhile the differ- insurances. ences of the hospitalization time, total costs and payment In this study, we compared the differences between manners between the two groups were also analyzed. All day care and inpatient cataract surgery, the results of statistical analyses were assessed using a t-test and χ2test Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 3 of 5 by IBM SPSS Statistics 24, and P < 0.05 was considered to Table 2 Intraoperative and postoperative complications be statistically significant. Complications Number of participants (%) P Day care (total Inpatient (total n = 4151) n = 2509) Results + 291 (7.0%) 170 (6.8%) General information Posterior capsule rupture 0.715 A total of 2809 males (1724 in the day care group and 1085 in the inpatient group) and 3851 females (2427 in – 3860 (93.0%) 2339 (93.2%) the day care group and 1424 in the inpatient group) pa- + 466(11.2%) 281 (11.2%) tients were included in the current study. The average Cornea edema 0.973 age was 70.54 ± 11.5 in the day care group and 70.01 ± – 3685 (88.8%) 2228 (88.8%) 12.59 in the inpatient group. The average preoperative + 323 (7.8%) 205 (8.2%) BCVA was 3.82 ± 0.48 in the day care group and 3.80 ± Intraocular hypertension 0.569 0.50 in the inpatient group. Generally, there were no sig- nificant differences in gender (P = 0.170), age (P = 0.150), – 3828 (92.2%) 2304 (91.2%) or preoperative visual acuity (P = 0.062) between day n number of participants; + numbers of participants having complications; − numbers of participants not having complications; P > 0.05 shows no care patients and inpatients (Table 1). significant difference Complications and outcomes conclusion, day surgery of cataracts is more efficient and Posterior capsule rupture (PCR) as a intraoperative com- cost-effective than inpatient surgery. plication (P = 0.715) was noted in 291 cases in the day care group and in 170 cases in the inpatient group Medical insurances (Table 2). The main postoperative complications such as To minimize sampling error, the data of payment method cornea edema (P = 0.973) and intraocular hypertension for each patient who underwentcataract surgery within (P = 0.569) occurring the first day after surgery were two years was analyzed. There were over six methods with noted in both groups (Table 2). The average postoperative which to pay for total costs of the medical care. Two main BCVA was 4.84 ± 0.18 in the day care group and 4.86 ± methods were Urban Employees Basic Medical Insur- 0.84 in the inpatient group, with no significant difference ance (UEBMI) and Out-of-pocket Medical Care (OMC) (P = 0.290) between the two groups (Table 3). As afore- (details in Table 4). There was a significant difference mentioned, there were no significant differences in intra- in these main payment methods between these two groups operative complications, postoperative complications, and (P < 0.05). postoperative BCVA between the two groups. Discussion Hospitalization time and costs In our study, the clinical outcomes exhibited by the pa- The average hospitalization time was 1 ± 0 days for the tients of the day care group were nearly equivalent to those day care group and 4.40 ± 1.69 days for the inpatient of the inpatient group, underscoring the safety and effectiv- group. Those patients who chose the day care option for ity of cataract day surgery. The results also demonstrated cataract surgery were hospitalized for a much shorter that day care surgery shortened the patient’s hospitalization time (P < 0.001) than those who chose the inpatient pro- time, which according to the patients’ satisfaction investiga- cedure (Table 3). The average costs paid by patients in tions, resulted in a reduction of nervousness, anxiety, and the day care group were ¥6893.68 ± 1362.89. While the mental stress caused by the long-term hospital stay sub- average costs paid by inpatients were ¥7849.70 ± 1432.70, sequently reducing the operation burden and improving the total costs paid by patients in the day care group were patient satisfaction. Before the cataract surgery, patients less (P < 0.001) than those in inpatient group (Table 3). In were typically required to undergo general examinations Table 3 General information after the surgery Table 1 General information before the surgery Information Average ± SD P Information Day care (total n = 4151) Inpatient (total n = 2509) Day care (total Inpatient (total Gender Male 1724 1085 n = 4151) n = 2509) Female 2427 1424 Postoperative BCVA 4.84 ± 0.18 4.86 ± 0.84 0.290 Age 70.54 ± 11.51 70.01 ± 12.59 Hospitalization 1 ± 0 4.40 ± 1.69 < 0.001 time (days) Preoperative BCVA 3.82 ± 0.48 3.80 ± 0.50 Costs (¥) 6893.68 ± 1362.89 7849.70 ± 1432.70 < 0.001 The data of gender were presented as number of participants (%); the data of age and preoperative BCVA were presented as average ± SD Total n = 1000; P > 0.05 shows no significant difference Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 4 of 5 Table 4 Different payment manners for surgery expenses (UEBMI and OMC) to pay the expenses, and patients who chose UEBMI in the day care group were more than Payment manners Number of participants (%) P those in inpatient group, mainly because local residents Day care (total Inpatient (total n = 4151) n = 2509) with UEBMI preferred day care due to the aforementioned Urban employees basis 2029 (48.9%) 765 (30.5%) < 0.001 advantages. Patients who chose OMC in the inpatient medical insurance group were more than those in the day care group. For ex- Urban residents basic 73 (1.8%) 70 (2.8%) 0.006 ample, most non-Nanjing natives who had other medical medical insurance insurances at their registered permanent residence, chose New rural cooperative 3 (0.1%) 3 (0.1%) 0.533 inpatient for cataract surgery because they had to pay the medical care medical costs through OMC and apply for reimbursement Poverty salvation 0 (0%) 2 (0.1%) 0.069 back to the origin residence. Day care medical expenses Free medical care 197 (4.7%) 102 (4.1%) 0.214 not being reimbursed may be the reason why more OMC patients chose regular hospitalization and not day care Out-of-pocket medical care 1768 (42.6%) 1529 (60.9%) < 0.001 procedures. Others 81 (2.0%) 38 (1.5%) 0.200 In order to improve day surgery, the Guidelines on n number of participants; P > 0.05 shows no significant difference Comprehensive Reform Pilot of Urban Public Hospitals and tests, the expenses of which were included in the total announced by General Office of the State Council in May costs paid by inpatients and not included in the total costs 2015 (No.38 [2015] of the General Office of the State paid by day surgery patients. As these expenses were a Council) clarified that diagnosis and therapy technologies small part of the total cost, they were not the leading including day surgery should be gradually brought into cause of the the difference in cost between day care and the scope of medical insurance payments on the basis of intpatient procedures. At the same time, hospitalization normalizing day surgeries. In 2015, 20 day surgeries in- costs including ward bed expenses, nursing expenses, and cluding age-related cataract were brought into single dis- treatment expenses were significantly reduced due to the eases in Jiangsu province. Twenty-three day surgeries have shortened hospitalization time. Day surgery patients were been paid according to medical insurance since 2016, with discharged from hospital within 24 h, which had the dual the highest reimbursement rate reaching 85% in Jiangxi benefit of greatly reducing the total hospitalization costs province [18]. The Guidelines on Comprehensive Reform and accelerating the turnover of hospital beds, leaving Pilot of Urban Public Hospitals announced by General more hospital beds available for severe cases and subse- Office of the State Council on June 28, 2017 (No.55 quently greatly increasing the efficiency of bed utilization. [2017] of the General Office of the State Council) clarifies UEBMI was the first basic medical insurance established the importance of medical insurance payments for day during medical security system reform in China. With the surgeries again. In this study, we didn’t distinguish the principle of “wide coverage and low level”, it provides costs of differingartificial lenses, which made the results basic medical insurance for urban workers by combining less rigorous. In further studies, this could be improved by government subsidies and medical insurance premiums a larger sample size. payed by individuals and enterprises together (called In conclusion, our results confirm that cataract day “social pooling combined with personal accounts”). [16]. surgery is high-quality and low-cost. Medical insurance The government has also launched a project called Pov- payments for day surgery is need urgent improvement. erty Salvation For The Poor. Free medical service refers to Further optimization and reorganization of the medical a social security system implemented by China to cover service process is essential for day care wards of hospi- state staff and offers free medical treatment and preventive tals to form a high efficiency management and operation service provided by the medical and health departments system, making it convenient for patients to seek medical according to the regulations. Currently, one of the biggest treatment and reducing the economic burden patients ex- bottlenecks in the development of day surgery in China is perience. Along with the rapid economic development in the inability to manage the reimbursement. Some studies our country, the organization and effective use of medical showed that the reimbursement level of medical insurance resources is an urgent and immediate concern. was an important factor influencing patients’ choice of day surgery [17]. In many areas of China, day care procedures Conclusions are not reimbursed by the hospital, or only the expenses In this study, we compared the differences between day for the operation can be reimbursed, excluding the pre- care and inpatient cataract surgery, the results of which operative inspection expenses. Although some terms have confirm that day care cataract surgery is high-quality already been piloted, there is still no national standard for and low-cost. Given these results, it is recommendable payment, limiting the development of day surgeries in that the practice of day care cataract surgery be expanded China. Patients in this study mostly chose two methods in China. Zhuang et al. BMC Ophthalmology (2018) 18:134 Page 5 of 5 Abbreviations 13. Wei Y, Liang Y, Wu Y, Chen M. Application of clinical pathway with day-care BCVA: Best Corrected Visual Acuity; IAAS: International Association for Ambulatory unit mode among patients with cataract. Chinese Health Quality Surgery; OMT: Out-of-Pocket Medical Treatment; PCR: Posterior capsule rupture; Management. 2016;23(4):55–7. UEBMI: Urban Employees Basic Medical Insurance; URBMI: Urban residents basic 14. Lin J, Fang X, Wu S. the management pattern carried out in a cataract medical insurance surgery day ward. Eye Sci. 2013;28(2):79–83. 15. Ng L, Mercerjones M. Day case surgery guidelines. Surgery (oxford). 2014;32(2):73–8. Funding 16. LinW,Liu GG,ChenG.The urban residentbasic medicalinsurance:a No funding was received by any of the authors for the writing of this manuscript. landmark reform towards universal coverage in China. Health Econ. 2009;(18):83–96. Availability of data and materials 17. Fang L, Cao J, Wang M, Du N, Yang L, Zhao R, Li G. Comparison research on All data generated or analyzed of this study are included in this published day surgery in different countries implementing different medical insurance article. Raw and processed data during the current study are available from system. Chinese Hospitals. 2014;18(10):78–80. the corresponding author upon reasonable request. 18. Yu L. Development and Prospect of day surgery in China. Chinese Hospital Management. 2016;36(6):16–8. Authors’ contributions MZ, STY and WF designed the research. MZ, JC and MLC performed all experiments and analyzed the data. MZ, JC and MLC prepared the manuscript. QHL and WF interpreted and edited the manuscript. All authors discussed the results and commented on the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the First Affiliated Hospital with Nanjing Medical University,Nanjing, China. Due to the retrospective nature of the study, informed consent was waived. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China. Department of Ophthalmology, The Fourth Affiliated Hospital of Nantong University, Yancheng, China. Received: 15 March 2018 Accepted: 25 May 2018 References 1. Liu YC, Wilkins M, Kim T, Malyugin B, Mehta JS. Cataracts. Lancet. 2017; 390(10094):600–12. 2. Ingram RM, Banerjee D, Traynar MJ, Thompson RK. Day-case cataract surgery. Br J Ophthalmol. 1983;67(5):278–81. 3. Nicoll JH. The surgery of infancy—I. Pediatr Anesth. 1998;8(3):248. 4. Hamed W, Fedorowicz Z. Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev. 2011;1:CD004242. 5. Wong TY, Zheng Y, Jonas JB, Flaxman SR, Keeffe JE, Leasher JL, Naidoo K, Pesudovs K, Price H, White RA. Prevalence and causes of vision loss in East Asia: 1990–2010. Br J Ophthalmol. 2014;98(5):599–604. 6. Zhao JL. Chinese ophthalmologists should firmly promote vision 2020 action. Practical Journal of Clinical Medicine. 2010;6:1-3. 7. Zhao J. Change to "prevention of the avoidable blindness and visual impairment" from "prevention of blindness". Zhonghua Yan Ke Za Zhi. 2015;51(7):481–3. 8. Wu M, Yip JLY, Kuper H. Rapid assessment of avoidable blindness in Kunming, China. Ophthalmology. 2008;115(6):969–74. 9. Britainireland AOAOG. Day case and short stay surgery: 2. Anaesthesia. 2011;66(5):417–34. 10. Mojonazzi SM, Mojon DS. The rate of outpatient cataract surgery in ten European countries: an analysis using data from the SHARE survey. Graefes Arch Clin Exp Ophthalmol. 2007;245(7):1041. 11. Hospital CCL. The development of day surgery in Hong Kong. Chinese Hospital Management. 1997(7):31–31. 12. Zhao R, Yang L, Zhang WW, Liu GH, Du N, Liu J, Jia TY, Zhang W. Assessment of the development of ambulatory surgery in shanghai municipal hospitals. 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BMC OphthalmologySpringer Journals

Published: Jun 5, 2018

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