The evolution of sites of surgery

Abstract

The shift to ambulatory surgery has taken decades. The history and causation of the move are complex. Key enablers are recounted. The complex interchange of ideas, and physicians, between Belfast and Boston was important in the development of relevant facilitating standards. US and UK governmental and hospital statistics in the increase of ambulatory surgery are presented. The transition of surgery away from hospitals was not all plain-sailing. Insurance companies, governments and hospital administrators hindered and then acquiesced. The shift to ambulatory surgery has not resulted in increased patient morbidity and mortality.

Fig 1

The total number of U.S. surgical operations has continuously increased. The rate of surgical procedures performed on hospital inpatients has slowly declined among the US resident population as this population has increased over the last decade. Hospital-based ambulatory surgery, MD office-based and free-standing surgicenter surgery continue to increase in volume. US Federal Statistics for surgicenter surgery only exist for 1994 and 1996; their collection will be resumed in 2006. In the US there are currently about 4,600 free-standing ambulatory surgicenters in operation, an increase of about fifty percent over the past five years. Almost nine million surgicenter operations (not represented in fig. 1) are projected for the US in 2005; the US federal figure was 5.1 million in 1996 (see “striped” data). Reliable data for MD-office based surgery are not yet available for the years after 2001.

Fig 2

The different states of the United States differ considerably in the proportion of surgery performed without admission to hospital. These figures provided by the American Hospital Association include only hospital-based surgery. Free-standing surgicenter and MD office-based surgery are excluded (see fig. 1). The differences between states may reflect different state laws and regulations, county and other local ordinances, as well as demographic factors and variations in physician practice patterns. US presidential electoral voting results for each state are indicated as red for Republican candidates and blue for Democratic Party candidates. The 1993 panel is mapped to the 1992 presidential election (GHW Bush versus WJ Clinton), the 1998 to the 1996 election (WJ Clinton versus R Dole) and the 2003 to the presidential election of 2000 (A Gore versus GW Bush). There appears to be no association between a state's political orientation and the percentage of surgery performed without admission to hospital.

Fig 3

According to the American Hospital Association over the decade from 1994 through 2003, the gross revenue of US acute care hospitals increased from approximately 450 billion dollars to just over one trillion, or doubled in the first nine years using constant dollars. During this decade, US Gross Domestic Product (GDP) increased 32% in constant dollars. Outpatient revenue as a percentage of total gross hospital revenue has shown a small but steady increase (28-35%) during the same decade.