Reflections on Refractive Surgery

Ambulatory Surgery:
American and European Models and Global Issues

The evolution and current status of ambulatory surgery in the United States and France were presented at the General Assembly of the United Nations' World Academy of Biomedical Technologies at UNESCO headquarters in Paris.

There has been a tremendous increase in surgery performed on an outpatient basis in both the United States and France over the last twenty years, but the transition from inpatient to outpatient surgery has been faster and has involved more procedures in the US than in France.

In the US, the number of freestanding ambulatory surgery centres (ASCs) increased from 40 in 1980 to over 3,500 in 2001. The vast majority of American ASCs are still independently owned and only about 10% are hospital affiliated. A higher percentage of ambulatory surgery is performed in hospital outpatient departments in France.

The number of different types of surgical procedures performed on an outpatient basis has increased almost tenfold over a ten year period. According to the office of the Inspector General of the United States Department of Health and Human Services, 12,000 different outpatient procedures were performed in 1990 and 120,000 in 2000.

Despite this large increase in types of procedures, a few procedures, such as cataract surgery remain the most commonly performed. At the legislative conference of the Federated Ambulatory Surgery Association in Washington DC, in February 2002, Representative Pete Stark, the senior member of the US House Ways and Means Committee, commented:

"I have some concern about your industry. I believe that something like 80% of the procedures are in about 20 codes. Groups are taking the most profitable procedures out of the hospitals and into the freestanding centres. The hospitals are left with emergency room and chronic disease cases. This is not very profitable care… Before you say (you) don't care what happens to the major hospitals or the teaching hospitals in your area be careful."

Many administrators of university medical centres are already worried about this trend. Indeed with changes in ambulatory surgery, hospital administration and reimbursements, ophthalmology departments are no longer viewed as desirable by many American medical centres and teaching hospitals, which can no longer bill ophthalmic patients for overnight stays. The situation is different in France where the system still enables ophthalmology departments to be more profitable and desired by medical centres.

It will be interesting to see how ambulatory surgery evolves in the United States and Europe over the next decades - hopefully with successful solutions to some of the developing problems

Multiple studies have shown that patients prefer non-sick and more personal settings for low-risk, uncomplicated surgery. The increase in ambulatory surgical centres has provided patients more access to urgical care closed to home.

The Outcome Monitoring Project in the 4th Quarter of 2001 by the Fedrated Ambulatory Surgery Association demonstrated the lowest complication and infection rate per 1000 patients encounters in ophthalmology and gastroenterology, with higher rates in multispecialty than single specialty ASCs.

Surgeons, industry and governmental agencies all agree that there will be continued ambulatory surgical growth. This growth will be triggered by an increasingly aging population with changing lifestyles, as well as by improved surgical techniques. New technologies will expand surgical indications and decrease the need for in-patient surgery

All predictions of the continued expansion include growth both in the number and utilisation of single and multispeciality ambulatory surgical centres. Although utilisation of non-sterile laser and diagnostic centres is also expected to increase, it is anticipated that there will be consolidation in over saturated markets.

Ophthalmic ambulatory surgery is predicted to grow at a faster pace that most specialties for several reasons. The ophthalmic market is growing faster than most markets. It is considered the most inventive in medicine. Ophthalmic surgeons are known to be among the most innovative physicians and surgeons. Expanding surgical indications in all ophthalmic sub-specialties but especially in refractive, glaucoma, oculoplastic, and vitreoretinal surgery combined with improved techniques and technologies for treating complex cases faster and more safely, will continue to increase the number of outpatient ophthalmic procedures.

The discussions at UNESCO focused on how developing countries could best apply the American and French ambulatory models in their countries. The global expansion of American and European corporations was questioned.

Unsuccessful global initiatives
Global initiatives in the 1990s were unsuccessful. Several companies owning and managing ambulatory surgical centres or laser centres expanded internationally, usually in partnership with local surgeons. Local surgeons and administrators obtained expertise and initial financial support for planning and construction. In many cases local surgeons demanded and obtained autonomy with the help of local governmental agencies and financial institutions. Investors in public corporations often lost money when ASCs were bought out by local groups or when managing expenses led to losses requiring fire sales to local or larger groups.

Moreover, at the present time, American companies are generally not interested in expanding globally since the US market currently is the largest. Previous unsuccessful experiences demonstrated the difficuly of correctly ascertaining market opportunities in different countries and cultures and the difficulty of controlling regulatory and monitoring aspects.

Nevertheless, cooperation between surgeons, industry, governmental agencies and non-governmental organisations from many countries will allow us to improve surgical delivery systems. By learning from the successes and failures in different countries and better understanding medical needs and resources, I believe we will be able to offer patients a higher standard of care throughout the world.

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