Exploring geographical variation in access to general surgery in Ireland: Evidence from a national study.

BACKGROUND: Improving the equity of surgical services is an important objective of all clinical programmes both local and overseas. Variations in access to care threaten to dismantle the structural paradigm of any health service and such information can aid in promoting quality and access to surgical services. The aim of this study was to explore the geographical variation in the utilisation of common general surgical procedures in Ireland as a measure of the population's access to surgical interventions. METHODS: Age- and gender-standardized rates for 6 common general surgical procedures were calculated for 28 geographic areas (counties) in the Republic of Ireland using data from the national Hospital Inpatient Enquiry System. Standard statistical indicators (systematic component of variation, coefficient of variation and extremal quotient) were used to measure the extent of regional variation. RESULTS: A total of 998,406 episodes of hospital care were included in the analysis. Large variation in utilisation was present between the studied counties; CV > 0.3 (range 19.4-31.2), SCV > 5 (range 5.2-14.6). Most procedures were utilised at substantially higher rates outside the larger cities (Dublin, Galway, Waterford). CONCLUSION: Variations stemming from inefficient and unequal access are important components and markers of modern health systems and should be minimal. County of residence appears to have a clear influence on a patients' inaccessibility to certain interventions. Our findings imply a need for improved access at a regional level by facilitating the integration of public policies and promoting services at the appropriate settings.

Elective ambulatory surgical care in Ireland-why it needs to be better coded, classified and managed.

BACKGROUND: In the year to July 2017, surgical disciplines accounted for 73% of the total national inpatient and day case waiting list and, of these, day cases accounted for 72%. Their proper classification is therefore important so that patients can be managed and treated in the most suitable and efficient setting. AIMS: We set out to sub-classify the different elective surgical day cases treated in Irish public hospitals in order to assess their need to be managed as day cases and the consistency of practice between hospitals. METHODS: We analysed all elective day cases that came under the care of surgeons between January 2014 and December 2016 and sub-classified them into those that were (A) true day case surgical procedures; (B) minor surgery or outpatient procedures; (C) gastrointestinal endoscopies; (D) day case, non-surgical interventions and (E) unclassified or having no primary procedure identified. RESULTS: Of 813,236 day case surgical interventions performed over 3 years, 26% were adjudged to accord with group A, 41% with B, 23% with C, 5% with D and 5% with E. The ratio of A to B procedures did not vary significantly across the range of hospital types. However, there were some notable variations in coding and practices between hospitals. CONCLUSION: Our findings show that many day cases should have been performed as outpatient procedures and that there were variations in coding and practices between hospitals that could not be easily explained. Outpatient procedure coding and a better, more consistent, classification of day cases are both required to better manage this group of patients.

Characteristics of patients who are acutely admitted to hospital under surgical care and do not have a surgical procedure - Is there an alternative to admission?

INTRODUCTION: Previous work has shown that 56% of all acute surgical admissions in Ireland in 2012 did not have a formal surgical procedure. In light of the pressures on health systems internationally and the lack of relevant data on this topic in the literature, we examined the characteristics of this cohort of patients in Ireland. METHODS: Discharge data on acutely admitted patients who did not undergo a surgical procedure was extracted from the Hospital Inpatient Enquiry (HIPE) database for the year 2013. These were analysed by age, sex, diagnoses, procedures performed and length of stay in hospital. RESULTS: In 2013, 63,079 patients were admitted acutely under surgical care and then discharged without undergoing a formal surgical procedure compared to 49,903 who had a surgical procedure. Most of the discharges not having formal surgery were treated by general surgical specialities (n = 41,434) and the average length of stay was 4.8 days. Approximately half of these patients (n = 32,194) did not have any HIPE coded procedure, surgical or otherwise, during their admission into hospital. CONCLUSIONS: A considerable number of patients were admitted to Irish surgical units in 2013 and were discharged again without any formal surgical intervention. We postulate that some of these patients may not require admission to hospital and outline mechanisms which may prevent admissions Such mechanisms could allow for greater capacity for scheduled patients in currently overstrained surgical units.