Socio-economic study of the activities of the Ambulatory Surgery Center of a multidisciplinary hospital

The dissertation is devoted to a comprehensive socio-economic study of the activities of the Ambulatory Surgery Center of a multidisciplinary hospital. The research focuses on the development of resource-saving technologies in healthcare, in particular on hospital-substituting forms of surgical care delivery, such as ambulatory surgery. Questions of hospital care restructuring, the organization of day hospitals and Ambulatory Surgery Centers in the conditions of a combined hospital are considered.

In the work, a comparative analysis of the medical and social characteristics of patients operated on in outpatient clinic and round-the-clock hospital settings was conducted, the economic efficiency of resource-saving technologies was studied, and the advisability of redistributing medical care volumes from expensive inpatient care to outpatient and polyclinic care was substantiated. Special attention was given to the problems of material, technical, personnel, and financial re-equipment of the primary level of healthcare under budget-insurance financing.

The main direction of development of the healthcare system of Russia, as defined by the Concept for the Development of Healthcare in the Russian Federation, is the improvement of the efficiency of resource utilization through the implementation of resource-saving technologies and the development of hospital-substituting forms of medical care delivery to the population.

The introduction of modern technologies into the practice of medical institutions depends on the state of the material and technical base, financial resource availability, and the ability to form and utilize the internal reserves of a medical and preventive care institution.

For many years, the healthcare system in Russia has been oriented toward extensive, distributive resource provision, which has led to economically inefficient development paths. The majority of material, technical, and financial resources were invested in inpatient care. As a result, the population's access to medical care was achieved through the expansion of the hospital bed capacity and the number of hospitalized patients. The hospitalization rate by the year 2000 amounted to 20.0–21.2% of the total population, with an average length of stay in hospitals exceeding 16 days. More than 60% of all funds allocated to healthcare are spent on inpatient care (Yu.L. Shevchenko, 2001; A.I. Vyalkov, 2002; V.I. Starodubov, 2003). At the same time, up to 30% of patients in hospitals do not require this type of medical care, and many of them could receive care in outpatient settings (N.F. Gerasimenko, R.A. Galkin, 1998).

At the same time, there is no differentiated approach in the selection of patients for inpatient and outpatient treatment. The prevailing situation applies fully to surgical patients. For example, the choice of treatment location for patients with hernias, constituting up to 20% of those operated on in the hospital, is made without regard to clinical variants of the disease course, as patients with ventral hernias scheduled for surgery are traditionally operated on in hospital settings regardless of the stage of the disease. Outpatient surgical treatment of such patients is 2–3 times less expensive than inpatient treatment (V.P. Sazhin, 2002).

Healthcare system reform implies a change in the financing and payment for medical care by directing financial flows primarily to the development of the outpatient and polyclinic service and hospital-substituting technologies.

The introduced financing methods should stimulate the process of healthcare restructuring. According to data from the Ministry of Health of the Russian Federation, by 2001, 8,336 day hospitals had been organized and were operating in medical care institutions of the Russian Federation, with 130 thousand beds deployed. During the period from 1990 to 2001, the number of beds in day hospitals increased from 1.2 to 9.0 per 10 thousand population, and the number of patients treated in institutions of this type increased from 4.1 to 24.9 per 1,000 population, accounting for 11.7% of all cases of hospitalization in hospital institutions.

The transition of healthcare to intensive development models is possible under the condition of effective utilization of available material, financial, and human resources potential. Modernization of the compulsory medical insurance system is necessary (V.I. Starodubov, 2003). One of the ways to improve the efficiency of a medical and preventive care institution is the reduction of the volume of inpatient care through the redistribution of medical care volumes from expensive inpatient care to outpatient and polyclinic care using hospital-substituting forms and the introduction of low-cost but modern surgical technologies. According to a number of authors, 40–70% of all surgical interventions should be performed in outpatient settings. The introduction of modern systemic hospital-substituting technologies is occurring slowly, and the use of resource-saving technologies in regions remains extremely limited (I.V. Uspenskaya, G.A. Ponomareva, O.E. Konovalov, 2003). Unresolved issues remain regarding the material, technical, personnel, and financial re-equipment of the primary level (V.O. Shchepin, V.K. Ovchаров, 2005). In this connection, the problem of optimizing the organizational structure of the inpatient and outpatient-polyclinic service of a medical institution becomes relevant and practically significant. In domestic literature, the economic aspects of this problem are insufficiently studied, and sociological studies are rare. For example, when studying the problem of providing care to surgical patients in hospital-substituting conditions, the extremely insufficient development of organizational issues regarding the creation and evaluation of the work of the Ambulatory Surgery Center in the conditions of a combined hospital attracts attention. Only in a few works are the theoretical foundations of evaluating the quality of medical services from the consumer's perspective studied (V.Z. Kucharenko, V.M. Alekseeva, T.V. Skomorokhova, 2003). The restructuring of medical care is one of the promising directions of healthcare development (V.O. Shchepin, V.K. Ovchаров, 2005).

Therefore, in this work, the following goal was set: on the basis of a comprehensive socio-economic study, to scientifically substantiate the advisability of using resource-saving technologies to improve the accessibility of qualified medical care.

In accordance with the stated goal, the following research tasks were defined:

1. To study the need for and the effectiveness of hospital-substituting care using the example of surgical technologies.

2. To determine the social and hygienic and medical conditions necessary for the use of resource-saving technologies.

3. To analyze the advantages and disadvantages of implementing resource-saving technologies in the conditions of a combined hospital.

4. To study the problems of a combined hospital in providing hospital-substituting care.

5. To conduct an analysis of the economic efficiency of resource-saving technologies.

The scientific novelty of the research consists in the fact that, for the first time:

— a comprehensive comparative assessment of the social and economic efficiency of hospital-substituting care was conducted based on the treatment of surgical patients;

— the impact of resource-saving surgical technologies on the activities of a combined hospital was studied;

— factors influencing the financial sustainability of hospital-substituting care development were identified.

The scientific and practical significance of the work. The results of the research allowed:

— the conditions for the development of hospital-substituting care for surgical patients to be studied;

— the advantages and disadvantages of organizing an Ambulatory Surgery Center in the polyclinic department of a hospital to be determined; the economic efficiency of hospital-substituting care to be studied on the basis of a comparative analysis of the medical technology cards "Organization of selection and clinical observation during hernia resection in the round-the-clock hospital and the Ambulatory Surgery Center";

— recommendations to be developed for optimizing the activities of a medical institution when using resource-saving technologies.

Implementation of the research results in practice:

1. In the Tula region, the research materials were used in the formation of the municipal order for providing free medical care to the population of the city of Novomoskovsk and the district (implementation act dated 17.01.05).

2. The results of a sociological survey of patients based on the developed questionnaire were applied in the work of the MUZ "Center for Medical Prevention" (implementation act dated 24.02.05).

3. The research results were used in the activities of two medical care institutions in the Tula region: MUZ "Sokolnicheskaya City Hospital" and MUZ "Novomoskovsk City Clinical Hospital" (implementation acts dated 12.01.05 and 01.03.05).

4. The materials of the work are used in the educational process of Ryazan State Medical University named after Academician I.P. Pavlov.

Presentation of the work. The main provisions and results of the work were discussed at:

— the conference of the Hernia Society "Current Issues in Herniology" (Moscow, 2002);

— the meeting of the Board of Chief Surgeons of the Central District (Novomoskovsk, 2003);

— the scientific and practical conference "Regional Problems of the OMS System. Approaches to Resolution" (Ryazan, 2003);

— the meeting of the scientific conference dedicated to the 60th anniversary of the founding of Ryazan State Medical University named after Academician I.P. Pavlov (Ryazan, May 21, 2004);

— the First Regional Conference of Surgeons "Modern Possibilities of Hospital-Substituting Technologies in Surgery" (Khanty-Mansiysk, October 12–13, 2004);

— the First Congress of Ambulatory Surgeons of the Russian Federation (Saint Petersburg, November 17–18, 2004).

Publications. The results of the research were reflected in 14 articles.

Main provisions presented for defense:

1. The organization of resource-saving technologies in a combined hospital is possible at the expense of the internal reserves of the hospital and the polyclinic, which has a positive impact on the efficiency of the hospital's work.

2. The implementation of hospital-substituting care makes it possible to reduce the costs of treating patients from budget, medical, and social insurance funds.

3. The development of resource-saving technologies improves the accessibility and quality of medical care for the population.