Introduction

Medical and health care in India have two parallel systems: the public sector and the private sector. The former caters to a larger population and is almost free, but proportionately lacks in funding and trained personnel. The private sector, which serves a small urban population, is at par with the best know-how and equipment available in the world, but is expensive. Only 17 per cent of all health care expenditure in India is borne by the government, making it one of the most privatised health care systems in the world.1

Of the total population of 1,073,000,000 (more than a billion!) in India, 73.87% live in the villages and smaller towns, some of which are accessible only by foot. The rest, 26.13%, only reside in the cities.2

A national census and detailed statistics of the surgical patients attending the OPDs and being operated upon has not yet been compiled by the government or any private agency.

The Western region of India, where the city of Mumbai is situated, drains a large number of patients from all over the country and abroad. Therefore, it has been taken as a ‘Sample’ for compilation and presentation of planned surgeries in this region.

In addition to its 20 million resident population and several million floating population, Mumbai caters to nearly 5 million patients annually. Some of the best equipped Public and Private Hospitals are situated in Mumbai.

History

More than 2000 years ago, Shushrut, the great Ayurvedacharya of ancient India, has documented surgeries in his compilation, which were based on the concept of Ambulatory surgery.3 Development of Hospitals were not seen till several centuries later, when Ashoka, described the medical ethics pertaining to surgical practice and set up ‘Sanatoriums’ for the care of the ill, which were managed by the Buddhist monks. The famous Ashoka rock in Girnar, bears testimony to the high standards of medical care and ethics expected from the physician and surgeons of those days. We have very little data or chronological details of the innovations of our ancient surgeons, but, whatever illustrations and instruments which have been preserved over the years show the brilliance of the designer who fashioned them to resemble the jaws of animals and fishes. These are very similar to the modern day instruments which were invented separately.4 Modern medicine has rekindled the interest in Ambulatory surgery and the last century has seen a gradual rise in its development.

In 1908, James Nicoll5 in one of the largest series to be published from the Royal Hospital for Sick Children in Glasgow, UK, reported the results of 7392 day care procedures in over 9 years. He stated that admitting children for certain operations “constitutes a waste of resources of a children’s hospital”. He recognized that results were comparable to those in admitted patients, with significant savings to the patient and to the hospital, and further stated that “with a mother of average intelligence, assisted by advice from the hospital sister, the child fares better than in the hospital”. Even then, he recognised and stressed on suitable home conditions, with proper co-operation of the General practitioners, and a promise of re-admission if needed.6 Much later, a study in the early 1950s revealed that there was a significant rate of hospital related infections in children admitted for elective surgery.7

As the cost of surgical treatment increased, Palumbo et al (1952),8 reported on early ambulation in a group of 2955 male patients who had undergone major surgery and noted that the economic advantage of outpatient surgery hastened its acceptance.9 It was soon realized that about 35% of all operations could be performed without the need for hospital admission and more patients were treated on the same number of hospital beds. In 1972 Cloud presented a large series of wide varieties of case performed under endo-tracheal anaesthesia, establishing its absolute safety. Outpatient surgery quickly gained momentum and surgical care acquired a new dimension.10,11

Definition

UK- The admission of selected patients to hospital for a planned surgical procedure, returning home on the same day. ‘True day surgery’ patients are day case patients who require full operating theatre facilities and / or a general anaesthetic, and any day cases not included as outpatient or endoscopy.13

USA- Minor Ambulatory surgery or out patient surgery, as that, where care is provided to non-hospitalised patients with immediate discharge. Local anaesthesia is almost invariably used.

Major Ambulatory Surgery is defined as surgery done under GA, Regional or LA, in which a period of post-operative recovery and / or observation is required before the patient is discharged home later the same day.14

Working definition

We propose: Day care or ambulatory surgery is one wherein the patient is discharged on the same day of surgery or an invasive procedure. These patients require a fully equipped operation theater facility. Depending on the type of anaesthesia used, require a few hours of observation, thus, avoiding hospitalization.15

Nomenclature

Day surgery is known by several names world over. The most commonly in use are: Day Case, Day Surgery, Major/Minor Ambulatory Surgery, 23-hours surgery, One-Day surgery, In and Out surgery, OPD procedures, etc. In our country, it is most prevalently known as Day Care surgery.

Statistics

These have been taken from 3 leading Public hospitals and 2 Private Hospital, situated in the city of Mumbai. They are amongst the largest hospitals in the country. Their total bed strength is 5997 and they cater to approximately 1.5 million patients every year. Surgical OPD attendance is 258,889 patients, all surgical specialities combined. Of these patients, 80,991 underwent surgical procedures during the year 2003-2004.

The number of Day Surgery cases, including Minor and OPD procedures, was 36,239 surgeries. Out of which 27,138 would come under the category of Minor / OPD cases. Making True Day Surgery cases a mere 9,101, that is, 11.23% of the total number of cases being performed in this sample study. Most of the hospitals perform Day surgery as part of the regular surgical list.

Table 1 shows a one year (2003-2004) statistics of Day Surgery cases performed in Private Nursing Homes in the city of Mumbai. The proportion of beds to the number of cases performed clearly shows that Ophthalmology has taken the lead, performing 136.36 cases/bed/year. Urology being the lowest, that is, 37.12 cases/bed/year. These have been taken from centres run by leading surgeons with several years of practice; the given numbers are major cases, performed as true day care surgery. Theses are surgeons who are closely associated with the propagation of day surgery.

Discussion

The criteria’s for patient selection and preparation remain similar to those followed all over the world with a few variations to suit the local needs.

The sheer size of the population and lack of funds have made Health care more and more dependent on Private sector which is sometimes out of bounds to the poor patient.

In a recent study, the expenditure as per cent of the GDP, from 175 countries shows:

India to be spending 0.9% in the Public sector, 4.2% in the Private sector, totalling 5.1% of the GDP. Whereas, the USA spends 6.2% in the Public sector and 7.7% in the Private sector, totalling to 13.9% of its GDP. India stands 171st in expenditure on its Public health care system. In contrast with the rank of 18th in the world, in terms of expenditure in the Private Health Care sector.16

The statistics show, that as compared to Western medical centres, where Day surgery is a well established modality of dispensing surgical care, we are lagging far behind.

Amongst all the surgical specialities, less than 15% of cases operated upon are true Day Cases. The bulk of these patients come from the specialities of Ophthalmology and ENT, followed by Gynaecology and General surgery. The other super-specialities contribute only a small fraction.

In the USA, nearly 40 million cases were performed as Day surgery last year. In the UK, during the year 2003, 50% of the cases were performed as Day surgery, which has been projected to increase upto 75% in the year 2005. The NHS is overburdened by the sheer number of cases they have to operate, making a waiting period of more that 2 months for simple surgical cases. The cost cutting in the USA on healthcare spending, mostly by the medical insurance companies, has lead to the development of Ambulatory surgery, which works out to be very economical.

In India, we are faced with the unique problem of over burdened Public hospitals, as well as, increasing cost of surgeries in the Private hospitals. Also, there is a fast emerging group of jet-setting executives and business men, who do not have the time to ‘waste’ in hospitals, and are looking for fast recovery, enabling they to get back to work as early as possible. The answer lies in the proper and complete utilization of Day Care surgery.

According to the latest government estimates, the doctor-patient ratio is 1:1800 and the hospital bed-patient ratio of 1:1259. There is an estimated shortage of 42,000 beds in just the government hospitals which cater to 60% of the population.16

As far as National programme and policy making is concerned, the government agencies have been over-burdened by the epidemics and pandemics of AIDS, Malaria, Kala Azar, Polio and malnutrition. Consequently, the surgical speciality, especially, Day surgery, is not on their priority programme.

Medical insurance covers a small fraction of population but most of these insurance companies still insist on a 24 hrs. admission. Hopefully, these policies will soon change, and would make it easy for all to get benefit from day surgery.

The problems we face are: lack of awareness in the patient population and poor facilities for training doctors in this specialty. The Medical education system has not incorporated day surgical training into their curriculum. These have to be acquired as part of your practical experience once you have completed your specialisation. Ambulatory surgery or Day surgery will have to be a super speciality, creating its own identity.

The Indian Association of Day Surgery was conceptualised in 2003 by a few like minded surgeons, who were interested in day surgery. They got together with the sole purpose of furthering the concept of day surgery in the country by increasing the awareness among the patients, creating training facilities for the surgeons and working with government agencies to help them make policies which will be beneficial to all.

The Association has to address these issues one by one and quickly, so that soon we will be in a position to contribute to the national economy by reducing costs and reducing the loss of time. This would minimise the financial losses faced by an individual and increase his work output, thereby helping in the national growth. Paucity of funds has been the main deterrent in achieving your goals, but it is hoped that the perseverance and devotion of a few dedicated surgeons will extensively establish Ambulatory surgery in India.

We have started by proposing protocols for patient selection and setting up of centres for the safe and successful delivery of surgical care to the patient. Help will be provided in the form of technical know-how in setting up and running of the centre to Govt., NGO or private agencies. More interaction is needed between the Association and the policy making agencies for devising ways and means to take day surgery to the rural India.

In addition to making Day surgery a part of regular CME programmes, we should also encourage other agencies to take up Lectures, workshops and seminars, targeting the young trainee surgeons by exposing them to day surgery in their medical institutions.

Indian Journal of Day Surgery will be published yearly, to begin with, giving day surgeons a platform to share their experiences and also learn from others, from India and abroad.

More information regarding the Association can be gathered from the recently launched website: www.daysurgeryindia.org

It seems that, a revolution of sorts would be required to bring about the betterment of Ambulatory or Day Care Surgery in India. This can only happen with a combined effort by the GP’s, physicians, surgeons, hospital administrators and insurance companies.

Conclusion

Keeping in mind the safety of the patient, with all due precautions and careful patient selection, meticulous preparation, day surgery has a wide safety margin and good success rates. It has economical benefits, which, developing nation like India, with 29% of its population living below the poverty line, cannot afford to ignore. Its 20% urban population with not enough time to spare would tremendously benefit by popularising the concept of Day surgery. There is little doubt that, like anywhere in the world, Day surgery will be the Future of Modern Surgery, in India too.

References

1. Siddharth Narrain. In a critical condition, Cover story, Frontline, June 18, 2004; 19-20.
2. Statistical outline of India 2004-2005, Tata Services Limited, Department of Economics and Statistics.
3. Mukhopaddhya G. Ancient Hindu Surgery: Ancient Medical author and their works, 1994; 1- 22.
4. Davis James E. Major Ambulatory Surgery Today, 1987, USA, 6-7.
5. Nicoll JH. The Surgery of infancy. Br Med J 1909; 2 : 753.
6. Bradshaw EG, et al. The development of day surgery: Day Care Surgery, Anaesthesia and Management, 1989; 1-10.
7. Izant RJ. Non operative aspects of paediatric surgery, Report of 27 Ross paediatric research conference. Columbus, Ohio, 1957.
8. Palmbo LT, et al. Results of primary inguinal herniorraphy as an outpatient procedure. Lancet 1955; ii : 517-9.
9. American Medical Association: Factors responsible for increasing costs of medical care. Chicago, American Medical Association, 1979.
10. Cloud DT Reed WA Ford JL. Surgi-center: A fresh concept in Outpatient Paediatric Surgery. J Paediatr Surgery, 1972; 7 : 206.
11. Cloud DT. Outpatient paediatric Surgery: A Surgeons View. Intl Anaestheol Cli 1976; 14 : 130.
12. Reed RA, Ford JL. Development of an independent outpatient centre. Int Anaesthesiol Clin 1976; 14 : 130.
13. Darzi A. Dept. of Health, The Day Surgery Operational Guide, August 2002, U.K.,1-28.
14. Davis James E. Major Ambulatory Surgery Today, 1987, USA, 33-57.
15. Row TN, Begani MM, Day Care Surgery in India. The Journal of One-Day surgery. The British Association of Day Surgery, Spring 2003; 12 (4) : 53-4.
16. Singh S, Mukherjee A. India hits rock bottom on public heath spending: Times News Network.

#Printed with the permission of the Editor, Day Surgery Journal of India
*Consultant Surgeon, Abhishek Day Care Institute and Medical Research Centre, Mumbai - 400 005.
**Consultant Surgeon, Bombay Hospital, Mumbai - 20.