The developement of one-day surgical care in Hungary between 2010-2019

doi:10.21203/rs.3.rs-1411121/v1

Background

The constant increase in the utilization of one-day surgical care could be identified since more than a decade in most of European countries. Initially, according to the international rankings, the exploitation of one-day surgery in Hungary was not really significant. In 2010, the Hungarian policy makers intended to increase one-day surgical care as a priority strategy. The aim of our study was to analyze the evolution of the Hungarian one-day surgical care during the last decade in DRG- based performance financing system in Hungary.

Methods

The dataset of the research was provided by the National Health Insurance Fund Administration of Hungary. The most important indicators related to the one-day surgical care were compared to inpatient care (market share, number of cases, and DRG cost-weights). To discover the impact of one-day surgical care to the utilization of inpatient treatment, the number of hospitalized days was also analyzed.

Results

Between 2010-2019, the market share of one-day surgical cases increased from 42%, to 80%. Simultaneously the constant increase of one-day surgical cases, the number of hospitalized days were decreased in inpatient care by 17%. The value of Case Mix Index has also increased, approximately by 140%, which could confirm that more complex interventions are being conducted in one-day surgical care as well.

Conclusions

Due to the comprehensive health policy strategy related to the dissemination of one-day surgical care in Hungary, several important performance indicators were improved between 2010-2019. Given that Hungary belongs to the low- and middle-income countries, the results of the study could be considerable even in an international comparison.

health policy reform

Diagnosis-Related Groups

financing

Case Mix Index

Hungary

Although one-day surgical care already appeared in the international literature at the beginning of the 1900s, in the early years it was considered to be safely applicable only for the simplest procedures and for patients in a very good overall condition. ^1,2

The benefits of one-day surgical care compared to inpatient care have been discussed by numerous publications including the prevention of nosocomial infections³, reduced accommodation, catering and laundry costs, ⁴high levels of patient safety, ⁵ and shorter hospital stays for patients. ⁶ The above may also contribute to an increased level of trust among health care providers, policy makers, as well as patients which has undoubtedly facilitated the rapid spread of one-day surgical care. A prerequisite for the advancement of treatment modalities, however, is the development of surgical and anesthetic techniques, as has recently been emphasized in the international literature. ⁷ Although one of the main goals and benefits of one-day surgical care is the reduction of high inpatient care costs ⁸, one-day surgery remained to play a marginal role in recent decades, in higher-income countries as well. ⁹ The expansion of available information about one-day surgical care may have contributed to the significant increase in its proportion of inpatient care services performed within elective interventions during the 2000s. ¹⁰ A previously published paper highlighted that adequate funding techniques are essential for increasing the market share of one-day surgeries within elective interventions, as without suitable financing health care institutions will only have limited interest in performing one-day surgical treatment.¹¹

DRG-based funding is widespread in Europe, and Hungary was one of the first countries where DRG-based funding was introduced into clinical practice and one-day surgical care as well. ¹² ¹³ ¹⁴

The aim of our study was to analyze the evolution of one-day surgical care through the past decade in the DRG- based performance financing system of Hungary.

Characteristics of the Hungarian one-day surgical care and its financing

The Hungarian health care system is a solidarity-based national health insurance system with compulsory participation for every citizen. There is one purchaser, the NHIFA. ¹⁵

In Hungary, legislation defines the scope of one-day surgical care. Annex No. 9 to the 9/1993 (IV.2.) Public Welfare Ministerial Decree sets out the types of surgical procedures that could be performed in the form of a day surgery which can be eligible for public funding.

By 2010, the financing rules and regulations regarding one-day surgical care have changed in Hungary. Since then, a several policy aims have been realized enhancing the application of one-day surgical care. In the first years of the research period it was mainly additional capacity redeployment opportunities that were provided by the Hungarian Government. In 2015, one-day surgical care was removed from the domain of hospital financing restricted by PVL, consequently, there was no limit in funding interventions by the health insurance fund for the Hungarian hospitals at 100% of the basic DRG fee, without the utilization of degressive financing technique. The most recent, major policy measure became operative on 1 January 2017; an additional 10% funding DRG fee was introduced to further increase the number of one-day surgical interventions. Due to the change in financing technique, treatment on a day surgery basis has become more beneficial from a financial aspect for Hungarian hospitals, compared to inpatient care.

Our database was provided by the NHIFA. The database included all case numbers, DRG cost-weights, number of hospital days from both one-day surgical and inpatient care between 2010-2019. Additionally, the research database also contained specifically defined cases and DRG cost-weights that were eligible to be financed as one-day surgical care. Furthermore, we also considered the gender and age of patients, the type of health care institution, the interventions according to ICPM performed as day surgery as well as the type of medical professional that carried out the intervention.

In the study, the market share of one-day surgical care relative to DRGs of surgical inpatient care by case and DRG cost-weight was evaluated. First, we divided the number of reported cases and DRG cost-weights of one-day surgery compared to the total number of surgical cases and DRG cost-weights of inpatient care. In addition, the annual ratio of one-day surgical cases and DRG-cost-weights were compared to the theoretical maximum of specified cases and DRG cost-weights according to the interventions listed in the Annex No. 9. of Public Welfare Ministerial Decree 9/1993 (IV.2.).

Taking into consideration the constant increase of the market share of one-day surgery cases, the number of hospital days, as well as the number of hospital days per patient were analyzed in inpatient care as well.

With respect to the research period, the CMI value for one-day surgical care was annually determined. The CMI represents the average DRG-cost-weight per case and it reflects the position of hospitals according to the progressivity level of health care institutions: the value of CMI is generally the lowest in small urban hospitals and the highest in clinical centers belonging to universities.

Subsequently, the mean age of patients in one-day surgical care by gender was defined. Our prior hypothesis was that with time, one-day surgery cases would shift towards including an older age spectrum, based on the continuous development of surgical and anesthetic techniques. We expected that the development in the above areas would also manifest in the fact that more complex interventions could be treated in the form of one-day surgeries. To determine which type of medical profession performed the most day surgeries, the market share of DRG cost-weights according to different medical fields was calculated.

The data were analyzed by Microsoft Excel and descriptive statistical tests were performed.

Over the period examined, 2010-2019, 2,435,611 one-day surgical cases, and 1,327,280 one-day surgical DRG cost-weights were reported and reimbursedby the NHIFA in Hungary. The sum of financed DRG cost-weights during the period investigated was 888,831,990 USD related to the one-day surgical care in Hungary. The lowest public expenditure was in 2010 (41,135,747 USD), while the highest was in 2019 (138,483,547 USD). One-day surgery cases and DRG cost-weights showed a linear increase through the years between 2010 and 2019. However, this kind of linear increase in the number of cases and DRG cost-weights of inpatient care could not be justified. Among the performance indicators of inpatient care, the scope of surgical DRGs should be highlighted: as with respect to the fundamentals of one-day surgical care, comparisons were made relating to the DRGs of inpatient care in order to clearly reveal the development of one-day surgical care in Hungary. In the first year of the research, only 20% of surgical cases belonged to one-day surgical care, however, this ratio already reached 45% in 2019. Similar increase was discovered among surgical DRG cost-weights, however, the dynamics of the increase was less remarkable as that observed in the number of cases (2010: 6%, 2019: 18%). The change in the utilization of Hungarian inpatient and one-day surgical care are shown in table 1, and the change in the proportion of one-day surgical cases financed and DRG cost-weights compared to the inpatient care are shown in figure 1.

Table 1

The change of public expenditure related to the inpatient and one-day surgical care between 2010-2019

Year	Number of DRG cost-weight in inpatient care	Number of DRG cost-weight in one-day surgical care	Finance of 1 DRG cost-weight in Hungarian Forint (HUF)	Finance of 1 DRG cost-weight in US Dollar (USD)	Public expenditure for inpatient care in Hungarian Forint (HUF)	Public expenditure for one-day surgical care in Hungarian Forint (HUF)	Ratio of one-day surgical care's expenditure compared to inpatient's expenditure	Hungarian Forint/1 USD	Public expenditure of inpatient care in USD	Public expenditure of one-day surgical care in USD
2010.	2 221 528	57 083	150 000	721	333 229 197 767	8 562 405 716	2,57%	208.15	1 600 908 949	41 135 747
2011.	2 274 859	88 340	150 000	746	341 228 787 563	13 251 021 333	3,88%	200.94	1 698 162 574	65 945 164
2012.	2 247 074	104 481	150 000	666	337 061 033 952	15 672 118 052	4,65%	225.37	1 495 589 626	69 539 504
2013.	2 268 421	113 569	150 000	671	340 263 102 098	17 035 278 045	5,01%	223.70	1 521 068 852	76 152 338
2014.	2 304 664	118 601	150 000	645	345 699 560 838	17 790 081 323	5,15%	232.52	1 486 751 939	76 509 897
2015.	2 300 690	128 357	150 000	537	345 103 538 304	19 253 570 717	5,58%	279.46	1 234 894 219	68 895 623
2016.	2 329 430	148 503	180 000	640	419 297 367 710	26 730 504 212	6,38%	281.44	1 489 828 623	94 977 630
2017.	2 334 282	176 923	185 000	675	431 842 206 045	32 730 830 880	7,58%	274.27	1 574 514 916	119 337 991
2018.	2 346 672	188 158	198 000	733	464 641 094 442	37 255 191 774	8,02%	270.25	1 719 300 997	137 854 549
2019.	2 374 061	203 284	198 000	681	470 064 001 536	40 250 242 888	8,56%	290.65	1 617 285 400	138 483 547

The proportion of cases and DRG cost-weights that could fall under one-day surgical care in accordance with Annex No. 9 of Public Welfare Ministerial Decree 9/1993 (IV.2.) was analyzed in the research. In 2010, only 42% of eligible one-day surgical cases were actually treated on a day surgery basis and only 32% of the maximum of related DRG cost-weights were financed by the NHFIA. In 2019, 80% of cases are eligible for one-day surgical care were actually treated in one-day surgical form by Hungarian hospitals and the related portion of the DRG cost-weights had already increased up to 74%. The years 2011, 2015, and 2017 proved to be milestones in the provision of one-day surgical care in Hungary, as policy and financing measures supporting the significant spread of one-day surgery emerged, the impact of which could already be detected. Throughout the study period, the availability and utilization of one-day surgery has grown significantly indicated by the fact that the proportion of cases and DRG cost-weights increased remarkably.

The continuous increase of one-day surgical care significantly affected the number of inpatient hospital days: the total number of hospital days in inpatient care was 975,746 in 2010, while in 2019 it was 806,019. The total number of hospital days in inpatient care decreased more than 160,000 days during the research period. Similar decrease was found with regard to hospital days per single patient. While the number of hospitalized days per patient in 2010 was 6.20 days, in 2019 it was 5.33 days.

During the study, the value of CMI in one-day surgical care was also analyzed for each year. CMI was the lowest in 2010 (0.436) and the highest in 2019 (0.599). Between 2010-2019, only the year 2015 witnessed a decline in CMI (0.511). In May 2015, an important health policy initiative was introduced to the clinical and financial areas of the Hungarian health care system. As the previously applied PVL technique in one-day surgical care was abolished, it became possible for each case, which could be treated on a day-surgery basis, to be reimbursed without limitation by the NHFIA.

One-day surgery has a pivotal importance for the working-age population, as the mean age of those who were treated in one-day surgical treatment was less than 53 years old [(52.63 years, CI (95%) =5.19-86.55)]. The mean age (55.75 years) of patients who were treated in one-day surgical care in 2019 was 8.39 years higher than it was in 2010 (47.36 years). While the mean age of women who were treated in one-day surgical care between 2010-2019 was less than 51 years, [(50.99 years, CI (95%) = 8.25-85.98)] that of men surpassed 56 years [(56.36 years, CI (95%) =5.21-86.86)]. The mean age of women patients in the first year increased by more than 9 years during the period under investigation (2010: 44.93 years, 2019: 54.66 years); the mean age of male patients also increased, although the difference was less than 3 years (2010: 54.74 years, 2019: 57.65 years).

The increase of mean age in the reported cases in Hungary may be explained by the fact that the number of Hungarian citizens aged 0-14 years decreased by 53,991, and the number of citizens between15-64 years decreased by 327,515 as well, while the number of the Hungarian population over 65 years old increased by 164,743 persons.

The market share of one-day surgical performance was analyzed according to type of medical profession on the basis of financed DRG cost-weights (1,327,280). Most financed one-day surgery DRG cost-weights were linked to ophthalmology care (507,986 weights), which accounted for nearly 40% of the total, financed, one-day surgical DRG cost-weights between 2010-2019. Financed DRG cost-weights in obstetrics and gynecology –that had the second highest DRG cost-weights in the ranking – were significantly lower than that of the ophthalmology (168,939 weights). One-day surgical performance rates related to cardiology, surgery and urology were respectively similar according to market share (cardiology: 11%; surgery: 9%, urology: 10%). Those medical professions involved into the treatment of the diseases affecting the musculoskeletal system (orthopedics and traumatology) represented a similar market share in terms of financed DRG cost-weights (orthopedics: 5%; traumatology: 6%). Although, in Hungary, there are several medical interventions that are carried out in a day- surgery setting in otorhinolaryngology, the related market share was only 2%. The cumulative one-day surgical DRG-cost weights during the analyzed period (1,243,002) of the afore-mentioned 8 professions listed in Figure 5 amounted to 94% of the whole performance financed in Hungary within one-day surgical care (1,327,280 weights).

The purpose of our study was to provide a comprehensive analysis of the development of Hungarian one-day surgical care in a DRG-based performance financing system, as several policy measures facilitating the broader application were implemented in Hungary in the past decade. The increased utilization of one-day surgical care is a generally witnessed process throughout Europe, together with the development of this treatment modality as part of several health-related policy strategies, due to its effectiveness in a wide array of areas. ^3,16 Several publications have highlighted the advantages of one-day surgical and outpatient care, as they can effectively reduce the high costs of inpatient care which is a major challenge for health care- related policies today. ^17-19During the observed period, more than 15 billion USD were financed for Hungarian inpatient care, meanwhile the public expenditure of one-day surgery did not exceeded 900 million USD. Regarding inpatient care, the annual public expenditure in 2019 was 16 million USD higher than it was in 2010, while the annual publicly financed health care expenditure related to the one-day surgery was more than 97 million USD higher than it was in 2010.

Internationally, health policy makers follow a diverse set of practices to support the spread of one-day surgical care, however the academic literature emphasizes that besides meeting medical standards, the application of supportive funding techniques are also a major key for success. ²⁰

There is a well-known Western European approach that identifies “innovative financing techniques” among university clinics ²¹ thereby, providing financial incentives for wider dissemination of interventions. A similar policy goal may have been in the background of the introduction of the 110% DRG funding in one-day surgical care in Hungary. In addition to policy support, the development of appropriate institutional DRG-coding mechanisms resulting in institution-specific optimization of DRG-based accounting for funding may be of paramount importance. ²²Previous studies have highlighted the positive association between health insurance systems and the utilization of different types of the treatment. ²³ Given that the Hungarian health insurance system provides coverage for all Hungarian citizens, the use of one-day surgical care mainly depends on the medical condition of the patients and the decision of the management of the hospitals as well. Based on the Hungarian health policy initiatives, we expected and did detect a shift in everyday practice from inpatient care towards one-day surgery.

Our results showed that based on inpatient DRGs, the market share of one-day surgery increased year by year, while more and more of the interventions defined by law – that are allowed to be executed on a one-day surgery basis– are performed by Hungarian healthcare institutes. Recent years have seen several reports on the low rate of Hungarian one-day surgeries in the case of the most common intervention, cataract surgery (2007-2011: >40%). ²⁴ As a result of the health policy efforts of the previous decade, – taking into account all medical professions – in less than10 years, the utilization rates of Hungarian one-day surgical care already approached the level of northern European countries. ^16,25 The country's health policy intentions for one-day surgical care and the associated development dynamics could be well illustrated by the fact that the more economically advanced country, France, set a target of 66% market share of one-day surgical care by 2020. ²⁶ This has already been achieved in Hungary in 2016. There are no currently available validated one-day surgical rates published in the international academic literature that would cover all areas of the medical professions from the neighbor countries of Hungary, but several publications address recommendations for the demand to expand one-day surgical care. ^11,27 Similar to inpatient care, CMI is also an informative indicator in the performance evaluation of one-day surgery, which increased between 2010-2019 in Hungary. This could be explained by the significant role of university clinical centers in one-day surgical care which resulted from favorable financing techniques that were introduced– 110% basic DRG fee and PVL-free reckoning. As a result of the constantly increasing health care costs and the rapid development of surgical and anesthesiologic techniques, more and more complex diseases could be found to have contributed to this trend of increase of CMI ²⁸ One-day surgery patients are predominantly from the working-age population, which has also been described by several previously published studies. ^19,29 Considering types of medical profession or the interventions performed, the results of our study are in line with the international trend, as the importance of obstetric-gynecological, ophthalmological, orthopedic, surgical, and urological interventions performed in a day- surgery setting may have multiple advantages and benefits. ³⁰

In the beginning of the last decade, the market share of one-day surgical care was marginal in Hungary, due to the fact that most of the less complex invasive interventions were still executed in an inpatient setting. Therefore, the amendment of health care financing legislations – mainly the abolition of volume caps and the implementation of increased DRG fee –aimed to support the widespread availability of less cost-demanding treatment modalities, consequently, there was a simultaneous increase in the number of interventions which could be concluded in one-day surgical care. The modified financing techniques contributed to the creation of a supportive environment for the spread of one-day surgical care for all public-funded Hungarian hospitals.

The institutional implementation of the afore-mentioned health policy initiatives was rather different during the period analyzed: those hospitals that provided fewer complex interventions could benefit more rapidly from the reform compared to those that produced higher CMI.

In the last few years, the supportive financing environment with regard to one-day surgical care has become an essential feature of the Hungarian health policy system, which has apparently, led to a significant increase in the market share of one-day surgical care. The increased impact of one-day surgery upon the Hungarian health care system is not only a result of advantageous financing techniques. On the one hand, potential interventions which are eligible to be executed in one-day surgical care have increased, on the other hand one-day surgical care has become less cost-demanding and provides just as equal patient safety as inpatient care. All the above may have increased trust among patients towards this form of treatment.

Given that the Hungarian reforms have achieved significant progress with regard to the proliferation of one-day surgical care, these rules and regulation could even be considered as an international best practice for those low- and middle-income countries which currently underutilize one-day surgical care.

In the research only the performance in publicly funded hospitals was analyzed, because the private health care services in Hungary are not subjected to performance evaluation and reporting requirements towards any authorities, thus there were not available data related to the one-day surgical or inpatient treatment related to the Hungarian private health care services.

DRG

Diagnosis-Related Groups

PVL

Performance Volume Limit

NHIFA

National Health Insurance Fund Administration

CMI

Case Mix Index

ICPM

International Classification of Procedures in Medicine

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

The data that support the findings of this study are available from National Health Insurance Fund Administrations of Hungary, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of National Health Insurance Fund Administrations of Hungary.

Competing interests

The authors declare that they have no competing interests.

Funding

European Union and Hungarian Government

EFOP-3.6.2-16-2017-00009 Establishing and Internationalizing the Thematic Network for Clinical Research.

Authors' contributions

RP, DE, IB compiled the study design. RP, DK, EP, BKK searched and analyzed the international academic literature. IB provided the research database. RP, ED, NN executed the statistical tests. RP, AV, IB were responsible for the interpretation of the findings and the comparison with the results from the international academic literature.

All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

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The developement of one-day surgical care in Hungary between 2010-2019

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Abstract

Figures

Background

Methods

Results

Discussion

Conclusions

Limitations

Abbreviations

Declarations

References

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Version 1