Comparative analysis of day surgery and elective operations in patients with thyroid tumors

doi:10.21203/rs.3.rs-3613359/v1

Download PDF

Research Article

Comparative analysis of day surgery and elective operations in patients with thyroid tumors

https://doi.org/10.21203/rs.3.rs-3613359/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective:In recent years, day surgery has gained widespread attention from the medical industry and has been recognized and promoted as a new service model that enhances medical service efficiency and reduces medical expenses. With the rapid increase in the incidence of thyroid tumors, medical institutions are exploring day surgery for thyroid patients in order to meet their needs. This study compared the length of hospital stay, payment methods and costs of thyroid day surgery and general elective surgery, so as to understand the advantages and limitations of day surgery, improve the efficiency of medical resources, and provide reference for other medical institutions to promote day surgery.

Methods:In total, 624 day surgery cases and 1,078 inpatient cases underwent the same cataract surgery in the day care surgery and ordinary ward respectively, and were defined as two groups. General information, distribution of surgery, hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient.

Results:There were no significant difference in these main payment methods and distribution of sex between these two groups(P＞0.05).The period of stay in hospital was significantly different (P < 0.05). The total costs were lower for day surgery than for inpatients (P < 0.05). Day surgery patients were younger than inpatients. Patients with day surgery had a higher proportion of unilateral thyroidectomy, and patients with elective operations had a higher proportion of total thyroidectomy..

Conclusion:Day surgery for patients with thyroid tumors is more cost-effective and efficient than inpatient surgery. As a new service model, day surgery not only reduces the burden of patients, but also improves the efficiency of medical insurance funds, helps to relieve the pressure of medical insurance funds, so as to improve social benefits, which should be further promoted with the support of policies.

Day surgery

Inpatient

Thyroid tumor

In 1909, James Nicoll^[1], a Scottish pediatric surgeon, reported 8988 cases of pediatric surgery in the British Medical Journal, which first put forward the concept of day surgery, laying the prototype of modern day surgery, and since then the day surgery service model has been widely carried out in Europe, America and other developed countries^[2–4].After more than 110 years of development, the proportion of day surgery to inpatient surgery in Europe and the United States is now as high as 90%. The earliest domestic day surgery can be traced back to 1955, it was proposed by Zhang Jinzhe and other professors of Beijing Children's Hospital to perform high hernia sac ligation under basic anesthesia combined with local anesthesia; the mode of day surgery is common and formally entered into China around 2001; during 2001–2009, Shanghai, Sichuan, Beijing, Hunan, Shaanxi, Zhejiang and other places carried out the medical service of day surgery one after another. Since 2015, the state has issued a series of policy documents to guarantee the implementation of daytime medical care, and the forms of daytime medical services currently carried out in China include daytime surgery, daytime chemotherapy, radiotherapy, blue light irradiation, and daytime intervention. According to statistics, the volume of day surgery in China has increased by 6 times in the past 7 years, and nearly 60% of tertiary public hospitals have carried out ambulatory care in 2022.

Through the current status of the development of day surgery in various countries, the definition of day surgery varies according to the culture, national conditions, policies and systems of each country. In Europe and the United States, day surgery refers to surgery that is not observed overnight in the hospital^[5], and in China, day surgery refers to the medical service model in which hospitals provide patients with a full range of inpatient diagnostic and therapeutic services within 24 hours under the premise of safeguarding the quality and safety of medical care^[6].

Literature search shows that the research on day surgery has also experienced a change in the scope of research from "point" to "surface", and the status of research from "secondary" to "primary". Internationally, research on the use of surgical techniques and anesthesia methods in day surgery was mostly conducted in the beginning; in recent years, research on the management of the whole process of day surgery has been more common, such as the appropriate scope of day surgery, deployment management of daytime operating rooms, and postoperative community rehabilitation of patients, etc.Moreover, there are fewer comparative studies on day surgery patients and general patients, and most of them are dominated by patients who undergo eye surgery, especially mainly for cataracts.

Therefore, this thesis selects patients with thyroid tumors from tertiary general hospitals in China that have an early and mature development of day surgery, with a day surgery volume of more than 10,000 cases.Through this thesis, we hope to understand the advantages and limitations of day surgery, and provide a reference for other medical institutions to implement day surgery.

In recent years, the incidence rate of thyroid tumors has been rapidly increasing. According to data from 2016^[7], the overall incidence rate of thyroid tumors ranked 7th among malignant tumors in the country, and 3rd among malignant tumors in females. In 2018, the incidence rate of thyroid cancer in Chinese females was 15.8 per 100,000^[8]. Surgical intervention is the primary method for treating thyroid tumors. Some thyroid surgeries have short duration and minimal impact on overall organ function. As the concept of enhanced recovery after surgery (ERAS) has been widely introduced into the surgical field, some hospitals in China have begun to try thyroid day surgery and confirmed its effectiveness and safety^[9–10]. With the continuous improvement of medical technology, the 5-year survival rate of thyroid cancer patients in China has increased from 67.5% in 2003 to 84.3% in 2015^[11].With the gradual acceptance of day surgery and a deeper understanding of the ERAS concept, day surgery is expected to be gradually promoted and applied in China^[12].

1.1 Research subjects

In this study, patients with thyroid tumors who were discharged from a hospital during the period of January 1-December 31, 2022, and whose primary diagnostic code for discharge was C73.x00 according to the National Classification of Diseases, were selected as the study subjects.The patients were divided into a day surgery group and a elective operation group, which was also known as the "control group".

1.2 Source of data

The data for this study came from the hospital case statistics management system from January 1 to December 31, 2022, with a total of 1,702 data items, including 624 data items for the day surgery group and 1,078 data items for the control group.

Data inclusion criteria: discharge primary diagnosis code of C73.x00 and primary procedure code of subheading 06.2–06.4 for neck access.

Data exclusion criteria: (1) 19 patients discharged with a primary diagnosis of thyroid malignancy, ICD-9-CM3 procedure code C73.x00, who ultimately did not have the procedure performed for various reasons; and (2) 1 patient who had day surgery with a primary surgical operation name of laser massothermia for head and neck lesions, ICD-9-CM3 procedure code 17.6200x001. A total of 1,682 patients were included in the analysis, including 622 day surgery patients and 1,060 non-day surgery patients.

1.3 Research method

In this study, Excel 2017 and SPSS 25.0 statistical software were used to describe and statistically analyze the data on the first page of the cases of patients with thyroid malignant tumors in the study hospital in 2022, and the t test was used for the comparative analysis of the measurement data that conformed to the normal distribution; for the measurement data that showed a non-normal distribution, the non-parametric test was used for the comparative analysis. For the count data, Z-test was used for comparative analysis. The difference was considered statistically significant at P < 0.05.

2.1 Basic information of patients

A total of 1,682 patients were included in this study for analysis, including 432 male patients and 1,250 female patients (Table 1); the average age distribution of day surgery patients was (40.02 ± 10.28) years old, and the average age distribution of elective operation patients was (42.50 ± 11.82) years old, and by analyzing the differences in the gender and age distribution of the patients of the two groups.There was no statistical difference in gender distribution (P = 0.06 > 0.05), while there was a statistical difference in age distribution (P = 0.001 < 0.05).The age group with the highest number of patients in the day surgery group and elective surgery group is 31–40, followed by 41–50 years old, and then 21–30 years old (Table 2).

Table 1

Gender of patients with thyroid malignancy in the study hospitals in 2022
Gender	Day surgery group		Control group		Total	Proportion
Gender	Number of patients	Proportion	Number of patients	Proportion	Total	Proportion
Male	168	38.89	264	19.32	432	25.68
Female	454	61.11	796	33.87	1250	74.32

Table 2

Age of patients with thyroid malignancy in the study hospitals in 2022
Age	Day surgery group		Control group		Total	Proportion
Age	Total	Proportion	Total	Proportion	Total	Proportion
≤ 20	4	0.64	8	0.75	12	0.71
21–30	145	23.31	189	17.83	334	19.86
31–40	188	30.23	295	27.83	483	28.72
41–50	171	27.49	270	25.47	441	26.22
51–60	100	16.08	224	21.13	324	19.26
61–70	13	2.09	66	6.23	79	4.70
≥ 70	1	0.16	8	0.75	9	0.54
Total	622	100.00	1060	100.00	1682	100.00

2.2 Distribution of patient surgeries

In this study, the most common surgeries performed on patients with thyroid malignancy were total thyroidectomy and unilateral lobectomy, accounting for 88.70% (Table 3) of the total number of patients, followed by unilateral thyroidectomy with partial lobectomy, accounting for 6.06%, and other surgeries mainly included unilateral thyroidectomy with isthmus resection of the thyroid, unilateral thyroidectomy with lumpectomy, and resection of residual thyroid, accounting for about 5%., accounting for about 5% or so.Total thyroidectomy was performed in 59.49% of patients undergoing day surgery and in about 65.75% of patients undergoing non-day surgery.

Through the non-parametric test on the distribution of surgery between the two groups of patients, the results of comparative analysis X² = 15.439, P = 0.001 < 0.05, which can be seen that there are statistical differences in the distribution of the type of surgery between the tow groups of patients, of which the proportion of total thyroidectomy is higher than that of the day surgery group in the control group, and the proportion of unilateral thyroid lobectomy is lower than that of the day surgery group.

Table 3

Surgical distribution of patients with thyroid malignancy in the study hospitals
	Total thyroidectomy	Unilateral thyroid lobectomy	Unilateral thyroidectomy with partial resection of other lobes	Others	Total
Day surgery group	370(59.49)	189(30.39)	38(6.10)	25(4.02)	622
Control group	697(65.75)	236(22.26)	64(6.04)	63(5.94)	1060
Total	1067(63.44)	425(25.27)	102(6.06)	88(5.23)	1682

2.3 Distribution of hospitalization time of patients

The average hospitalization days were(1 ± 0) for the day surgery group and (7.50 ± 2.82) days for the inpatient group(Fig. 1). Those patients who chose the day care option for cataract surgery were hospitalized for a much shorter time (P < 0.001) than those who chose the inpatient procedure.Combined with the age composition, the correlation coefficient = 0.015, P = 0.619 > 0.05, and it is not yet possible to conclude that there is a correlation between length of stay and age in patients undergoing ambulatory surgery.

2.4 Comparison of patient hospitalisation costs

The average costs were (¥14008.17 ± 1355.69) paid by patients in the day surgery group. While the average costs paid by inpatients were ¥(21267.25 ± 4677.39). The total costs paid by patients in the day surgery group were less (P < 0.001) than those in inpatient group.The inpatient costs of surgery for patients with thyroid malignant tumours include comprehensive medical service expenses, diagnostic expenses, treatment expenses, medicine expenses, and consumable expenses, of which the above costs for patients undergoing day surgery are: ¥493.52 ± 40.61, ¥1715.10 ± 296.59, ¥6786.46 ± 879.46, ¥1849.23 ± 266.31, ¥2998.29 ± 839.93;the above costs for general surgery patients were: ¥1698.73 ± 615.08,¥4681.63 ± 1041.72, ¥6979.80 ± 1041.81, ¥3546.89 ± 1577.52, and ¥4082.50 ± 1923.94 (Table 4).There were statistically significant differences in the various types of costs incurred by the two groups of patients during hospitalisation, and the various types of costs of patients with general surgery were higher than those of patients with day surgery.Excluding the portion paid by the medical insurance, the out-of-pocket expenses of patients were (¥8533.16 ± 3557.13), which were significantly lower than those of patients in the non-day surgery group (¥12608.55 ± 5736.76).

Table 4

Hospitalization days and costs paid by patients
Information	Day surgery	Inpatient	P
Hospitalization days	1 ± 0	7.5 ± 2.82	< 0.001
Costs	14008.17 ± 1355.69	21267.25 ± 4677.39	< 0.001
Out-of-pocket expenses	8533.16 ± 3557.13	12608.55 ± 5736.76	< 0.001
comprehensive medical service expenses	493.52 ± 40.61	1698.73 ± 615.08	< 0.001
diagnostic expenses	1715.10 ± 296.59	4681.63 ± 1041.72	< 0.001
treatment expenses	6786.46 ± 879.46	6979.80 ± 1041.81	= 0.003
medicine expenses	1849.23 ± 266.31	3546.89 ± 1577.52	< 0.001
consumable expenses	2998.29 ± 839.93	4082.50 ± 1923.94	< 0.001
P > 0.05 shows no significant difference

2.5 Medical insurances

There were over five methods with which to pay for total costs of the medical care. The main method was Urban Employees Basic Medical Insurance,occupied over 50% (details in Table 5). There were no significant difference in these main payment methods between these two groups(P = 0.844> 0.05).

Table 5

Different payment manners for surgery expenses
Payment manners	Number of participants (%)
Payment manners	Day surgery(total n = 622)	Inpatient (total n = 1060)
Urban employees basis medical insurance	317(50.96)	545(51.42)
Urban residents basic medical insurance	82(13.18)	148(13.96)
New rural cooperative medical care	99(15.92)	177(16.70)
Out-of-pocket medical care	1(0.16)	9(0.85)
Others	123(19.77)	181(17.08)

3.1 Day surgery patients are younger than elective surgery patients

Some older patients with thyroid malignancy may be accompanied by cardiovascular, cerebrovascular and metabolic diseases such as hypertension and diabetes mellitus, and doctors often need to take into account the impact of related complications in such patients, thus the proportion of elderly patients included in day surgery is less than that of elective surgery patients.

3.2 Differences in the type of surgery between day patients and elective surgery patients with thyroid malignancies

The proportion of patients undergoing total thyroidectomy was higher in the elective surgery group than in the day surgery group, and the proportion of patients undergoing unilateral lobectomy was lower than in the day surgery group. Total thyroidectomy was classified as a level IV surgery and unilateral thyroid lobectomy was classified as a level III surgery in this hospital, which shows that the coefficient of surgical difficulty was higher in the elective surgery patients than in the day surgery patients.

3.3 Day surgery can effectively reduce hospitalisation costs

There was a significant difference in the cost of treatment, medication, consumables, and comprehensive services in patients undergoing day surgery for thyroid malignancy compared to patients undergoing elective surgery.The total cost of surgery for patients with thyroid tumours who underwent day surgery was significantly lower than that of patients who underwent elective surgery, which is consistent with the findings of Brebbia ^[13], Cai YuTing ^[14], Yu JunRen ^[15]and other authors, that is, the use of day surgery effectively reduces the cost of hospitalization for the patients, and reduces the economic burden of the patients' diseases.The reason for this is that day surgery can not only save bed and nursing costs by reducing the length of hospitalisation, but also save the hidden costs of work leave, companionship, and anti-infective medication brought about by prolonged hospitalisation.

3.4 Day surgery can effectively shorten the length of hospital stay

Day surgery shortens the hospitalisation time of surgical patients from several days to no more than 24 hours in the hospital, effectively alleviating the pressure of insufficient health resources. For hospitals, the implementation of day surgery can shorten patients' pre-operative waiting time, accelerate the turnover rate of hospital beds, improve the utilisation rate of medical resources and increase the economic benefits of hospitals.

3.5 The promotion of day surgery helps to improve the social benefits of hospitals.

The use of day surgery has market segmented the amount of medical demand and service capacity at different levels, effectively diverting difficult and critical patients and ordinary single-disease patients, so that single-disease patients do not take up inpatient department bed resources as much as possible.This model helps to balance the allocation of medical resources, alleviate the imbalance between the supply and demand of medical resources, and to a certain extent, alleviate the social problems of "expensive treatment, difficult hospitalisation, and late surgery", thus realising a win-win situation for patients, hospitals and society. At the same time, the development of day surgery also reduces the burden of patients, improves the efficiency of the use of health insurance funds, helps to alleviate the pressure on health insurance funds, and improves social benefits.

According to the current situation of medical resources allocation in China, the increase in the number of aging population, and the implementation of the "Healthy China" strategy, there is a huge potential for the development of day surgery service model in China.It will be important to explore a way of day surgery that meets the "Chinese characteristics", and how to better improve and develop our own day surgery model is still a long-term research and exploration issue in the future.

Author contributions

YW performed the data analyses and wrote the manuscript; XW contributed to the conception of the study and helped perform the analysis with constructive discussions; all authors read and approved the final manuscript.

Funding

No funding was received by any of the authors for the writing of this manuscript.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available. They contain information that could compromise research participant privacy but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All methods were conducted in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki. Ethics approvals for the patient experience survey and study was obtained from the ethics committee of National Institute of Hospital Administration, National Health Commission of the People's Republic of China. Due to the retrospective nature of the study, informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Nicoll JH. The surgery of infancy. BMJ. 1909;2(2542):753–4.
Kotiniemi LH, Ryh?Nen PT, Valanne J, et al. Postoperative symptoms at home following day-case surgery in children: a multicentre survey of 551 children.[J]. Anaesthesia. 2015;52(10):963–9.
Watters DA, Hollands MJ, Gruen RL, et al. Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe Surgery and Anaesthesia[J]. World J Surg. 2015;39(4):856.
Gramke H, De Rijke J, Van Kleef M, et al. The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital.[J]. Clin J Pain. 2016;23(6):543.
International Association for Ambulatory Surgery. Ambulatory surgery handbook: 2nd edition., 2014. (2015-02-02)[2019-01-20]. http://www.iaasmed.com/files/2014/Day_Surgery_Manual2.pdf.
General Office of the National Health Commission. Circular on the Issuance of Interim Provisions on the Quality Management of Medical Institutions for Daytime Healthcare.State Health Medical Affairs[2022]No. 16.
Cancer incidence and mortality in China. 2016[J]. J Nat Cancer Cent. 2022;2(1):1–9.
Gabalec F, Srbova L, Nova M, et al. Impact of Hashimoto′s thyroiditis, TSH levels, and anti -thyroid antibody positivity on differentiated thyroid carcinoma incidence[J]. Endokrynol Pol. 2016;67(1):48–53.
Zhang XY, Cai YC, Sun RH, et al. Discussion about the safety of outpatient thyroid surgery[J]. Chin J Otorhinolaryngol Head Neck Surg. 2019;54(2):157–60. 10.3760/cma.j.issn.1673–0860.2019.02.014.
Zhang Z, Xia F, Wang W, et al. Ambulatory thyroidectomy is safe and beneficial in papillary thyroid carcinoma: Randomized controlled trial[J]. Head Neck. 2021;43(4):1116–21. 10.1002/hed.26557.
Zeng H, Chen W, Zheng R, et al. Changing Cancer Survival in China during 2003–2015: A Pooled Analysis of 17 PopulationBased Cancer Registries[J]. Lancet Glob Health. 2018;6(5):e555–67.
Li XY, Zheng QQ, Jiang KW. Chinese expert consensus on ambulatory thyroid surgery (2021 edition) [J]. Chin J Gen Surg 2021,30(05):499–509.
Brebbia G. Carcano G,Boni L,eta. Audit in day surgery in general surgery. Quality and criticality are compared. Int J Surg. 2008;6(12):59–S64.
Cai YT, Song YH, Long XQ et al. Clinical study on the effect of ambulatory surgery for thyroid disease[J]J Cancer Trea 2019,32(3):248–52.
Junren YU, Ting SHEN, Yuejia CHENG, Yuanyuan XU. HOU Lengchen.Evaluation and countermeasures of day surgery operation in municipal hospitals in Shanghai[J] Chin Hosp 2023,27(9):43–6.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Comparative analysis of day surgery and elective operations in patients with thyroid tumors

Status:

Version 1

Abstract

Figures

Introduction

Information and Methods

Results

Discussion

Declarations

References

Additional Declarations

Status:

Version 1