China’s overuse of inpatient treatment and routine preoperative testing

Barriers to day case surgery

The example of ophthalmology is particularly important: cataract extraction remains the most commonly performed elective surgery in the UK,7 and probably the world. However, the situation is similar for other non-invasive surgical specialties in China. There are several possible explanations for this. Firstly, many patients and physicians apparently believe that testing and perioperative hospital stays are associated with greater safety. Perhaps high levels of mistrust between physicians and patients in China8 motivate both sides to opt for inpatient treatment as less likely to give rise to misgivings. However, a Cochrane review of day case cataract surgery found evidence of cost savings but no negative effect on outcomes.9 Another important factor is that reimbursement for surgical procedures under most of China’s government health insurance schemes, even laser treatment of diabetic eye disease, still requires inpatient treatment in many areas.10 Government hospitals, still the majority of providers in China, may be slower than their private counterparts to embrace more entrepreneurial approaches such as day operations, particularly because their low surgical output means there is little pressure to increase efficiency by adopting such reforms.

With support from local regulatory bodies, a pilot project aimed at moving to day case management of most ocular surgery is being carried out at Zhongshan Ophthalmic Centre in Guangzhou, one of China’s largest eye care facilities. The effect on output has been substantial: the number of operations rose by 120%, from 7150 in 2011 to 15 766 when day case surgery was introduced in 2012, and last year 63% of 19 810 operations were done on an outpatient basis. Our experience suggests that hospital admission may be a barrier to uptake of cataract surgery. This is an important concern given China’s relatively low rate of cataract surgery of 915/million population/year, far below that of less developed neighbours Vietnam (2000/million/year) and India (5000/ million/year).11

Even greater efficiencies remain to be realised. We estimate that discontinuing routine echocardiography, chest radiography, and blood testing just for cataract patients could save £69 (€97; $106) per patient annually, a total of £1.4m at our facility alone and £41.4m on 600 000 cases11 nationally. Further studies are needed to evaluate the safety, patient acceptability, and cost effectiveness of day case surgery in other specialties in China. Such data will guide policy makers in reducing cost and improving efficiency through implementing day case protocols for appropriate procedures.