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Six new reports issued by the AAAHC Institute for Quality Improvement (AAAHC Institute), a not-for-profit subsidiary of the Accreditation Association for Ambulatory Health Care (AAAHC), offer insights to enhance the quality and efficiency of some of the most common outpatient procedures. The reports range from addressing procedures that primarily affect the elderly (cataract surgery) to treatments for pain and mobility problems (low back injection, knee arthroscopy) and screening for one of the most common cancers (colonoscopy for colorectal cancer).
"An increasing proportion of all health care needs are met in outpatient settings, which makes it important to establish benchmarks and best practices for ambulatory services," said Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute. "Our reports illustrate that excellent ambulatory patient care doesn't depend on the volume of services offered or total spending. Rather, it reflects the ability to identify and adapt proven practice and procedural efficiencies, many of which are detailed in these reports. An important role of the institute is to call attention to practices that ambulatory health care professionals can use to improve care and provide a higher quality service to their patients."
The six new 2006 AAAHC Institute studies include:
Four clinical studies: Cataract extraction with lens insertion, colonoscopy, knee arthroscopy with meniscectomy, and low back injection.
Two non-clinical studies: Cataract extraction with lens insertion and colonoscopy.
Clinical reports include data such as pre-procedure, procedure and discharge time comparisons, operative techniques, complications, non-routine procedures, anesthesia, instrumentation and supplies, and patient outcomes. Non-clinical reports focus on factors such as type and ownership of facilities, staffing costs, billing and collections, supply management, annual spending, information technology, and patient satisfaction.
Procedure times are the only measures used for benchmarking because they reflect processes not dictated by clinical guidelines and are, for the most part, within the control of the organization. Note: In the results given, not every organization/patient answered every question. In most cases, patient outcomes are based on patient questionnaires administered in the days/week immediately following the procedures.
Highlights of the studies include:
Cataract extraction with lens insertion.
With more than 95% performed in an ambulatory setting, cataract and lens operations are the no. 1 outpatient surgical procedure. Two new AAAHC Institute reports offer data from ambulatory centers on clinical (78 organizations participated) and non-clinical (20 participants) aspects of cataract surgery.
The AAAHC Institute has conducted a series of clinical studies on this procedure since 1999. Key 2010 clinical findings include:
Procedure times. The median pre-procedure time (defined as patient check-in to start of the procedure) was 80 minutes overall (range 29 to 144 minutes). Practices followed by the organizations with the lowest pre-procedure times included additional staffing and standardized charting. The median discharge time (defined as end of the procedure until patient meets discharge criteria) was 24 minutes (range 3 to 47). Organizations with the shortest discharge times attributed their results to practices such as cross-training staff and standardizing instructions and paperwork.
Patient outcomes. Ninety-six percent of patients were able to schedule their procedures as soon as they wanted. Ninety-nine percent said they were comfortable before the procedure and after discharge. Ninety-five percent reported their vision was better post-surgery. Ninety-six percent returned to activities of daily living within one week of the procedure. Ninety-nine percent would recommend the procedure to friends or relatives with cataracts
Supplies, staffing and costs (non-clinical findings). All but two organizations standardize their cataract surgery supplies. Seventy-five percent are members of purchasing groups. Overall costs per procedure range from $74 to $1,215, with a median of $303.50. The lens costs were factored into some figures. Ninety percent have information technology systems, primarily for billing (89%) and scheduling (89%). Twenty-two percent have electronic medical records.
Organizations with the lowest staffing costs attributed their success to a variety of factors, including cross training staff and pre-procedure preparation. Organizations with the lowest billing costs/collection times also cited a number of factors, including using online services, automated statements and patient education
Colorectal cancer screenings are the second-most frequently performed procedures in ambulatory care, with nearly 10 million performed annually; the AAAHC Institute has been studying this procedure since 2001. Key clinical findings from 69 organizations that participated in the 2010 AAAHC Institute clinical report include:
Procedure times. The median pre-procedure time was 62 minutes (range 33 to 109). Organizations with the shortest times use processes such as preparing before the patient arrives and having enough staff to keep the patient moving through the procedure room.
The median discharge time was 30 minutes (range 20 to 81 minutes). Organizations with the shortest times attributed their results to the use of sedatives that allow patients to recover quickly, and attentive recovery room staff.
Patient Outcomes. Ninety-seven percent of patients were able to schedule their procedures as soon as they wanted. Seventy-one percent reported little or no discomfort during the pre-procedure bowel preparation. Ninety-six percent reported little or no discomfort during the procedure. Ninety-nine percent said they would recommend the procedure to a friend.
Supplies, staffing and costs (non-clinical results reported by 32 centers). Ninety-four percent of organizations standardize their colonoscopy supplies. Seventy-five percent are members of purchasing groups. Ninety-four percent have information technology systems, primarily for scheduling (97%) and billing (90%). Fifty-three percent have electronic medical records.
Overall costs per procedure range from $17 to $2,000 with a median of $293.50. Organizations with low costs attributed it to a variety of factors, such as efficient coordination with physicians' offices, streamlined registration, and patient education/communication.
Knee arthroscopy with meniscectomy.
Virtually all knee arthroscopies are now performed in the ambulatory setting. A new AAAHC clinical study of knee arthroscopy with meniscectomy, the latest in a series conducted since 2000, includes results from 39 organizations. Among the findings:
Procedure times. Median pre-procedure time was 91 minutes (range 56 to 138). Organizations with the shortest times attributed their results to careful scheduling and gathering patient information prior to the procedure.
Median discharge time was 73 minutes (range 37 to 123). Organizations with the shortest times attributed their results to factors such as short-acting anesthesia combined with local anesthetics and preparing patients to expect short discharge times.
Patient outcomes. Ninety percent said they were able to schedule their procedures as soon as they wanted. Ninety-nine percent said they experienced little or no discomfort during the procedure. Ninety-six percent had begun walking (with or without crutches). Ninety-nine percent would recommend the procedure to a friend or relative.
Low back injection.
More than 1.5 million low back injections (LBI) for the treatment of pain or mobility problems are conducted each year, and that number is expected to rise as the population ages. The 2010 study was the first survey of organizations performing LBI conducted by the AAAHC Institute.
Procedure times. Median pre-procedure time was 48 minutes (range 5 to 122). Organizations with the shortest times attributed their results to factors such as gathering patient information and preparing prior to the procedure.
Median discharge time was 29 minutes (range 2 to 74). Organizations with the shortest times attributed their results to rarely sedating patients for this type of procedure.
Patient outcomes. Ninety-five percent said they were able to schedule the procedure within a reasonable period of time. Eighty-two percent were performing their usual daily activities. Seventy-eight percent indicated their pain had improved. Fifty-three percent had reduced their pain medications.
Organizations that participated in the AAAHC Institute studies were volunteers that had opted to participate in previous AAAHC Institute studies and/or were accredited by AAAHC. Organizations are invited to participate through the AAAHC Institute website and, when possible, through mailing to members of relevant specialty societies. Study results should not be used, nor were they designed, to assign "relative values" to processes and outcomes or to set reimbursement policies, AAAHC says. (To order copies of the reports or for more information, visit the AAAHC Institute online at www.aaahciqi.org and select "order products.")