SEARCH

SEARCH BY CITATION

Sir,

Recent changes in the funding of American medicine have resulted in pressures for physicians to financially optimize their practice. One of the key factors in improving their economic efficiency has been to reduce the length of hospital stay after operative procedures. In the UK, this trend to increase turnover has been echoed, the impetus to do so being pressure partly from waiting lists and partly from other sources. There has been an increase in both the number and type of cases which are now undertaken as day-surgery or short-stay cases. Procedures such as laparoscopic cholecystectomy are now routinely performed in the Day Case Unit.

One area in which there is still great disparity between the USA and the UK is in the management of patients undergoing open radical retropubic prostatectomy (RRP). In recent years great progress has been made in the USA in reducing the length of hospitalization after open RRP. Stays, traditionally of 5–8 days [1,2], have been dramatically reduced. One series quotes a mean hospitalisation of 1.34 days, with no impairment in patient satisfaction or clinical outcome [3]. In another small study, 15 RRPs were performed as day-cases [4].

This has been achieved by implementing comprehensive management pathways which require a significant change in the traditional paradigms and attitudes held by doctors and patients alike. Chodak et al. [5] reported on 252 patients who underwent RRP; they were admitted on the morning of surgery and received only epidural anaesthesia. After surgery a single dose of intramuscular methadone was administered and oral analgesia commenced at 4 h. Clear oral fluids were commenced on the evening of surgery and the intravenous infusion removed. Patients were discharged when a clear diet was tolerated.

The implications of a shorter hospital stay go further than merely reducing costs. Patient satisfaction questionnaires revealed favourable results and there was no increase in morbidity from the procedure. There have been no reported differences in the rates of complication or readmission. It has been suggested that recovering at home prompts patients to mobilize sooner, eat better and be less dependent on analgesics [4]. In addition, there is less exposure to the risks of hospital-acquired infection. Furthermore, reducing hospital stay might prove an effective means of meeting the new targets set out in the national cancer guidelines.

The question is ‘Why has the community of British urological surgeons not moved to implement these changes when the need to meet oncological targets and clinical outcomes guidance is so important?’ For an American physician to be commercially successful he or she must adopt an attitude of optimizing without compromising; the paradox is that in the UK healthcare system, where financial constraints are tighter, the more expensive option continues to be the choice.

  • 1
    Licht MR, Klein EA. Early hospital discharge following radical retropubic prostatectomy. impact on cost and complication rate. Urology 1994; 44: 7004
  • 2
    Koch MO, Smith JA, Hodge EM, Brandell RA. Prospective development of a cost-efficient program for radical retropubic prostatectomy. Urology 1994; 44: 3118
  • 3
    Worwag E, Chodak GW. Overnight hospitalisation after radical prostatectomy. The impact of two clinical pathways on patient satisfaction, length of hospitalization and morbidity. Anaes Analg 1998; 87: 627
  • 4
    Hajjar JH, Budd HA, Wachtel Z, Howhannesian A. Ambulatory radical retropubic prostatectomy. Urology 1998; 51: 4438
  • 5
    Kirsh EJ, Worwag EM, Sinner M, Chodak GW. Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology 2000; 56: 1017