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«Day Surgery Development Aspects in Slovakia BEÁTA GAVUROVÁ a, ADELA KLEPÁKOVÁ b, LADISLAVA IVANČOVÁ c a Technical University in Košice, ...»

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ESTUDIOS EC ON OMÍ A AP LI C AD A V O L. 31 - 2 2013 P Á G S. 477 – 496


Day Surgery Development Aspects in Slovakia



Technical University in Košice, Faculty of Economics, Němcovej 32, 040 01 Košice, Slovakia. Email: beata.gavurova@tuke.sk


University of P.J. Šafárik in Košice, Faculty of Public Administration, Popradská 66, 040 11 Košice,

Slovakia. E-mail: aklepakova@gmail.com c University of Economics in Bratislava, Faculty of Applied Languages, Dolnozemská cesta, 852 35 Bratislava,Slovakia. E-mail: ladislava.ivancova@euba.sk


The day surgery is a highly effective tool for providing health care which has been used in Slovakia only for the last decade. The unified system of payment for inpatient or outpatient (day care) surgeries causes the reduction of health insurance companies´ spending. Incorrectly configured and economically demotivating system of refunding is a cause of lagging behind the European average in utilization of day surgery. Without the evaluation of day surgery it is not possible to link the progress in the social sphere, which leads to the restriction of day surgery availability for some social groups and thus the subsequent stagnation of day surgery in Slovakia. This contribution presents a pilot study conducted in Slovakia and its partial findings focused on the development and trends in the implementation of day surgery in order to increase the efficiency healthcare system.

Keywords: Day Surgery, Healthcare, Health Care Development.

Aspectos del desarrollo potencial de cirugía ambulatoria en Eslovaquia


La cirugía ambulatoria (CA) constituye una herramienta altamente eficaz en la prestación de asistencia sanitaria que en Eslovaquia se está utilizando sólo durante la última década. El sistema de pago único por actos de cirugía ambulatoria y normal es motivo de reducción de gastos de la seguridad médica. El sistema de pagos incorrectamente ajustado y económicamente desmotivador causa atraso en el aprovechamiento de la CA en comparación con la media europea. Sin evaluar la CA resulta imposible interrelacionar el avance de la misma con la esfera social, por lo cual se produce la limitación de su accesibilidad para ciertas capas sociales y, por consiguiente, su estancamiento en Eslovaquia. Este artículo presenta el estudio piloto realizado en Eslovaquia y sus resultados parciales enfocados al desarrollo y tendencias de implementación de la CA con el fin de aumentar la eficacia del sistema sanitario.

Palabras Clave: Cirugía ambulatoria, sanidad, desarrollo de asistencia sanitaria.

JEL Classification: I13, I14, I15, I18 ____________

Artículo recibido en junio de 2013 y aceptado en agosto de 2013 Artículo disponible en versión electrónica en la página www.revista-eea.net, ref. ә-31213 ISSN 1697-5731 (online) – ISSN 1133-3197 (print)


1. INTRODUCTION The hospital sector remains the largest single component of health spending in OECD and EU countries, accounting for around one third of total health expenditure. The progress in the development of less invasive surgical interventions and better anesthetics have enabled shorter lengths of stay in hospitals and the expansion of same-day surgery in hospitals or in other health care facilities (Lafortune et al., 2012). Besides from the extraordinary cases, the day surgery is advantageous for patients and their families, but also for health care providers, health insurers and health system regulator. There are significant differences in the development and use of day surgery among the countries arising from varying legislative incentives and regulations, financial reimbursement paid for day surgery, as well as the approaches of doctors and anesthesiologists (Aylin at al, 2005; Koechlin et al., 2010). Continuous improvement in surgical and anesthetic techniques are conditioned by further development of procedures suitable for day surgery, and this trend is particularly evident in the expansion of laparoscopic and minimum invasive surgery.

Following the results of numerous studies carried out abroad we can conclude that day surgery is expanding constantly, both in the number of operated patients, as well as in larger and more complex application of surgeries for patients with higher comorbidity (Martinussen and Hagen, 2009; Martinussen and Midttun, 2004). Day surgery covers a wide spectrum of surgical procedures, embracing all surgical specialties, from operations under local anesthesia to major ones under general anesthesia. Many procedures of medical services enable releasing patients from hospital to home care in the day of surgery. Other treatments require overnight stay in hospital or a short stay in hospital within 72 hours.

Despite the above mentioned, day surgery in Slovakia is characterized by a small number of workplaces designed for day health care. Also, it has a discouraging funding system of day surgery performances paid to health care providers. The population still prefers hospitalization prior to day surgery. Slovakia lacks in stronger legislative support, coordinated approach of day surgery actors, communication between health care providers, health insurers and patients, and follow-up home care or nursing care. For more than ten years of providing day surgery in Slovakia, there has not yet been realized and published any complex research study dealing with day surgery and its aspects. There is an absence of broader information for potential patients about the nature, conditions and other selected attributes of day surgery. This should be provided from the health insurance companies or individual health care providers, or from healthcare system regulatory body itself. Funding system of hospital facilities is suppressing the motivation of hospitals to move patients into a day surgery. It declares a very low use of day surgery, not reaching the level of 10% of the Estudios de Economía Aplicada, 2013: 477-496  Vol. 31-2


total surgeries performed. The neighboring Czech Republic achieves four times higher share of day surgery operations out of all operations performed.

Developed countries of Europe and the U.S. exceed this share by nine times (Hudecová, 2010). Slovak republic has not participated in collecting surgical data for OECD or Eurostat statistics yet; therefore it has not been possible to compare the results with other EU countries.

The goal of the research is to map the current condition of day surgery data collecting in Slovakia. This contribution reflects partial results of the historically first extensive pilot research study conducted in Slovakia. It emphasizes the negative findings which hinder the development of day surgery in Slovakia.


The Organization of Economic Cooperation and Development (OECD), European Statistics (Eurostat) and World Health Organization (WHO) in Europe have been collecting data on surgical procedures as part of their broader data collection on health care statistics since 1960. The three organizations are planning to integrate the data collection on this topic into the OECD/Eurostat/WHOEurope joint questionnaire in 2013. Collecting data on surgical procedures at the international level is challenging and difficult for three main reasons (Lafortune

et al., 2012):

1. Lack of unified international classification of procedures.

2. Differences in the methods of correct procedures reporting.

3. Problems with data reporting of the day surgeries provided.

In general, we can specify striking disparities in the rate of published surgical performances in particular European countries; those could be classified into the areas as seen in the Figure 1.

Research studies declare also significant changes in realized health care performances (procedures) as an important determinant influencing the rate of reported realized surgical performances. This means that changes in demand for the given type of surgical performances are not as important as the differences in medical practice linked together with factors on the side of supply. In medical practice are declared disparities not only between countries, but also in the frame of each country (ex. Dartmouth Atlas of Health Care, 2012; NHS, 2011).

They correlate also with the riskiness of the given type of performances for particular group of patients, or also with medical recommendation for the given type of performances for patients with exactly specified conditions (Lafortune et al., 2012). This only multiplies the importance and difficulties of solving the questions of efficiency and equality in the area of health care services providing.

–  –  –

Source: Own elaboration.

A comparison of the OECD, Eurostat and WHO-Europe data collection on the aggregate number of surgical procedures reported wide inconsistencies in national data submissions to the three international organizations (Table 1).

Recognizing the difficulties in promoting consistent data reporting across countries in the absence of international classification procedures, the three organizations decided to discontinue their data collection on the aggregate number of (surgical) procedures and to focus their work on improving the data collection. A proper monitoring of the development of day surgery in different countries should be based, ideally, on a full coverage of activities in hospitals and in other settings (e.g., in clinics or specialized ambulatory surgery centers).

The OECD and Eurostat data collections have traditionally included a breakdown between in-patient cases and day cases, with day cases usually defined as patients admitted to the hospital and discharged the same day. As to the day surgery activities, such data collection did not explicitly cover all the day surgeries that may have been carried out as outpatient cases (no admitted patients) in hospitals and in other settings. The results from the pilot data collection confirmed that many countries are still only able to report data on day cases in hospital, while unable to report data on outpatient cases. But among those countries that are able to report the data on outpatient cases, the collection of these data are crucial to properly document the development of day operations. The pilot data collection also helped to clarify the definition of “day cases” in the regular data submissions, and that some countries were already including such outpatient cases under their reporting of day cases. Recognizing both the current limitations in the ability of many countries to report data on outpatient cases and Estudios de Economía Aplicada, 2013: 477-496  Vol. 31-2


the value of collecting these data in a clearly-defined way where possible, the OECD, Eurostat and WHO-Europe have agreed to collect data on outpatient cases for two surgical procedures (e.g., cataract surgery and tonsillectomy) that are performed to a large extent as day surgery in their joint questionnaire on non-monetary health care statistics in 2013.

–  –  –

Source: OECD Health Data 2010; WHO-Europe HFA; Eurostat data.

It is one of the reasons why we decided to search for the barriers of collecting data about day surgery in Slovakia and to propose activities, which would allow other countries to get involved in a joint data collecting and comparison scheme.

–  –  –

Until 2010 the OECD and Eurostat realized data collecting about surgical performances using two types of reports: report with aggregated data with total number of performances, as well as report with detailed data regarding selected performances. WHO-Europe focused data collecting overall numbers regarding

two data groups:

a) File of aggregated data - all types of surgical performances in the group of in-patient and day cases,

b) File of structured data - gained on the base of surgery performance classification. The classification criteria is high number, or eventually high costs, with respect to in-patient and day cases where applicable (relevant).


–  –  –

The performance data comparison from international organizations (OECD, Eurostat and WHO) shows disparities. The problem is in contradicting definition used in data collecting process (Figure 2). The disparities cause problems with reporting of consistent and comparative data. Definition according to Eurostat has more general, wider character then stated definition according to OECD and WHO-Europe. It is from the reason of implementation other performances, as stated in definition. This fact is significantly consequential for reporting many more number of performances reported in data from Eurostat, in comparison with reported data for OECD or WHO-Europe (with respect to exception).

In continuity with above mentioned, international organizations agreed on discontinuation of collecting data about the overall number of surgical procedures until the time, when international classification of procedures with be agreed and implemented. This classification would guarantee higher consistency of reported data between the countries. Those conclusion fully correspond with the conclusions of the Hospital Data Project 2 (EC, 2008), that also appealed from the same reason on discontinuation of collecting data about the number of surgical procedures (EC, 2008).


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