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Optimum surgical intervention for low-grade haemorrhoids is unknown. Haemorrhoidal artery ligation (HAL) has been proposed as an efficacious, safe therapy while rubber band ligation (RBL) is a commonly used outpatient treatment. We compared recurrence after HAL versus RBL in patients with grade II–III haemorrhoids. This multicentre, open-label, parallel group, randomised controlled trial included patients from 17 acute UK NHS trusts. We screened patients aged 18 years or older presenting with grade II–III haemorrhoids. We excluded patients who had previously received any haemorrhoid surgery, more than one injection treatment for haemorrhoids, or more than one RBL procedure within 3 years before recruitment. Eligible patients were randomly assigned (in a 1:1 ratio) to either RBL or HAL with Doppler. Randomisation was computer-generated and stratified by centre with blocks of random sizes. Allocation concealment was achieved using a web-based system. The study was open-label with no masking of participants, clinicians, or research staff. The primary outcome was recurrence at 1 year, derived from the patient's self-reported assessment in combination with resource use from their general practitioner and hospital records. Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year. This study is registered with the ISRCTN registry, ISRCTN41394716. From Sept 9, 2012, to May 6, 2014, of 969 patients screened, 185 were randomly assigned to the HAL group and 187 to the RBL group. Of these participants, 337 had primary outcome data (176 in the RBL group and 161 in the HAL group). At 1 year post-procedure, 87 (49%) of 176 patients in the RBL group and 48 (30%) of 161 patients in the HAL group had haemorrhoid recurrence (adjusted odds ratio [aOR] 2·23, 95% CI 1·42–3·51; p=0·0005). The main reason for this difference was the number of extra procedures required to achieve improvement (57 [32%] participants in the RBL group and 23 [14%] participants in the HAL group had a subsequent procedure for haemorrhoids). The mean pain 1 day after procedure was 3·4 (SD 2·8) in the RBL group and 4·6 (2·8) in the HAL group (difference −1·2, 95% CI −1·8 to −0·5; p=0·0002); at day 7 the scores were 1·6 (2·3) in the RBL group and 3·1 (2·4) in the HAL group (difference −1·5, −2·0 to −1·0; p<0·0001). Pain scores did not differ between groups at 21 days and 6 weeks. 15 individuals reported serious adverse events requiring hospital admission. One patient in the RBL group had a pre-existing rectal tumour. Of the remaining 14 serious adverse events, 12 (7%) were among participants treated with HAL and two (1%) were in those treated with RBL. Six patients had pain (one treated with RBL, five treated with HAL), three had bleeding not requiring transfusion (one treated with RBL, two treated with HAL), two in the HAL group had urinary retention, two in the HAL group had vasovagal upset, and one in the HAL group had possible sepsis (treated with antibiotics). Although recurrence after HAL was lower than a single RBL, HAL was more painful than RBL. The difference in recurrence was due to the need for repeat bandings in the RBL group. Patients (and health commissioners) might prefer such a course of RBL to the more invasive HAL. NIHR Health Technology Assessment programme.

The increasing prevalence of ambulatory surgeries has highlighted the need for effective postoperative follow-up. While telemedicine represents a promising option for perioperative support and postoperative monitoring, evidence of its actual benefits remains limited. This study aims to evaluate the medico-economic impact of a personalized telemedicine platform for postoperative follow-up in day-surgery patients in terms of cost-effectiveness and cost-utility. This single-blinded, 2-group randomized controlled trial was conducted at the Centre Hospitalier de l'Université de Montréal (CHUM) from August 2022 to September 2023. Adults undergoing elective day surgery were randomized into 2 groups: the intervention group, which received postoperative follow-up via the LeoMed telemedicine platform, and the control group, which received standard care. The intervention group used a personalized telehealth platform offering preoperative education, psychological support, and postoperative monitoring through daily follow-up forms sent to patients' smartphones. Alerts generated by patient responses were reviewed by CHUM's telehealth support unit. The primary outcome was unanticipated health care usage, including emergency visits, readmissions, and medical consultations within 30 days postprocedure. Secondary outcomes included gained quality-adjusted life years (QALYs), patient satisfaction, health care costs, and greenhouse gas emissions. Demographic and outcome data were summarized using descriptive statistics; categorical variables were reported as frequencies and percentages, and continuous variables as means with standard deviations. Between-group comparisons were conducted using appropriate statistical tests by the HEC Montréal health economics team, following an intention-to-treat approach. Of 1411 patients screened, 1214 were randomized, with 436 in the intervention group and 445 in the control group analyzed. Compliance with the platform was high, with a mean compliance index of 0.89 in the intervention group. No significant differences in unanticipated health care usage were observed. The average cost of unplanned care was CAD $370 (US $275) in the control group versus CAD $323 (US $239) in the intervention group (P=.60). The intervention group demonstrated a statistically significant QALY gain at postoperative day 14 (0.002; P=.01), but the difference was no longer significant at day 30 (0.001; P=0.14). There were also no significant differences in GHG emissions between the groups, with the intervention group emitting an average of 0.870 kg CO₂-eq compared with 1.055 kg CO₂-eq in the control group (P=.52). However, patient satisfaction was significantly higher in the intervention group at both days 14 (P=.02) and 30 (P<.001). This trial demonstrates the potential of telemedicine platforms to enhance postoperative care in ambulatory surgery settings. While no significant reductions in health care usage were observed, the intervention improved QALYs and patient satisfaction, suggesting potential cost-utility benefits. Larger trials are needed to confirm these findings and explore the impact on long-term recovery and health care savings.

Introduction Hysteroscopic myomectomy is the first‐choice treatment for symptomatic type 0 and 1 fibroids and was traditionally performed under general anesthesia. Over the last decade, surgical procedures have increasingly been performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating the safety and cost‐effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia are lacking. This study aimed to assess the cost‐effectiveness of procedural sedation and analgesia with propofol in an outpatient setting for hysteroscopic myomectomy compared to general anesthesia in an operating room. Material and Methods This was a cost‐effectiveness analysis from a societal perspective alongside a multicenter randomized controlled non‐inferiority trial. It was conducted in 14 Dutch university and teaching hospitals. Women aged ≥18 years with symptomatic type 0/1 fibroids (maximum number 3, maximum diameter 3.5 cm), sufficient knowledge of Dutch/English, and American Society of Anesthesiologists class 1/2 were included. A total of 209 women were randomized to hysteroscopic myomectomy with procedural sedation and analgesia in an outpatient setting (n = 106) or general anesthesia in an operating room (n = 103). The primary outcome of the clinical trial was the percentage of complete resections measured by transvaginal ultrasonography 6 weeks postoperatively (non‐inferiority margin 7.5% of incomplete resections). Societal costs and quality‐adjusted life years (QALYs) were assessed. Societal costs were related to the percentage of complete resections and QALYs. Incremental Cost‐Effectiveness Ratios (ICERs) were calculated. Uncertainty surrounding these was estimated using bootstrapping. Follow‐up period was 12 months. Dutch Trial Register NTR 5357. Results Hysteroscopic resection was complete in 86/98 women (87.8%) with procedural sedation and analgesia and 79/89 women (88.8%) with general anesthesia, mean difference −0.0052 (95% CI −0.097 to 0.086). Non‐inferiority could not be demonstrated. There was a statistically significant difference in costs between procedural sedation and analgesia and general anesthesia (€−2577, 95% CI −3950 to −1157), but not in QALYs (0.011, 95% CI −0.019 to 0.040). The ICER per additional complete resection was €498 797 and for QALYs the ICER showed that procedural sedation and analgesia was dominant over general anesthesia. Conclusions In this study, procedural sedation and analgesia for hysteroscopic myomectomy in an outpatient setting is cost‐effective compared to general anesthesia in an operating room, although non‐inferiority for complete resections could not be demonstrated. We therefore suggest the outpatient use of procedural sedation and analgesia for hysteroscopic myomectomy. Data on cost‐effectiveness of procedural sedation and analgesia for hysteroscopic myomectomy was lacking. Procedural sedation and analgesia for hysteroscopic myomectomy in an outpatient setting is cost‐effective compared to general anesthesia in an operating room. It should be considered to perform hysteroscopic myomectomy in an outpatient setting with procedural sedation and anesthesia.

Objective To investigate the assumption that day-case cochlear implantation is associated with lower costs, compared to inpatient cochlear implantation, while maintaining equal quality of life (QoL) and hearing outcomes, for the Dutch healthcare setting. Study design A single-center, non-blinded, randomized controlled trial in a tertiary referral center. Methods Thirty adult patients with post-lingual bilateral sensorineural hearing loss eligible for unilateral cochlear implantation surgery were randomly assigned to either the day-case or inpatient treatment group (i.e., one night admission). We performed an intention-to-treat evaluation of the difference of the total health care-related costs, hospital and out of hospital costs, between day-case and inpatient cochlear implantation, from a hospital and patient perspective over the course of one year. Audiometric outcomes, assessed using CVC scores, and QoL, assessed using the EQ-5D and HUI3 questionnaires, were taken into account. Results There were two drop-outs. The total health care-related costs were €41,828 in the inpatient group ( n  = 14) and €42,710 in the day-case group ( n  = 14). The mean postoperative hospital stay was 1.2 days (mean costs of €1,069) in the inpatient group and 0.7 days (mean costs of €701) for the day-case group. There were no statistically significant differences in postoperative hospital and out of hospital costs. The QoL at 2 months and 1 year postoperative, measured by the EQ-5D index value and HUI3 showed no statistically significant difference. The EQ-5D VAS score measured at 1 year postoperatively was statistically significantly higher in the inpatient group (84/100) than in the day-case group (65/100). There were no differences in postoperative complications, objective hearing outcomes, and number of postoperative hospital and out of hospital visits. Conclusion A day-case approach to cochlear implant surgery does not result in a statistically significant reduction of health care-related costs compared to an inpatient approach and does not affect the surgical outcome (complications and objective hearing measurements), QoL, and postoperative course (number of postoperative hospital and out of hospital visits). Level of evidence 1.

Short-acting regional anesthetics have already been successfully used for peripheral nerve blocks in an ambulatory surgery setting. However, the impact on direct and indirect perioperative costs comparing 2 different short-acting local anesthetics has not been performed yet. Observational, prospective, case-control, cost-minimization study. Operating room, regional hospital One hundred adult American Society of Anesthesiologists status I-III patients scheduled for popliteal block after minor ambulatory foot surgery. Application of 30 mL chloroprocaine 3% or of 30 mL mepivacaine 1.5% for anesthesia. Cost-minimization evaluation. Direct and indirect perioperative costs were calculated. Block success, onset time and block duration, patient satisfaction, and unplanned outpatient visits or readmissions after discharge were also assessed. Onset time (sensory: 4.3 ± 2.4 vs 11.5 ± 3.2 minutes; motor: 7.1 ± 3.7 vs 18.4 ± 4.5 minutes) and block duration (sensory: 105 ± 26 vs 317 ± 46 minutes; motor: 91 ± 25 vs 216 ± 31 minutes) were significantly shorter (P < .001) when chloroprocaine 3% was used. This translated to P < .001, basically due to a faster discharge home 55 ± 1 vs 175 ± 2 minutes; P < .001) in favor of chloroprocaine 3%, without negatively affecting either block efficacy or patients satisfaction. There were no unplanned outpatient visits or readmissions and no complications in the follow-up at 6 weeks. We conclude that the more expensive chloroprocaine 3% for ambulatory foot surgery can reduce total perioperative costs and reduce length of stay in outpatient patients. Moreover, the saved time and personal resources could be used for additional cases, further increasing the revenues of an ambulatory surgical center. •Cost reduction is an extremely hot topic in perioperative medicine.•A faster discharge is associated to fix cost reduction and increased turnover in ambulatory surgery.•A case-control cost-minimization study to compare chloroprocaine with mepivacaine for outpatient popliteal block was performed.•Chloroprocaine was shown to be as effective as mepivacaine but was associated with a reduction in total costs.

To examine temporal trends and outcomes of outpatient adrenalectomy in a population-based sample. We performed a retrospective cohort study using the Healthcare Cost and Utilization Project's State Inpatient and State Ambulatory Surgery Databases, 2016–2020. Patients undergoing minimally invasive adrenalectomy were identified using billing codes. The primary exposure was admission status defined by length of stay. Outcomes included temporal trend in admission type, readmission rates and costs. Among 4431 adrenalectomies, 51.3 ​% were performed in the outpatient setting. The majority were observed overnight with only 100 patients (2.3 ​%) discharged same-day. Outpatient adrenalectomy increased annually from 44.1 ​% in 2016 to 59.2 ​% in 2020 (p ​< ​0.01). Median costs were similar with a risk-adjusted marginal difference of $179 (same-day: $9565 vs overnight $9491; p ​= ​0.81). Odds of readmission were similar between same-day and overnight stays (OR 0.18; p ​= ​0.10). Given similar costs and readmission rates, case selection and surgeon expertise should continue to guide decision-making on same-day adrenalectomy. •From 2016 to 2020, outpatient adrenalectomy increased from 44.1 ​% to 59.2 ​%.•Same-day discharge after adrenalectomy is rare, with only 2.3 ​% of patients discharged on the same-day.•No significant difference in 30-day readmissions between same-day and overnight discharge.•Similar costs between same-day and overnight discharge.

INTRODUCTION:Rising healthcare costs have led to decreasing reimbursements for various procedures and providers. We chose to analyze Medicare reimbursement trends for 26 esophagogastroduodenoscopy (EGD) and 31 colonoscopy current procedural terminology (CPT) codes from 2018 to 2023 for hospital outpatient centers, ambulatory surgical centers (ASC), and gastroenterologists. We also wanted to look at the effects of inflation on these Medicare reimbursements.METHODS:We calculated the nominal percentage change from 2018 to 2023 for each CPT code. We then took inflation data provided by the US Bureau of Labor Statistics and calculated the real change in reimbursements from 2018 to 2023 for each of the 31 colonoscopy and 26 EGD CPT codes.RESULTS:Our results show that although nominal reimbursements to physicians have been steadily declining for performing gastrointestinal procedures, nominal reimbursements to hospital outpatient and ASC have been increasing from 2018 to 2023. After taking into account inflation, physicians saw significant decreases in real purchasing power for performing EGD and colonoscopies. ASC and hospital outpatient centers saw reimbursements keep up with inflation.DISCUSSION:Physician reimbursements for gastroenterology procedures make up a small portion of reimbursements by Medicare compared to Medicare reimbursements to facilities such as ASC and hospital outpatient centers. However, physicians have seen significant reimbursement cuts, whereas facilities have not. Moreover, higher inflation leads to increased expenses for gastroenterology practices. It remains to be seen how these reimbursement changes will affect patients access to care and physicians practice sustainability.

Private negotiated facility fees at hospitals are on average double the ambulatory surgery center facility fees for common outpatient procedures.Private negotiated facility fees at hospitals are on average double the ambulatory surgery center facility fees for common outpatient procedures.

In 2023, changes were made to the Current Procedural Terminology (CPT) codes for anterior abdominal hernia repair to more uniformly reimburse hernia repair and better reflect current practices. These changes were made to address a shift toward the outpatient setting however general surgeons may be negatively impacted. A retroactive analysis of an ambulatory surgery center compared the surgeon's average reimbursement from old CPT codes from 2019 to 2022 to new CPT codes in 2023 including the evaluation and management (E/M) services in the new 0-day global period. Average case reimbursement to the surgeon decreased significantly for incarcerated hernia repair (p ​= ​0.01, −58.89 ​% change) and to the surgical facility for reducible hernia repair (p ​= ​0.004, −56.97 ​% change) between the combined average of 2019–2022 and 2023. Average procedural work relative value units for hernias from 2019 to 2022 were found to decrease by 25.4 ​% for incarcerated and 45 ​% for reducible hernias compared to 2023. Further evaluation with a larger surgical facility is needed to confirm these findings. •Average case reimbursement of incarcerated abdominal hernias decreased by 59 ​% in 2023 compared to 2019 to 2022 combined.•Change in reducible abdominal hernias repairs decreased by 44% but was not found to be statistically significant.•E/M reimbursement per case was about $165 in 2023.•In 2023, surgeon reimbursement for the repair alone is $248.97 for reducible and $272.70 for incarcerated abdominal hernias.•These CPT code changes are detrimental to surgeons performing abdominal wall hernia repairs.

Purpose of Review To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. Recent Findings Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Summary Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.