Reducing the Need for Surgery
Tom Cropper, Editor
Tom Cropper, Editor
HEALTHCARE SERVICES face a range of challenges. The cost of providing care to an aging population is rising and bed capacity is reaching critical levels. Methods which can avoid invasive procedures not only reduce the risks posed to patients, but they also alleviate many of the most pressing strains on resources and infrastructure.
Bowel cancer represents a growing heath problem with a number of studies around the world point to an increase in bowel cancer rates among younger people. A study in the US found that bowel cancer rates had increased by 3.2% between 1974 and 2013 among people between the ages of 20-29¹.
There is a renewed focus, therefore, on raising awareness about the need for colonoscopies in younger people. In 2014, a national campaign was launched in the US designed to increase the rates of colorectal cancer screening rates by 80% by 2018². The focus is moving toward identifying and addressing problems at a much earlier stage and, while this will save lives, it also creates a number of issues.
Earlier identification will mean more people will present with issues such as polyps. Although these are harmless in most cases, they could potentially lead to more serious conditions such as bowel cancer if left untreated. Earlier diagnosis and removal of polyps can reduce the risk of cancer, but the procedure has risks. In some cases, the removal of polyps can increase the risk of cancer at a later date, which means further colorectal screening may be necessary.³
Depending on the position and size of the polyps, the removal procedure can present a number of risks. In an ideal world, these can be removed via an endoscopy but, if the polyps are large, have a broad base or are located in an anatomically inaccessible position, they may require more invasive interventions. These may include a laparoscopy, or open surgery both of which increase the risk of complications setting in.
Despite evidence showing that endoscopies are both safer and less expensive, laparoscopic surgery is becoming increasingly common. A study in the US identified a significant rise in the incidence of surgery for non-malignant polyps in the US from 5.9 per 100,000 adults in 2000 to 9.4 in 20094.
The number of laparoscopies has surged in recent years as technological advancements make it possible to deliver increasingly complex procedures in a safe and efficient way. However, they also bring with them a number of associated risks including infection, blood clots, adverse reaction to anaesthesia, abdominal inflammation and bleeding. There is also a significantly higher risk of damage to internal structures such as the stomach, bowel, bladder or blood vessels.
The risks become more severe with open surgeries. Patients will need several days to recover rather than being released on the same day and may require months of ongoing monitoring. Studies suggest laparoscopies lower the risk of complications when compared with open surgery as well as leading to shorter post-operative stays and earlier return of bowel functions. However, they are still significantly more invasive than endoscopic procedures.
As their use grows, therefore, laparoscopies not only present a risk to patients, but also a drain on the financial resources of the hospital. As health services struggle to cope with rising demand and tightening capacity, that is becoming a growing problem.
Hospital bed vacancies are at a premium in all health services, but the problem is particularly severe in the UK where bed shortages have become critical. According to a study from the Kings Fund the number of hospital beds in England and Wales has halved from more than 299,000 to 142,000 in 30 years.
The UK is not alone. Most other advanced health services have also reduced their total number of beds, but the UK currently has fewer acute beds relative to its population than most other comparable healthcare systems. The publication highlights growing signs of shortages. In 2016/2017 acute and general hospital bed occupancy rates averaged 90.3% rising to 95% in winter5.
The rate of decrease has slowed in recent years, but to meet its capacity restrictions, health services need to identify ways in which they can reduce hospital admissions and shorten stays. The problem is made all the more urgent by the growing demands on their services. Populations in the developed world are aging. As technology evolves, we have become much more effective at treating conditions and prolonging life.
While a longer living population should be welcomed, it comes at a cost. More people are requiring increasingly complex and ongoing treatment for various conditions They are more likely to require hospital care for much longer. New technologies also cost money. Delivering world class healthcare is becoming increasingly expensive.
Healthcare costs have risen dramatically over the past few years and are set to continue to do so. The next few decades, therefore, will be marked by a rapid and accelerating increase in the cost of care.
Across all areas, therefore, authorities are looking at ways they can reduce the level of interventions. Where possible, these might include greater education to reduce the risk of admission to hospital and, further down the line, surgical procedures, but these have to be managed in a way which minimises the risks involved to all patients.
Much of the focus, now, though, is growing on developing less invasive endolumenal therapies which can avoid laparoscopic or open surgeries. New technologies and techniques which can widen the range of conditions that can be treated endoscopically will have a dramatic impact on safety and turnaround times.
Patients who can be treated in this way will see hospital stays reduced from several days to 24 hours. Hospitals can ease the pressure on their bed capacity, and the risks of complications will be lower. It also fits in with the desires of patients who will be keen to avoid surgery if they can. This will require open communication between all parties to highlight what is available and how it can be practically applied to the clinical setting.