Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India (http://www.ammfoundation.org/SirIvanStedefordHospital/index.html). This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.

©M HEMADRI 

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DVT Prophylaxis for Day Case Surgery

DVT/PE results in 25000 deaths annually (House of Commons Health Committee report 2004-2005)
DVT happens in 15% to 20% of patients having surgery with a risk of 0.5% of PE (Thrift Consensus Group BMJ 1992) Sweetland et al in BMJ 2009 showed that 1 in 815 women who had day case surgery will develop DVT/PE but that study included biopsies etc and in that study only 60% day case rate was seen.

Many procedures that used to be done as in-patients are routinely done as day cases (and short-stay) these days due to different approaches in technique (e.g. laparoscopic), anaesthesia (e.g. not using opioids), pain control, support arrangements, government directives and societal expectations.

Taking the example of laparoscopic surgery it is different but leaves the patient with an equal or higher risk of hypercoagulable state (Caprini et al Surgical Endoscopy 1995).

On the above basis and the fact that many UK hospitals currently perform a high proportion of our surgery as day cases would lead me to believe that about 0.25% of our day cases are at risk of PE (potentially life threatening). It is one too many any way. We must also consider that most DVTs are silent and many PEs are sudden and many PE related deaths are also very sudden. Further many tend to happen within a 12 week period rather than 30 day mortality which we count.

NICE and DoH guidelines state that patients who are over 60 are at risk. They also state that if there was a risk of reduced mobility and acute illness the patients are risk. Normal logic would mean that we will not be able to predict if any individual patient would not have reduced mobility after surgery (especially the ones that involve general anaesthesia); again once a surgical assault has happened by definition the patient is acutely ill for a temporary period even though recovering quickly.

Cost benefit is an important issue DVT prophylaxis is $100 per day (much lower in many UK hospitals) vs treating an uncomplicated DVT $5000 to $8000. According 2005 House of Parliament health committee report the cost of treating DVT/PE is thought to be £640million (hence extrapolated to about £3.7million for a typical trust). It seems that DVT prophylaxis provides good cost benefit.

DVT general prophylaxis reduces complications and costs at the same time.

I suggest that ALL DAY CASE PATIENTS WHO HAVE A SURGICAL OPERATION UNDER A GENERAL ANAESTHETIC MUST HAVE CLEXANE (unless contraindicated)' This is very simple rule to operationalise in the healthcare world where complexity rules.


It is important to note that -
Not provide prophylaxis at all is not option to be considered as it goes against every available evidence and guideline.
-Selective prophylaxis brings it down to individual complex judgement resulting in variation which is most often harmful.
-General prophylaxis for all day case patients having a surgical operation under a general anaesthetic is probably a better option.

© HEMADRI

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Note: This blog is not the epitome of high science. I would like to think about balanced practical operational views. 

Single Visit Surgical Service

When we look at providing healthcare services we should look at it from a patient's perspective. For instance, ''how often would the patient have to travel to the hospital to obtain healthcare services?'' is not the top question in any providers mind when they design the service.

This results in the patients traveling often to secondary care services even for obviously clear problems such as hernias, varicose veins etc.

At Goole Hospital we provide a single visit general surgery service for patients who need day case and short stay surgical procedures. This may mean procedures likes superficial lumps and bumps, toe-nails, etc. This also means patients who have groin hernias including recurrent groin hernias and gall stones (needing laparoscopic cholecystectomy).  Obviously there has to be a clear cut diagnosis based on obvious findings followed by some appropriate investigations by the general practitioners. These patients visit Goole Hospital only once to obtain their surgical care. The patients are telephone pre-assessed. They come to the hospital at about 8 am and are seen by nurses, anaesthetists, surgeons and residual simple investigations are performed instantly; they are operated during the day and discharged when they meet clinical criteria often within the day. They are not offered specific follow up out patient appointments but can ring to make one if they felt they needed it.

We do inguinal hernia repairs, laparoscopic cholecystectomies and many other procedures as a part of this service. The service has been running for a good few years.

My personal calculations are that this saves money overall, especially saves on travel costs for patients and their relatives. My feeling is many of the services provided by healthcare are currently very hospital focussed. When the processes becomes patient focussed there is a good chance that quality could improve while saving on costs at the same time. It is up to us to manage our services and processes maturely - our poor design should not trouble the patients.

© HEMADRI

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Warning & Disclaimer:
We do not claim superior clinical results. We only describe our process/pathway. Not all patients with any of the conditions stated above or with other similar conditions are suitable for this service. Your GP is best placed to advice the kind of pathway that could be suitable to you. This blog/website does not give clinical/medical advice. The views expressed are my personal views and not those of my hospital or the NHS.