Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis

Abstract

BackgroundAlthough the effect of the recent Greek economic crisis and austerity on the population’s health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens’ attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties.MethodsThe present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005–2009 and 2012–2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated).ResultsAn equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108–1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p < 0.001). In contrast the percentage of patients with intestinal resection, their hospitalization length and treatment-cost remained unchanged. During the crisis there was a non-significant increase of emergency patients requiring ICU postoperatively (0 vs 4, p = 0.07) and a non-significant 60% increase of emergency operations in migrants/refugees population (3.5% vs 5.8%, p = 0.28). Epidural anesthesia was significantly more frequent during the crisis.ConclusionDuring the crisis: (i) the emergency hernioplasties increased significantly, (ii) more patients (exclusively Greek) presented with intestinal ischemia requiring longer hospitalization and higher treatment cost, (iii) the mean age of the urgently treated patients decreased significantly (iv) regional (epidural) anesthesia was more frequent. Although a direct causal relation could not be proven by the present study most observations can be explained by an increase of the patients who delayed the elective treatment of their hernia, and by a redistribution of the surgical workload towards big central hospitals. This can be prevented by adequately supporting the small district hospitals.

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience – A Realist Review

“…Examples of negative patient outcomes included increased mortality associated with reduced resources and quality of care (staff, infrastructure, delayed discharges) 24 - 29 ; increased suicide/suicidal attempts 30 - 33 ; increased mental health problems 34 - 36 ; and unmet need 37 - 41 (see Supplementary file 4 ). These adverse impacts were often directly or indirectly associated with decreased healthcare expenditure 42 - 47 ; increased household expenditure often associated with increased out-of-pocket payments for healthcare 48 - 55 ; reduced access to or utilisation of care 56 - 62 ; and reduced and strained workforce. 63 - 71 The positive results included reduced inequalities in male amenable mortality due to increased health expenditure in deprived areas, 72 achievement of long-standing policy goals of increased public-patient discharges resulting in reimbursement – due to introduction of information systems, 73 and decreased prescription medication use due to introduction of co-payments 74 – although the latter was reported positively in terms of achieving policy goals, the consequences of these changes were unknown and possibly negative in the longer term.…”

“…Preliminary Context-Mechanism-Outcome Configurations care (staff, infrastructure, delayed discharges) [24][25][26][27][28][29] ; increased suicide/suicidal attempts [30][31][32][33] ; increased mental health problems [34][35][36] ; and unmet need [37][38][39][40][41] (see Supplementary file 4). These adverse impacts were often directly or indirectly associated with decreased healthcare expenditure [42][43][44][45][46][47] ; increased household expenditure often associated with increased out-of-pocket payments for healthcare [48][49][50][51][52][53][54][55] ; reduced access to or utilisation of care [56][57][58][59][60][61][62] ; and reduced and strained workforce. [63][64][65][66][67][68][69][70]…”