The preliminary study identified 3 correctable factors. Elimination of individual variation did not require formal guidelines. Comparison of individual results coupled with demonstration of the safety of the outpatient approach for all patients standardized practices voluntarily. Although this may be slower than the use of edict, voluntary change of practice is probably the best test for the usefulness of new therapy. Prudent surgeons would not adopt a therapy voluntarily unless personal experience convinced them of its superiority.
Irreversibility is said to be the measure of a revolution.
In this regard, this has been a successful revolution, for none of the participating surgeons is willing to return to overnight admission for cholecystectomy. Both age and comorbidity correlate strongly with the need for admission, but neither, alone or together, is a contraindication to safe outpatient surgery. There seems to be no benefit from preselecting higher risk patients for admission. Variations in individual practice and available day surgery facilities also strongly influence outpatient rate. Eschewing preselection, eliminating individual variations and ensuring adequate day surgery facilities maximizes institutional outpatient rates to match individual rates.