Office-based anesthesia: a contemporary update on outcomes, incentives, and controversies.

PURPOSE OF REVIEW: The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies. RECENT FINDINGS: Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates. SUMMARY: The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery.

Decision aids in anesthesia: do they help?

PURPOSE OF REVIEW: Patient decision aids are educational tools used to assist patients and clinicians in healthcare decisions. As healthcare moves toward patient-centered care, these tools can provide support to anesthesiologists by facilitating shared decision-making. RECENT FINDINGS: Recent research has shown that patient decision aids are beneficial in the clinical setting for patients and physicians. Studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression, and decisional conflict after using patient decision aids. In addition, a structured approach for the development of patient decision aids in the field of anesthesia has been established. SUMMARY: Patient decision aids can support patient-centered care delivery and shared decision-making, especially in the field of anesthesia. Current research involves implementing the use of patient decision aids in the discussion for monitored anesthesia care. Further development of quality metrics is needed to improve the decision aids and maximize decision quality.

Concepts for the Development of Anesthesia-Related Patient Decision Aids.

Patient decision aids are educational tools used by health care providers to assist patients in choosing their treatment and care. The use of anesthesia-related patient decision aids can help practitioners provide patient-centered care by facilitating shared decision-making. The benefits of these aids have been well documented, yet a structured approach for developing patient decision aids in anesthesia has not been well established. Educating patients on various anesthesia-related options is paramount in their decision-making, yet accessible and validated resources are limited. In addition, many limitations exist with current patient decision aids that must be addressed. We have reviewed multiple processes for developing decision aids and have suggested a structured approach to their creation. We address the common limitations of current patient decision aids and provide improvements to the developmental process. Improvements include increasing patient input during development, thoroughly evaluating data included in the aids, and integrating a cyclic review of the aids before and after their use. Using the provided developmental process and checklist, anesthesia providers can create evidence-based patient decision aids in a standardized manner. It is important to evaluate decision aids and measure their decision quality, or patient-centeredness, to further improve them and maximize their effectiveness. Moving forward, development of proper metrics for patient participation and decision quality are required.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019.

PURPOSE OF REVIEW: Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included. RECENT FINDINGS: Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other. SUMMARY: New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards.

Office-based surgery and patient outcomes.

PURPOSE OF REVIEW: The purpose of this review is to provide an update on the current knowledge about patient safety and outcomes in the office-based setting. Ambulatory procedures performed outside the hospital are steadily increasing, resulting in an increasing number and complexity of office-based procedures and patient comorbidities over the past two decades. In this review we focus on most recent outcomes studies encompassing different surgical specialties and patient populations. RECENT FINDINGS: Rates of complications in the office-based surgical (OBS) setting from the latest publications are similar to, or lower than previously reported studies. Many of the studies published were in the field of plastic surgery, with a few publications on office vascular and dental procedures. The most common complications were haematoma, infection and venous thromboembolism (VTE) and pulmonary embolism. Death was a rare finding, though when it occurred, it was often associated with VTE/pulmonary emboli and abdominoplasties. SUMMARY: Overall, these studies contribute positively to our current understanding of the safety of office-based anaesthesia. As an increasing number of procedures migrate from the hospital setting to ambulatory and office-based environments, it will be critically important to ensure high quality and safe patient care in these settings.

The Need for Accreditation of Office-Based Interventional Vascular Centers.

The rise in office-based interventional vascular laboratories in recent years was prompted in part by expedient ambulatory patient experience and favorable outpatient procedural reimbursement. While studies have shown that clinical safety and treatment efficacy can be achieved in office-based vascular facilities, critics have raised various concerns due to inconsistent patient care standards and lack of organizational oversight to ensure optimal patient outcome. Available literature showed widely varied clinical outcomes which were partly attributable to nonuniform standards in reporting clinical efficacy and adverse events. In this report, various concerns and pitfalls of office-based interventional vascular centers are discussed. Strategies to improve patient care delivery in office-based laboratories including accreditations which serve as external validation of processes to ensure patient care and safety are also mentioned. Finally, the requirements to obtain accreditation in an office-based practice and the differences between these nationally recognized accrediting organizations are discussed herein.

Office-based anesthesia: safety and outcomes.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Administrative issues to ensure safe anesthesia care in the office-based setting.

PURPOSE OF REVIEW: Office-based practice is distinct from other ambulatory practices and has unique considerations for an effective administrative structure to support its operations. RECENT FINDINGS: National guidelines have been promulgated by various entities addressing both management and clinical care aspects of the practice. Specific regulations vary by practice location, and practitioners need to comply with the pertinent accreditation and licensing requirements. Anesthesiologists have been at the forefront of promoting the culture of safety in the office-based setting. Specific practice considerations include provider credentialing, maintenance of documentation, quality assessment, professional liability, facility safety, patient health information, billing, and finance. Although there is emerging literature linking office accreditation to improved patient outcomes, more work is needed in this area. SUMMARY: Office-based practice will continue to evolve with the national emphasis on patient safety, cost reduction, value-based care, and outcomes measurement and reporting. Each practice must comply with the state and national regulations that could limit the types of procedures being performed and who can administer sedation or anesthesia, and require the facility to be accredited by a nationally recognized accrediting agency.

Office-based surgery: embracing patient safety strategies.

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients.

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Patient safety and office-based anesthesia.

PURPOSE OF REVIEW: Office-based anesthesia is a new and growing subspecialty within ambulatory anesthesia. We examine major developments in office-based anesthesia and how patient safety can be maintained. RECENT FINDINGS: The emergence of office-based anesthesia as a subspecialty of ambulatory anesthesia is a result of economic and social factors, and is also due to the development of better surgical techniques and anesthestic drugs. There is still a dearth of primary literature that addresses patient safety in the office-based setting. Some existing literature points to increased risk in the office, although others suggest that proper provider credentialing, qualifications, and appropriate facility accreditation can improve patient outcomes compared to surgicenters and inpatient facilities. There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of check lists and professional society guidelines, can help promote safer practices. SUMMARY: There is no uniform standard of care for performing procedures in the office-based setting. Healthcare providers are facing the challenge of creating a safer, efficient, cost-effective and patient-centered environment. Available data show that the office-based practice can be as safe as any ambulatory surgicenter or hospital, as long as patients, regulators, and physicians become educated advocates of safer practices. In addition, procedures can be performed safely with general anesthesia or conscious sedation, provided that there are properly trained personnel and adequate equipment and facilities. Moreover, physicians should be credentialed to perform the same procedure in a hospital that they perform in an office.

The assessment of a growing mobile anesthesia practice from 2016 to 2019: A retrospective observational cohort study of 89,999 cases comparing ambulatory surgery (ASC) and office-based surgery (OBS) centers using a high-fidelity, anesthesia-specific electronic medical record (EMR).

Office-based surgery (OBS) has emerged as a significant subspecialty of ambulatory surgery. There are few clinical trials and limited published data on patient characteristics, anesthesia, or outcomes distinguishing OBS from ambulatory surgery centers (ASCs). We examined retrospective data from a large mobile anesthesia practice for 89,999 procedures from 2016 to 2019. Data was abstracted from billing and an anesthesia-specific electronic medical record, segregating procedures performed in ASCs versus OBS. The number and breadth of procedures increased substantially. Compared to ASCs, OBS patients were more likely male (52% vs. 48%), older (61 years vs. 55 years), and to have a higher American Society of Anesthesiologists (ASAs) status (33% vs. 20% ASA 3 or higher). The procedure mix varied substantially between the two settings. The major complication rate was 0.07% for the ASCs and 0.24% for OBS (p = 0.2, confidence interval [CI] -0.15 to 0.04). Minor complications were 11.2% in OBS versus 17.3% the ASCs (p < 0.0001, 95% CI 5.2-7). The practice demonstrates a low rate of complications, and despite the limitations of this study, the organization and structure of this large mobile anesthesia practice serves as a template for effective risk mitigation and patient safety.

Patients, procedures, and PPE: Safe office-based anesthesia recommendations in the COVID-19 era.

The growth of office-based surgery (OBS) has been due to ease of scheduling and convenience for patients; office-based anesthesia safety continues to be well supported in the literature. In 2020, the Coronavirus Disease 19 (COVID-19) has resulted in dramatic shifts in healthcare, especially in the office-based setting. The goal of closing the economy was to flatten the curve, impacting office-based and ambulatory practices. Reopening of the economy and the return to ambulatory surgery and OBS and procedures have created a challenge due to COVID-19 and the infectious disease precautions that must be taken. Patients may be more apt to return to the outpatient setting to avoid the hospital, especially with the resurgence of COVID-19 cases locally, nationally, and worldwide. This review provides algorithms for screening and testing patients, selecting patients for procedures, choosing appropriate procedures, and selecting suitable personal protective equipment in this unprecedented period.

Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers.

OBJECTIVE: We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). METHODS: We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value. RESULTS: Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325. CONCLUSIONS: Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.

Office-Based Anesthesia: A Comprehensive Review and 2019 Update.

Over the last 25 years, with an exponential growth in the complexity of patients and procedures in the office-based setting, the topic of patient safety is becoming more fundamental. Current research efforts focus on the implementation of customizable safety checklists for both the patient and provider, and an emergency manual specifically adapted to guide providers though challenging and unexpected emergencies in this unique setting. Additional efforts are focusing on legislative changes and accreditation to standardize and ensure increased accountability and patient safety.

Safe anesthesia for office-based plastic surgery: Proceedings from the PRS Korea 2018 meeting in Seoul, Korea.

There has been an exponential increase in plastic surgery cases over the last 20 years, surging from 2.8 million to 17.5 million cases per year. Seventy-two percent of these cases are being performed in the office-based or ambulatory setting. There are certain advantages to performing aesthetic procedures in the office, but several widely publicized fatalities and malpractice claims has put the spotlight on patient safety and the lack of uniform regulation of office-based practices. While 33 states currently have legislation for office-based surgery and anesthesia, 17 states have no mandate to report patient deaths or adverse outcomes. The literature on office-base surgery and anesthesia has demonstrated significant improvements in patient safety over the last 20 years. In the following review of the proceedings from the PRS Korea 2018 meeting, we discuss several key concepts regarding safe anesthesia for officebased cosmetic surgery. These include the safe delivery of oxygen, appropriate local anesthetic usage and the avoidance of local anesthetic toxicity, the implementation of Enhanced Recovery after Surgery protocols, multimodal analgesic techniques with less reliance on narcotic pain medications, the use of surgical safety checklists, and incorporating "the patient" into the surgical decision-making process through decision aids.