Is office-based surgery a harbinger of things to come for ophthalmology?

(Image Credit: AdobeStock/xixinxing)

Although cataract surgery was once a hospital-based procedure, 86% of cataract surgeries are now performed on an outpatient basis. Trends such as this suggest a shift to office-based surgery (OBS) as the new normal for lens-based procedures. My own personal experience reflects this. After becoming frustrated with challenges inherent to the ambulatory surgery center (ASC) process, my practice began to explore the option of opening an OBS suite at our cataract and refractive surgery center in Orlando, Florida. Since then, we have opened an OBS suite at our main facility and another at a satellite location, with a third in the works.

My initial concerns about opening an OBS suite were similar to those expressed by most ophthalmic surgeons who are curious about the practice model. I wanted to know: Is OBS advantageous for our practice? Will patients be comfortable with the paradigm? And above all else, is it safe? Here’s what I’ve learned since branching out into OBS.

Safe and sound

OBS suites are regulated in all 50 states, operate under the physician’s license governed by the individual state board of medicine, and are accredited by The Joint Commission and QUAD A, which are the same national organizations that accredit ASCs and hospitals. These organizations require the same reporting and compliance process for OBS suites that they do for ASCs. Results from the recently published peer-reviewed study Safety of Office-Based Lens Surgery: A U.S. Multicenter Study unequivocally support the safety of ophthalmic OBS. The study evaluated case records of more than 18,000 consecutive patients who underwent office-based lens surgery for visually significant cataract, refractive lens exchange, or phakic IOL implantation at 36 participating US sites. Study results found that office-based lens surgery is as safe or safer than modern lens surgery performed in ASCs or hospital outpatient departments.¹ These findings are consistent with findings from the 2016 Kaiser Permanente study that reported successful outcomes in more than 21,000 cataract cases in the office setting.²

These findings lay the groundwork for the viability and value of OBS to ophthalmic surgeons and our patients. My experience offers a blueprint for the many ways that this model benefits my practice and patients.

Gaining control

I became interested in OBS because I was growing frustrated with many aspects of performing surgery in a multispecialty ASC. It’s no secret that ASCs are deprioritizing ophthalmic surgeries in favor of cardiac and orthopedic procedures. In the ASC, my offered surgical block time was Friday, so we were essentially relegated to Friday mornings. This was insufficient for our surgical volume and inefficient for a growing practice. ASC scheduling and availability was the determining factor that pushed me to explore and ultimately embrace OBS.

We started planning our first OBS suite in 2019 in conjunction with iOR Partners, a company that provides assistance with space build-out, staff training, accreditation, and all aspects of OBS. We opened the center in 2020. Despite launching during one of the most complicated times for the provision of health care—the early days of COVID-19—we quickly began to see that we had made a good choice. I was able to gain control of the entire process, including surgical volume, scheduling, equipment, staffing, and the overall patient experience. We opened our second OBS site in the past year, and we will launch our third later this year.

Patient feedback

My staff and I were quick converts to the OBS model, and once it became clear that patients preferred it, there was no turning back. I perform cataract surgery, refractive lens replacement, and implantable collamer lens procedures in our OBS centers, and these suites are designed to provide a soothing, spa-like experience. Our premium patients tend to have elevated demands and expectations, and we have received a tremendous amount of positive feedback. Many of our patients who had their first eye treated in an ASC and their second eye treated in an OBS suite point out how much better it is to have their surgery performed in a facility they are familiar with, and they appreciate the continuity of being treated by the same staff. What’s more, they say they were relieved to learn that they did not have to fast prior to surgery or that they would not be stuck with an intravenous (IV) needle. For most patients treated in our OBS suites, oral sedation is sufficient. Sometimes we underestimate how the seemingly minor intervention of starting an IV needle can compound what is, for some, an already stressful situation.

OBS 101

The questions we had when considering OBS reflect those had by most ophthalmic surgeons: How long does it take to get up and running? How much space do we need? Are these suites accredited? How does this affect reimbursement? Will we need specially trained staff? Based on my experience, approximately 700 sq ft is sufficient to house a small OBS operating room (OR) and a dedicated preoperative and postoperative area. Each of our OBS suites was up and running within 4 months.

No special staff is needed; iOR trains existing office staff to assist in the OR. This works out well because our employees have grown more invested in their work as they have become involved in all aspects of the process. Also, staffers used to have idle time in the clinic when I was scheduled at the ASC, but now we can keep our staff busy all the time, which is good for morale and the practice’s bottom line. As far as reimbursement, although coding and billing are different from the process associated with ASC reimbursement, we are compensated at approximately the same rate. Billing and coding professionals at iOR are experts at managing this aspect of the process. We also benefit from economies of scale in inventory because iOR works with a vast network of practices across the country and we all share in the savings realized from that.

Conclusion

Lens surgery can be performed just as safely in an OBS suite as in an ASC, according to the literature.¹ Frankly, in my experience, by granting more control over the entire surgical process, an OBS suite makes it even safer. An added bonus to OBS is that it has been a practice builder. I can offer an elevated patient experience and have more OR time available to accommodate my schedule and growing practice.

Michael J. Shumski, MD, MSE

E: DrShumski@Magruderlaservision.com

Shumski. of Magruder Laser Vision in Orlando, Florida, is a shareholder in iOR partners.

References:

1. Kugler LJ, Kapeles M, Durrie DS. Safety of office-based lens surgery: a U.S. multicenter study. J Cataract Refract Surg. Published online June 5, 2023. doi:10.1097/j.jcrs.0000000000001231

2. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-based cataract surgery: population health outcomes study of more than 21 000 cases in the United States. Ophthalmology. 2016;123(4):723-728. doi:10.1016/j.ophtha.2015.12.020