How expanding sites of service can benefit everyone
Expanding - not disrupting - sites of service broadens access while bringing down overall costs.
As procedures have migrated out of HOPDs and ASCs, so to has anesthesiology. The field of ambulatory anesthesiology has grown alongside and aided the evolution of care delivery. Advances in anesthesiology have allowed providers to expand sites of service for a wider variety of procedures, and have facilitated a growth in patient buy-in by providing safe, comfortable, and convenient care that equals if not exceeds that in a hospital. Recently, we spoke with Dr. BobbieJean Sweitzer about the history of ambulatory anesthesiology and what’s on the horizon.
Dr. BobbieJean Sweitzer is dual trained and boarded in anesthesiology and internal medicine, and is currently Systems Director, Preoperative Medicine at Inova Health in Virginia, and a Professor of Medical Education at the University of Virginia. What’s more, Dr. Sweitzer is immediate past President of the Society for Ambulatory Anesthesia (SAMBA), and a founding member of the Society for Anesthesia and Sleep Medicine.
Dr. Sweitzer shares her insights on a decade of advances in ambulatory anesthesiology, the growth of non-hospital surgical procedures, and the role anesthesia and anesthesiologists play in perioperative care and patient acceptance
Dr. BobbieJean Sweitzer: In the United States, the proportion of surgical procedures performed outside of a hospital setting is now approximately 60%, with a growing number of these procedures being done in office-based settings. It is estimated that 20%-25% of all interventional procedures, including pain management and endoscopies in addition to traditional surgeries, are currently performed in office settings.
There are no formal training requirements for anesthesiologists to practice ambulatory or office-based anesthesia (OBA). However, most training programs expose residents to some ambulatory anesthesia, though this rarely occurs in free-standing centers. I am unaware of any institutions with OBA-specific curricula or practice opportunities for trainees. There are a few ambulatory anesthesia fellowships in the United States. But, the vast majority of “ambulatory” and OBA anesthesiologists have developed their expertise individually. This can lead to variabilities. That said, American Society of Anesthesiology (ASA) and SAMBA offer educational sessions at their annual meetings. SAMBA has sponsored separate OBA meetings, and there is a growing body of scholarly activity to support safe ambulatory anesthesiology practices.
Dr. BobbieJean Sweitzer: Much of what I highlighted in my answers above shows the important initiatives and leadership of anesthesiologists to advance safe care of patients which supports the increasing numbers and complexity of cases done outside of hospitals. The ASA and SAMBA have guidelines, practice advisories and recommendations for both ambulatory and office-based anesthesiology. The existing information is not specific enough. I believe more is needed, and, frankly, many of the procedures offered in ambulatory and OBA settings simply cannot be done without the skills of anesthesiologists. Because we are willing and capable of providing safe anesthesia, our expertise is directly responsible for the growth of care outside of hospitals.
Dr. BobbieJean Sweitzer: Some believe that office-based anesthesia is currently where ambulatory anesthesia was in the 1980s. We are just beginning to explore the possibilities of what procedures and surgeries can be done outside of traditional locations. Some even believe we will be providing anesthesia for some procedures in patients’ homes in the future. As anesthesiologists continue to gain expertise in ambulatory surgicenters they will be skilled to provide care in office settings.
The development of shorter acting and safer drugs, and increasingly compact monitors, infusion pumps and anesthesia machines will allow safe provision of deep sedation or general anesthesia in more remote locations. As CMS approves payments for various procedures, such as cardiac interventions and joint replacements the economic incentives will drive more of these procedures to outpatient settings. Many of these procedures will require regional or general anesthesia, not just a bit of Propofol.
Dr. BobbieJean Sweitzer: The rapid growth in OBA has not been widely accompanied by adherence to the safety standards present in hospital settings or ambulatory surgical facilities. Anesthesiologists can offer consistent care and efficiencies, and assist surgeons to have flexibility in scheduling office-based procedures. Anesthesiologists can provide the same level of safe anesthesia care regardless of the surgery setting. We need to gather data, create standards and guidelines, develop important metrics of quality, and educate ourselves in this emerging specialty. We need to work with federal and state regulatory bodies to develop standards and statues and enforce them.
I think this will go a long way in convincing surgeons, proceduralists and patients to avail themselves of all the advantages of out of hospital care. Anesthesiologists have long been leaders in patient safety, including teaching others how to protect patients. We need to extend these principles to office-based settings.
Dr. BobbieJean Sweitzer: It is vitally important for anesthesiologists to develop criteria for appropriateness of patients for any given setting. The ASA statements on ambulatory surgery and OBA are essentially agnostic to specific procedure and patient selection criteria. SAMBA does have several practice advisories (e.g., on patients with obstructive sleep apnea and diabetes mellitus) that are extremely valuable. I think SAMBA’s recent practice advisory on the Preoperative Care for Cataract Surgery is a great step in this direction.
I think the ASA and SAMBA can assist by developing more specific and granular guidelines and recommendations. Anesthesiologists must develop methods to obtain information from patients and not simply rely on surgeons to evaluate patients. Anesthesiologists need to understand the implications of acute and chronic medical conditions such as Covid infections, heart failure, chronic kidney disease, ischemic heart disease, and frailty on the risk of anesthesia and surgeries. Anesthesiologists need to be involved in developing and critically examining the resources available to care for specific patients with specific comorbidities and specific procedures and especially the interaction of the risks, and hold the line on appropriateness of offering care. Resources I speak of include the facility design, the number of staff, the training and skills of the personnel, the available medications and equipment, and the ability to “rescue” from adverse events. Anesthesiologists should participate in continuous quality improvement and risk management activities.
Dr. BobbieJean Sweitzer: I think patients generally do what their physicians suggest. In fact, patients may trust the advice of their physicians a bit too much. Patients like convenience. Procedures that are not covered by insurance but paid “out of pocket” by patients can be cheaper in ambulatory and office settings. Patients find these lower costs very favorable. In fact, patients may not be asking enough questions or seeking enough information about who is providing anesthesia; what training do the staff in the setting have to deal with basic airway management and emergencies; will there be a dedicated trained provider delivering anesthesia; what monitoring will be used during the anesthesia; what will happen during immediate recovery?
These are just a few examples of vitally important information that patients, in a shared decision model, should be seeking. I have long found it baffling that patients will research a restaurant choice in much more detail than their healthcare choices. I think much of this is due to their “trusting us,” and difficulties in actually obtaining useful information. At the recent ASA annual meeting, I proposed “direct-to-consumer” outreach to educate patients on the value of safe anesthesia care in all care settings, but specifically in offices. I think patients take for granted that the healthcare providers are trained and skilled to provide the level of care that is being offered and patients are consenting to. I think they are used to having procedures in hospitals where this is generally the case. And, when it’s is not it’s because regulations have not been adhered to. It is not because there are NO regulations to begin with, or if there are the oversight is much less than what occurs in hospitals.
Expanding - not disrupting - sites of service broadens access while bringing down overall costs.
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