What opportunities do office-based procedures present in urology?

a urologist discusses office-based procedures options with his patient

Where are you performing your urology procedures? Whereas once the hospital and the ASC were the only venues available, urologists today have more options depending on the acuity of the case.

As detailed in a 2020 Mayo Clinic article, more physicians routinely perform procedures such as cystoscopies, hydrocelectomies, and vasectomies in their own office and clinic setting. Although urologists have performed some procedures safely and comfortably with local anesthesia, many are learning about options to perform more invasive procedures under general anesthesia in their office and clinic. Office-based general anesthesia has a myriad of benefits.

Physicians enjoyed increased control of their day and a better reimbursement structure with office-based procedures versus performing procedures in a hospital or ambulatory surgery center (ASC). Those who routinely perform procedures in the office are also often able to perform more procedures in a day, which stands to expand their bottom line. And, their patients can see decreased out-of-pocket costs coupled with the convenience and comfort of having a procedure performed in their own physician’s office or clinic.

Procedures moving into the office

Placement of the SpaceOAR Hydrogel System is increasingly being performed in urology office. This small device temporarily creates space between the prostate and rectum and provides protection of the rectum, urinary and bowel function, and sexual health, reports manufacturer Boston Scientific. This is inserted using an 18-guage needle through the skin of the perineum.

Another in-office urology procedure that is becoming more common is UroLift. In this procedure, men who are suffering from benign prostatic hyperplasia, have a small catheter inserted in the urethra that allows the physician to access and expand the effected area of the urethra with the placement of implants through the prostate.

These procedures are quite different in execution and function, but what they do have in common – at least in a plurality of physician’s offices – is that they’re not performed under general anesthesia because the urologists, and the patients, do not know that office-based general anesthesia is an option. As urologists are decidedly not anesthesiologists and thus not qualified to administer anesthesia or monitor the patient while under, many resort to perform these procedures with a long-acting sedative, such as Valium, and either a topical or local anesthetic. Patients generally do not tolerate these more invasive procedures well under Valium and local anesthesia.

Blocking pain

While it is hard to deny the benefits of office-based procedures across a variety of specialties, anesthesia care proves a weak spot for many physicians and practices. Working under the assumption that anesthesia care is not an option, they work with the tools they have available.

Valium is a common anxiolytic and sedative used to treat a range of symptoms and illnesses. As pointed out by the Review of Ophthalmology, Valium, generically known as diazepam, depresses respiratory function and lowers the patient’s pain threshold in addition to providing sedation. The drawback is that its effects can sometimes last as long as 12 hours. Patients treated with Valium may need to convalesce for hours in a physician’s office before they can be escorted home, where they likely will remain under for several more hours.

To block pain and discomfort that procedures cause, urologists turn to local anesthetics, such as lidocaine or bupivacaine. Both provide relief from pain with lidocaine often applied directly to the skin for fast-numbing and bupivacaine applied or injected for longer procedures where numbness is required for an increased duration. The problem here lies not with the efficacy of these drugs, but the urgency the physician has to start the procedure. No one wants a procedure to begin before pain is as thoroughly blocked as is possible (but most of the time they start anyway).

Turnkey solutions

Physicians strive to do no harm, primum non nocere. But that is only possible within the context of the tools they are limited to, or think they are limited to. Some might think general anesthesia is not an option for their practice. They may see it as reserved for hospitals and ASCs, where anesthesiologists, the drugs they use, and the equipment they require are based. The thought of investing in expensive anestheisa equipment, licensing, and the requisite drugs as well as paying for an anesthesia provider, would admittedly be too much for many smaller practices to bear. So, they, and their patients, do without.

Office-based anesthesia practices, such as Dallas-based Noble Anesthesia Partners, offer physicians across a spectrum of specialties a broader range of anesthesia options…and more. Just as office-based procedures are growing in popularity, so too are services that bring not just the anesthesia provider, but peri-operative nursing staff, monitors, equipment, and drugs, directly to the physician’s office or clinic. Many of these ambulatory anesthesia providers will even prepare the procedure room and provide surrounding perioperative care, freeing the physician to concentrate on the procedure, handle paperwork or cases, and move more quickly to the day’s next procedure.

These are turnkey anesthesia and perioperative solutions for office-based surgery that essentially, bring the OR to a physician’s office often with outcomes that meet or exceed those in facility settings, and provide the best possible experience to patients and providers alike. Many ambulatory anesthesia services will send in-network claims directly to insurance companies and require no start-up cost or ongoing anesthesia expense as would be required to create an anesthesia service in-house.

From the perspective of payers and patients, moving procedures, including some of those requiring general anesthesia, into the office often makes the most sense. Increasingly, payers are lowering or altogether eliminating reimbursements for procedures performed in ASCs that could be performed in-office. That increased expense is generally passed on to patients in the form of higher out-of-pocket costs. And physicians who are investors in an ASC see no benefit from performing procedures there under this model, but can garner a more equitable fee if they move the same procedure into their practice.

Quadruple aim

As the awareness of the safety, convenience, and comfort provided by moving certain procedures into the office space grows – and as payers and the government increasingly incentivize this – it becomes necessary for physicians of all specialties to avail themselves of tools and services that advance their practice and improve the patient experience. Further, in-office procedures stand to be a cornerstone of the sought-after quadruple aim, which seeks to ensure healthcare is affordable, accessible, effective, and provides a better experience for patient and provider.

Ambulatory anesthesia providers help practices of all sizes increase throughput and efficiency for urology procedures within their walls, many offering wrap-around perioperative care and billing solutions that allow physicians to get back to what they’re passionate about.

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