Many medical procedures are moving from the operating room to the doctor’s office, and a Forum held Oct. 9 at the Simches Research Center at Massachusetts General Hospital provided full and illuminating discussion of the significant trend.

Four speakers presented on a variety of topics, including “Office-based gynecologic procedures,” “Office-based anesthesia,” “Technology implications of office-based anesthesia safety,” and “Regional anesthesia in the office-based setting.”

Keith Isaacson, MD, medical director of the Minimally Invasive Gynecological Surgery Unit at Newton Wellesley Hospital, and CIMIT site miner at that institution, said that many gynecologists are moving toward office procedures because the net rate of reimbursement is greater.

He said that the federal Center for Medicare and Medicaid Services (CMS) is “directing” doctors to office procedures because that venue is less expensive than an OR. But there is less regulation in such facilities, and he warned that office-based medicine could become “the wild West of medicine” if it is continues to develop with a minimum of oversight.

Fred Shapiro, DO, who is with the Department of Anesthesiology, Critical Care and Pain Medicine Unit of Beth Israel Deaconess Medical Center, said that the use of anesthesia in an office setting is increasing rapidly because in the past 10 years, the number of office-based procedures has grown from 5 to 10 million cases. He noted that only 22 states have any regulations regarding office-based anesthesia, and he said that patient care could be compromised if medical professionals are not vigilant.

Beverly Philip, MD, director of the Day Surgery Unit at Brigham and Women’s Hospital, said there are both opportunities and challenges associated with OBA. She said that doctors must choose their patients carefully, and train in emergency procedures should an incident occur. She said that office-based medical personnel must excel in information management so that appropriate patients are chosen, and adequate data is available should doctors need it. Dr. Philip concurred that reimbursement is significant for those who practice outside of an operating room.

Lisa Warren, MD, director of ambulatory anesthesia at MGH’s Department of Anesthesia and Critical Care, said that regional anesthesia could be better utilized by those who use the office setting. Noting that about 25 percent of all elective surgery procedures in the U.S. are done in the office now, she suggested that doctors consider greater use of regional procedures.

Many office-based procedures require significant anesthesia, which can be risky if not administered properly, and a number of patients have died during surgery from cardiac arrest or malignant hyperthermia.  Many of the victims were healthy people undergoing elective, often cosmetic, procedures.   

Anesthesia in the office is often referred to as the “Wild West of Healthcare” because office-based procedures are sometimes performed without needed safety equipment and because they are poorly regulated.  Ten million office-based procedures were performed in the U.S. in 2005, and four out of five cosmetic procedures are done in the office.  One recent study found that 46 % of the deaths that have occurred during office-based surgery could have been prevented.  Many offices need better monitoring and alarm systems and better equipment, but unfortunately, office-based procedures are not regulated in 28 states. 

Many states and professional associations are attempting to use accreditation as a means of ensuring that office-based procedures are performed safely.  Although there is some controversy, certain studies have suggested that procedures not involving general anesthesia performed in accredited facilities are as safe as similar procedures performed in the hospital.  Researchers are currently attempting to create new anesthetics designed specifically for the office.  Dexmedetomidine is a new anesthetic that seems to work effectively for surgeries involving the face.    

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