Challenges and opportunities in office-based medicine

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.

Regional anesthesia is widely used in ambulatory care but is rarely used in office settings.  It usually results in fewer complications and in quicker patient discharges, but because it can be difficult to administer safely, it seems destined to remain a technique used in the hospital and not in the office.  

Of the different types of regional anesthesia, distal blockades, which can be used to numb the upper or lower extremities, would be the easiest to perform in an office.  Spinal and epidural blockades cause more nausea and sometimes cause life-threatening hemodynamic instability.

The risks of regional anesthesia should not be downplayed.  It can cause bleeding, infection, nerve damage, and local toxicity, which can be fatal.  Office practitioners have also hesitated to use the technique because they are uncomfortable sending a patient home with an insensate limb, which could be injured if not minded properly.

Recent advances have made regional anesthesia safer.  Ultrasound machines now allows doctors to guide anesthesia needles more precisely than in the past.  Biomarkers, such as epinephrine, help them avoid injecting drugs into blood vessels.  Single-enantiomer drugs are replacing racemic mixtures, and these new drugs appear to be safer.  In the past, a patient experiencing toxicity and cardiac arrest was put immediately on a bypass machine, but now, in some cases, a lipid emulsion can be used to help reverse the toxicity.  Despite these advances, the skill and the potentially serious consequences of regional anesthesia preclude its widespread adoption in the office, at least for now.

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