Trend to Watch: The Rise of Office-Based Surgery

As more data emerges, expect cases to migrate.

One way to understand the current landscape of office-based surgery is to think back to a time when both patients and payers were unsure about what ASCs could do.

While plenty of providers knew certain cases could be done safely and efficiently in an ASC, it took a little while for the data to catch up and back up those assertions.

That seems to be where we’re at with office-based surgery. “I anticipate that the number of office-based procedures will increase and this type of care will become more common among patients as more robust data about positive outcomes becomes available,” says Linda Cendales, MD, a hand and transplant surgeon, and a professor of surgery for Duke Health in Durham, N.C. “The more data that becomes available, the more likely it is that the number of procedures and the types of procedures will also increase.”

Provider, patient perspectives

That’s not to say that office-based surgery isn’t already experiencing a surge among certain service lines. Specialties like ENT, ophthalmology, dermatology, certain GYN cases and Dr. Cendales own specialty, hand surgery, are regularly performed in an office-setting for a variety of reasons. Generally, the two most common denominators of office-based procedures are time and health. “The procedures are shorter, and the patients undergoing office-based procedures are healthier than those who go to the OR,” says Dr. Cendales. From the patient’s perspective, the convenience of office-based care is often the major selling point. In fact, in extremely mild cases, patients can bring themselves to the office, get evaluated and have a procedure done on the same day, finding themselves home within a couple of hours. “The surgery can be done on the same day as the evaluation,” says Dr. Cendales. “This not only benefits local patients but also patients who come from out of town because the scheduling is faster, more efficient and flexible.” Careful, discerning patient selection, a critical component of outpatient surgery of any type, is absolutely imperative when it comes to office-based procedures.

I anticipate that the number of office-based procedures will increase and this type of care will become more common among patients as more robust data about positive outcomes becomes available.
Linda Cendales, MD

For the surgeons and the facility leaders, “less is more” is the general sentiment regarding office-based care. The pros include the reductions that office-based procedures afford providers. “There’s less overhead, fewer staff and typically anesthesiologists and anesthesia providers aren’t available for every procedure in an office-based setting,” says Dr. Cendales. However, although the hand cases in her clinic — procedures that include carpal tunnel and trigger finger release procedures, superficial soft tissue mass removals and nailbed injuries, among others — are all performed under wide-awake local anesthesia. Dr. Cendales does point out that there are certain specialties that have contracts with anesthesiology providers for office-based cases.

What we’ve seen

While the majority of our coverage centers on outpatient ASCs and HOPDs, we’ve made sure to keep tabs on the procedures that are increasingly making their way into the office-based landscape. Some of those procedures that Outpatient Surgery Magazine has chronicled in recent years include:

• Balloon sinuplasty is a minimally invasive procedure that treats sinusitis by widening the sinus cavity. Local or topical treatments greatly minimizes patient discomfort, so general anesthesia is not required. A septoplasty balloon for correcting deviated septums has been manufactured for use as an alternative to the traditional surgery that requires an incision.

• Urolift is an intervention used to treat benign prostatic hyperplasia, a common condition for men in their 50s and older. Oral or conscious sedation using nitrous oxide and/or a local anesthetic is used before a rigid cystoscope gains access to the prostate. Then polypropylene sutures are implanted to separate the gland’s two enlarged lobes.

• Some hand surgeries are office-appropriate, such as carpal tunnel release cases that surgeons like Dr. Cendales perform regularly, volar wrist ganglion and others that don’t cause significant bleeding or require metal implants. Advances in “wide-awake anesthesia” have proven effective, inexpensive and popular with patients in some settings, which has hastened this office migration.

Office-based surgical facilities, which must follow the safety standards of ASCs and hospitals and are regulated in all 50 states, were even highlighted in a release by the Joint Commission earlier this year. The accrediting agency offered guidance for office-based procedures as part of its 2023 patient-safety goals, including tips on medication safety, infection prevention, properly identifying patients, site-marking and time outs. You can view the complete release here: osmag.net/safetygoals.

What lies ahead?

For surgical leaders of ASCs and HOPDs, there’s also the question of competition. For decades, ASCs have worked tirelessly to prove to patients and payers alike that they can provide the safest, most efficient care. Will the expansion of office-based surgery cut into the ASC market? Not necessarily — at least not in theory.

Proponents of office-based surgery say the move works in concert with the inpatient-to-HOPD and ASC migration. Just as procedures at outpatient surgery centers freed up hospitals to perform the complex procedures they do best, performing some procedures in offices, when appropriate, will give practices that operate busy ASCs the increased flexibility and relief from staffing pressures that they need.

In the meantime, the natural migration of some procedures to physicians’ office settings will likely continue to increase over time, just as many surgeries have shifted over the last few decades from hospitals to ASCs. Technological advances in surgical instruments, imaging systems, diagnostic devices, anesthesia and pain control will pave the way for the relocations. Improvements in these areas will make it easier for patients to avoid traveling to other locations for pre-procedure tests before heading to their doctor’s office for the actual procedures.

Reimbursements from payers are likely to grow — and regulations should relax — as the data emerges and practices can show the office locales are safe settings, and patients’ preference for avoiding hospital settings doesn’t seem to be slipping post-pandemic. Until then, however, office-based surgery growth is a trend worth monitoring. OSM