In this episode of Interventional Mindset, Preeya K. Gupta, MD, and Jonathan D. Solomon, MD, explore the benefits and nuances of in-office ophthalmic surgery.
Currently, the majority of cataract surgeries are outpatient procedures, suggesting the potential to shift the treatment paradigm for uncomplicated cataract surgeries from an ambulatory surgery center (ASC) to an office-based setting.1
Drs. Solomon and Gupta discuss their experiences with transitioning to office-based ophthalmic surgery and pearls for clinicians interested in being at the forefront of medical advancements and patient care.
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Improving access to ophthalmic surgery with office-based procedures
Dr. Solomon’s decision to transition to office-based ophthalmic surgery stemmed from obstacles he experienced relying on ASCs, especially as his practice grew across state lines (i.e., requiring accommodations for states with certificate of need [CON] laws) and demanded greater surgical volume.
In contrast, after leaving an academic center, Dr. Gupta remarked that the impetus to transition to an in-office model for ophthalmic surgery was to fill open time in the clinic and offer a tailored experience for her patients, specifically for refractive and cataract surgery patients.
She emphasized that not all patients may be a good fit for office-based cataract surgery, so having access to both ASC and in-office facilities can be beneficial to ensure that patients with different needs receive appropriate treatment.
Office-based cataract surgery can help doctors:
- With a need for more operating room (OR) time or flexibility in scheduling due to a rapidly growing patient base
- Navigating different requirements between CON state laws
- Interested in controlling the entire surgical process to tailor and optimize the patient experience
Key considerations for office-based cataract surgery
Drs. Gupta and Solomon highlighted four key elements to factor into deliberations around integrating office-based ophthalmic surgery into a clinical practice setting:
- Patient base
- Insurance reimbursement
- Office space and staff training
- Accreditation
1. Patient base
When considering whether adopting office-based cataract surgery is a practical next step for your ophthalmology practice, Dr. Solomon recommended first examining the patient base.
Practices in which a significant portion of the surgical volume centers around refractive lens-based procedures, such as phakic intraocular lens (IOL) implantations, refractive lens exchange (RLE), and clear lens extraction, are likely strong candidates for office-based surgery.
This patient population has optimal candidates for refractive cataract surgery performed in the office itself, he added, because they are individuals who have shown an interest in self-pay procedures and are not necessarily relying on a third-party payer.
2. Insurance reimbursement
A notable issue clinicians tend to face in this process relates to insurance reimbursement. Dr. Solomon noted that doctors can partner with companies like iOR Partners that offer consultation, development, and management tools to provide billing assistance and perform insurance pre-authorization.
However, there are many different approaches to office-based ophthalmic surgery, explained Dr. Gupta. Clinicians would benefit from comparing what different pathways and partnerships can be offered in regard to charging for procedures and reimbursement, such as facility fees (which Medicare only covers for surgery done in hospital- or ASC-based surgeries),2 surgeon fees, out-of-network (OON) costs, and self-pay elective procedures.
Particularly in regard to the payer landscape, with time and broader adoption, she expressed hope for more standardization and regulations that clinicians can use as guidance when building out their in-office ORs to get the appropriate facility and surgeon fees.
3. Office space and staff training
At Dr. Gupta’s practice, they predominantly perform refractive and refractive cataract procedures. Consequently, she considered which specific equipment she needed in the surgical suite during the procedure to determine the opportunity and return on investment (ROI) cost of using that space for office-based surgeries.
She noted that office-based ORs can transition to a multifunctional space on days with no office-based surgeries with minimal changes. It could be repurposed for oculoplastic cosmetic procedures, for example.
Dr. Solomon discussed how cross-training laser surgery staff to assist with office-based cataract surgery was a critical component to succeeding with office-based surgeries as there is a common skill set. Additionally, transitioning to an in-office model helped to create a continuity of care for the staff and develop a sense of responsibility for patients as they handled their cases from pre- to post-op.
4. Accreditation
It is essential to understand the added responsibility that comes with managing and maintaining an in-office OR, expressed Dr. Gupta. In an ASC, surgeons can walk in, perform the procedure, and walk out because there is less personal responsibility in operating the facility.
She added that her office is certified by The Joint Commission, meaning the practice adheres to the rules, regulations, and documentation required by this accrediting body. There are other certification organizations that doctors can rely on, but it is not an insignificant task to take on in addition to managing a practice and treating patients.
Of note, office-based surgical suites have different accreditation criteria,1 but are accredited by the same national organizations as ASCs and hospitals, including:3
- The Joint Commission
- Accreditation Association for Ambulatory Health Care (AAAHC)
- Accreditation Commission for Health Care (ACHC)
- Quad A
Seeking approval from healthcare organizations like The Joint Commission helped Dr. Gupta to establish a level of credibility and trustworthiness in their attention to safety protocols along with enhanced quality of patient care. Further, most insurances require that practices have one of four different types of certifications, making it a necessary step in the process for her.
Studies comparing the safety of office-based and ASC ophthalmic surgeries
For clinicians with safety concerns around in-office cataract surgery, recent studies have demonstrated their efficacy and safety.
A 2023 study analyzed the case records of 18,005 cases of office-based cataract or refractive lens surgery performed across 36 clinical sites.4 The rates of post-operative endophthalmitis, toxic anterior segment syndrome (TASS), and corneal edema were 0.028%, 0.022%, and 0.027%, respectively.
Further, unplanned anterior vitrectomy was performed on 0.177% of patients, and while 0.067% of patients needed to return to the OR, 0.011% were referred to a hospital. Investigators reported that the events for office-based cataract or refractive lens surgery were similar to or less than the reported adverse event rate for cataract surgery performed in an ASC.4
In addition, a 2016 study of 21,501 eyes that underwent phacoemulsification demonstrated the safety and efficacy of office-based cataract surgeries performed in minor procedure rooms.5 The study authors reported no cases of endophthalmitis, and there were no life- or vision-threatening intra- or peri-operative adverse events.
Intra-operative ocular adverse events included 119 (0.55%) cases of capsular tear and 73 (0.34%) cases of vitreous loss. Post-operative adverse events included iritis (1.53%), corneal edema (0.53%), and retinal tear or detachment (0.14%).
The research team found that “office-based efficacy outcomes were consistently excellent, with a safety profile expected of minimally invasive cataract procedures performed in ASCs with hospital outpatient departments.”5
Conclusion
Dr. Solomon noted that he has learned a lot from moving from an ASC to an office-based surgery model in regard to specific standards, such as shifting the modality for administering anesthesia during cataract surgery. With this new understanding, he can share this information with colleagues to adapt and improve old protocols—the cornerstone of disruptive technology.
To close the discussion, Dr. Gupta emphasized that clinicians interested in pursuing office-based ophthalmic surgery should “do their homework” to know who can help in the process to learn about the necessary certifications for staff and the practice, assess the potential patient population and volume, and ultimately determine whether it is a viable model for their practice setting.
While a learning curve exists, it is exciting to be at the forefront of medical innovation.
