Q&A: Data show safety of in-office ophthalmic surgery
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Office-based surgery is a controversial topic among the ophthalmic community, with some ophthalmologists considering it a feasible option for their practice and investing in office-based suites.
In 2016, the Kaiser Permanente Study of Office-based Cataract Surgery reported positive results for visual outcomes and low rates of adverse events after office-based cataract surgery. There are now data on more than 40,000 procedures performed in the office-based surgery (OBS) setting with outcomes that are comparable or superior to those performed in the ambulatory surgery center.
Daniel S. Durrie, MD, chairman of iOR Partners, and his colleagues have collected safety data across 37 individual centers to support OBS as a viable option for ophthalmic surgeons.
Durrie, OSN Refractive Surgery Editor Emeritus, spoke with Healio/OSN about the most significant findings of the iOR office-based surgery occurrence data and what it may suggest for the future of office-based ophthalmic surgery.
Healio/OSN: Why are the iOR OBS safety occurrence data significant right now?
Durrie: CMS has been evaluating moving of ophthalmic surgery to the office for more than 10 years and it has been looking for input from the ophthalmic community on whether this is safe and effective and something that it should pursue. In 2015, Kaiser published a paper on more than 21,000 cases that were performed in an OBS setting in its facility, and that got everybody’s attention because the results were good.
In 2016, CMS requested information from the ophthalmic community on OBS, and many replies highlighted the need for more safety data. So, what we have collected is, outside of Kaiser, the first large data set that showed it was not only safe, but as safe or better than anything that has been published. This is important now because CMS came out with its 2023 Medicare Physician Fee Schedule Proposed Rule, which included cataract, glaucoma and retina codes to reimburse for office-based surgery, and it is requesting comments through Sept. 6.
Healio/OSN: How do the iOR OBS safety occurrence data build on the findings of the Kaiser study?
Durrie: I was impressed with the Kaiser data when it came out in 2016, but it was not real-world data, as it was done within Kaiser facilities. So, I was interested in how this related to multiple centers out in the real world. What is unique about this new data set is that it includes 37 individual centers; different practices using different techniques. It represents more of what the ophthalmic community could expect if practitioners did quality surgery within their office.
Healio/OSN: What are some of the most significant findings included in the iOR OBS safety occurrence data?
Durrie: In 18,539 procedures performed in iOR facilities, the safety profile is consistently as good or better as those in the Kaiser study and published literature. The endophthalmitis rate, which we all want to have as low as possible, was 0.027%, and the unplanned vitrectomy rate was 0.162%. Those are the data points that I have always used to evaluate surgery and how we evaluate fellows and residents on the success of their surgery. If you look at those two data points compared with the published literature, the two data points are comparable with the high-quality studies.
Return to the operating room was 0.054%. Some of these were for residual cortex removal, referred to retina (0.07%) and TASS (0.02%). This and other factors made me comfortable with the safety level across multiple centers.
When we carved out the Medicare population and looked at patients aged 65 years or older, the safety data in all seven categories are just as good in the older patients as it is in the younger patients.
Healio/OSN: Why are so many retinal procedures still performed in hospitals?
Durrie: One thing that a lot of people do not realize is that retinal procedures have not moved into ASCs like anterior segment procedures have, and 80% of all retinal procedures in the U.S. are still done in the hospital. What that has created for not only retinal surgeons, but the anterior segment surgeons, is difficulty getting access to the operating room for emergency cases.
What we have seen with the retinal colleagues who have moved their surgery to the office is that they can get patients with emergencies, like endophthalmitis, dropped nucleus or macula on detachments, into the operating room within hours, and we know that is going to give better results.
It is unfortunate that this has been an ongoing problem for retina surgeons and patients for years. Now, retinal surgeons have the option to move to accredited, fully equipped surgery centers within their office, giving them 24/7 access to an operating room. In talking to the retinal surgeons who have moved to the office, they could not be more excited about this. They have access to the operating room with the right equipment and trained personnel anytime they want, and it certainly seems to suggest that this will lead to potentially better outcomes for emergency cases.
Healio/OSN: How are the iOR OBS survey data on patient experiences with anesthesia relevant to the rest of the data?
Durrie: A separate survey included 32 centers with more than 11,000 cases and found that most surgeons are using topical and local anesthesia, and they report dramatically improved results on the patient satisfaction questionnaire. The centers that I have worked with can either do IV sedation with a standby nurse anesthetist or anesthesiologist or they can do light oral/topical sedation. One of the important things in these data are that surgeons and patients have the choice to do either.
Not only is this better for our oldest patients who need somebody on their arm and ambulating, but it is also better for diabetics because they can take their insulin and their meals the morning of surgery. This is the first large data set showing the options for anesthesia, and 95% of the doctors chose to use oral/topical anesthesia, which patients prefer, and this also saves money for the health care system.
Healio/OSN: How do you see these data contributing to the future of in-office ophthalmic surgery?
Durrie: CMS has reviewed the safety data and made the decision to put it into the proposed rule. The comment period goes on until Sept. 6, and many people have already commented on this topic. What I think will happen in the future is this will perpetuate through the entire health care system, as OBS is broader than just ophthalmology. Right now, there are procedures moving from the hospital to the ASC, and in multiple specialties, there are procedures moving from the ASC to the office. This will absolutely not threaten or change ophthalmic ASCs, as these have been one of the best things to happen to our patients and will continue to be, but there is a shortage of operating room space that is projected with the increased number of ophthalmic procedures that are going to be done in the next 10 years. And we are still retiring more ophthalmologists than we are graduating, so there is a need to provide more access to care for our seniors. This is just another option for physicians and practices to expand the services to our patients.
For more information:
Daniel Durrie, MD, can be reached at email: ddurrie@iorpartners.com.
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