The ASC Insider

Adding Vitreoretinal Surgery to an ASC

A special series sponsored by Alcon

By Pravin U. Dugel, MD

Adding vitreoretinal surgery to a general ophthalmology ASC was originally very cost ineffective. With new vitreoretinal techniques and equipment, vitreoretinal surgeons have become more efficient. Efficiency in medicine is the safe execution of a task using the least amount of effort necessary. In surgery, the primary concern is always safety.

I believe vitreoretinal surgery is more efficient than ever before, partly because the emphasis is on safety, not speed.

The world in general, and medicine in par ticular, is becoming more specialized. We've evolved from ENTs, to ophthalmologists, to retina specialists. Now, even within retina, there are multiple subspecialties. When you specialize, you see the same conditions repeatedly. Thus, you become more of an expert at diagnosing and treating those conditions.

If it makes sense for a surgeon to become more specialized and deliver better care for a specific group of diseases, doesn't it also make sense for a facility to become more specialized as well? Of course, so it's not surprising that there's a trend to move procedures away from hospitals where multiple types of surgeries are performed and into specialized surgery centers.

A Specialized Staff

Specializing allows you to operate with a highly experienced staff. We're very dependent on our staff to help us ensure every patient is safe and well cared for while in our ASC. It's nice to have a staff member who's with a patient from the time he enters the ASC until he leaves. Our staff members are experts in ophthalmology, specifically retina.

Because the staff has specialized knowledge, our patients know exactly what to expect, they're treated the way we want them to be treated and patients and their families can get answers to their questions and concerns easily and quickly. This isn't always possible in a hospital setting. Because our staff is focused on practicing ophthalmology — specifically retina, there's no "A" team, "B" team, or "C" team. Everyone is an "A" team member because that's what he has been trained for — all members of our OR staff are top-notch. In many of the hospitals I've worked in, there was one group of people you hoped to have in your OR because they were the only ones interested or experienced in retina. In an ASC, we don't have to worry about working with a "B" team.

For nurses and scrub techs, it's difficult to cross over to retina from plastics or orthopedics unless the staff members have been specifically trained to assist in retina. In an ASC, every member is trained in your specialty, so they're better equipped to provide the support that you need.

What general ophthalmologists must recognize is that adding retina to an ASC isn't like adding glaucoma or any other subspecialty. It's a large and costly investment. There's a considerable risk-reward scenario associated with it. In order to have one room up and running for retina, your costs may run as high as $500,000.

Instruments Improve Efficiency

From a physician's perspective, I have access to all of the best equipment. For example, I work with the CONSTELLATION® vision system (Alcon), which is designed to be user-friendly and efficient. The system provides feedback on whether or not you've properly connec ted the machine with a series of flashing lights. It also provides two different types of training — one walks you through the tasks; the other allows users to pause the tutorial and execute the task before moving on.

Because the CONSTELLATION system provides training, nurses and scrub techs well trained in cataract surgery can go through the system's set up and receive instantaneous feedback. With these intuitive machines, more people can be trained to assist in retina surgery.

The machine also provides the surgeon with more control than was ever possible in the past. If, for instance, we do air-fluid exchange, where we convert from BSS to air, we don't need a technician to convert from a fluid-filled eye to an air-filled eye. We have a foot pedal, so it's up to the surgeon to decide when to switch to air. The scrub tech isn't involved at all.

Additionally, with diathermy, if it's too hot, the retina can burn. The CONSTELLATION system has a proportional diathermy feature. The surgeon not only has control, but he can titrate the intensity of the parameters under these controls. This provides increased accuracy and the scrub tech doesn't have to be as highly skilled or experienced. This adds another level of safety and decreases dependence on staff.

The bottom line is that the machines themselves make for a more user�friendly and efficient environment, allowing for a faster turnover and the need for only one scrub tech. All of these benefits support moving retina procedures to an ASC setting.

Reimbursements and Smaller Incisions

Reimbursements for retina are favorable at this time, because the government can save money by having retina surgeries performed in ASCs rather than in the in-patient unit of hospitals. ASCs are actually part of the solution for healthcare reform. It's a perfect storm. On one hand, our surgical techniques are better and procedures are more conducive to being performed in ASCs. On the other hand, because the government wants us moving in that direction, they've increased our ASC reimbursements.

Coupled with this is the fact that we're undergoing a bit of a revolution in retina surgery because we've moved away from using sutures and 20-g surgery to using smaller gauges, in particular 23-g and 25-g, and the 25+ gauge™, which is sutureless. Thus, I believe our efficiency and, in turn, our outcomes are much better.

What to Look For in a Colleague

For a general ophthalmologist considering adding retina to his ASC, first ensure that you understand all facets of smaller gauge vitreoretinal surgery and the benefits of retina reimbursements in the global landscape.

The next step, and really the key step, is to find a surgeon who is like-minded and enthusiastic about performing surgery in an ASC. You need to ask yourself, "Is this partner a retina surgeon who is willing to place an importance on efficiency in an ASC?"

Having said that, there are some very good retina surgeons who prefer working in an in-patient hospital using 20-g surgery. They may not be amenable to an ASC setting. It depends on the region and the person. If you can't find someone who embraces new technology, and efficiency in an ASC, then it's best not to have retina in your ASC right now. Retina isn't something you can do half way — it's either a very good investment or a very bad one.

Adding retina is surgeon-dependent. The ideal candidate is a skilled retina surgeon, who also understands the value of being efficient. He should also be open to working with newer equipment and procedures.

Over the next few years, there will be fewer and fewer surgeons performing 20-g surgery in a hospital setting. I think there's a trend toward doing the newer microincisional surgery in an ASC setting and this has a growing appeal among newer surgeons. The transition is taking place now.

If you can't find a good partner now, you should wait — you don't want to rush one of the biggest decisions of your professional career. Not only will you be less likely to be disappointed by waiting, but you may very likely find that in the next few years you'll have a greater number of surgeons to choose from.

Pravin U. Dugel, MD, is managing partner, Retinal Consultants of Arizona, Phoenix, and founding partner, Spectra Eye Institute, Sun City, Ariz. Dr. Dugel is also Clinical Associate Professor of Ophthalmology, Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles.