Editor's note: the opinions expressed herein are those of the author and do not necessarily reflect the opinions of Ophthalmology Management, The Ophthalmic ASC, or the Outpatient Ophthalmic Surgery Society (OOSS), nor should they be taken as an endorsement by Ophthalmology Management, The Ophthalmic ASC, or OOSS.

Office-based surgery (OBS) has been a hot topic in the ophthalmic arena for years. However, recent forces—from COVID-19 mandates, increasing demand from baby boomers, a declining number of ophthalmic surgeons, and an impending reduction in Medicare fees paid to physicians—have substantially elevated interest in this surgical model. Couple this with hospital outpatient departments (HOPDs) and multispecialty ambulatory surgery centers (ASCs) that are deprioritizing ophthalmic surgeries in favor of cardiac and orthopedic procedures, and we have a looming capacity crisis for the No. 1 procedure performed in the United States: cataract surgery.

Today, there are at least 115 vision centers in the United States that perform cataract surgeries in office suites. Trends suggest a shift from ASC to OBS as the new normal for cataract surgery over the next 10 years. As the CEO of iOR Partners, an organization dedicated to developing and maintaining ophthalmic office-based surgery suites and leading the OBS movement, I am confident that this model will solve the capacity challenge by bringing surgery into the physician’s office safely and efficiently.

PATIENT SAFETY

The issue of safety invariably arises when OBS is discussed—and it should—because regardless of the setting, patient safety must be paramount. A substantial body of data supports the safety of office-based surgery. Since 2015, more than 40,000 cataract procedures have been safely performed in the office setting. In 2016 Kaiser Permanente published a study on 21,501 cataract cases performed in an office-like setting, with outcomes that were consistent with hospitals or ASCs.¹ Additionally, iOR has been gathering data, with findings from over 18,500 real-world cataract cases that match or exceed safety outcomes in other settings.²

Opponents of OBS claim that cataract patients, due to their age, are likely to have too many comorbidities for the office setting. However, iOR data shows safe and effective outcomes for patients 65 and older. Regardless, the surgeon determines which environment is best for their patient and may take certain cases to the ASC, as needed. What’s more, iOR has early data from 235 cases showing the benefits of OBS for retina surgery, where time to intervention is particularly critical for patient outcomes.² Office-based surgery gives retina surgeons 24-hour access to an operating room, allowing for more timely treatment of emergency cases like retinal detachments.

ACCREDITATION STANDARDS

While cataract surgery was once a hospital-based procedure, today 99 percent of cataract surgeries are performed on an outpatient basis.³ As the transition evolved, accreditation standards were developed specifically for the ASC setting. The same should happen for office-based surgery. Currently, OBS suites are regulated in all 50 states, and operate under the physician’s license governed by the individual state board of medicine using either Class A (oral sedation, such as diazepam) or Class B (monitored) anesthesia. iOR Suites operate at the same safety standards of care and are accredited by the same national organizations as an ASC or hospital. We believe that iOR safety standards should be adopted by OBS facilities nationwide, and are actively pursuing national accreditation standards with the Joint Commission.

CONTROL AND CONVENIENCE

OBS places the entire surgical process under the surgeon’s control. Surgeons are not limited to a block schedule and can perform cases when it’s best for them and their patients. Seeing clinic patients between surgical cases maximizes efficiency. Equipment, supplies, and staff are all surgeon selected. Furthermore, the OBS model grants surgeons flexibility to adapt to external factors. The recently released 2023 Medicare Physician Fee Schedule incudes a reduction in the physician professional fee. While this cut affects all physicians, those with an OBS are better poised to offset the loss, as they receive an additional professional fee in lieu of a facility fee. And as demand increases, the scheduling flexibility allows surgeons to keep up with the case volume instead of building up a backlog.

Patients also benefit when the entire experience is under the surgeon’s control. Cataract patients can have a LASIK-like experience, with all the benefits of a familiar, comfortable environment. Patient anxiety may be reduced, and the overall experience improved when patients are familiar with the staff and facility. Most importantly, OBS expands seniors’ access to eyecare—especially in rural areas where there are no other facilities nearby.

IN CONCLUSION

We can focus on the fact that OBS is safe, that surgeons enjoy the increased efficiency of in-office surgery, and that patients appreciate having their procedure done in the comfort of their doctor’s office to support the need for this option, but the crux of the matter is that we have a cataract surgery capacity problem and ophthalmic OBS represents a safe and effective alternative for the No. 1 procedure in healthcare. ■

REFERENCES

1. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-based cataract surgery: population health outcomes study of more than 21,000 cases in the United States. Ophthalmology. 2016;123(4):723-728. doi:10.1016/j.ophtha.2015.12.020
2. iOR Partners. Safety occurrence data. Accessed December 12, 2022. https://iorpartners.com/knowledge-resources/white-papers-presentations-case-studies/ior-partners-obs-occurrence-data/
3. Dickson R, Eastwood A, Gill P, Melville A, O’Meara S, Sheldon T. Management of cataract. Qual Health Care. 1996;5(3):180-5. doi:10.1136/qshc.5.3.180
4. Wier LM, Steiner CA, Owens PL. Surgeries in hospital-owned outpatient facilities, 2012. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Statistical Brief #188 (February 2015). Accessed December 12, 2022. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-Hospital-OutpatientFacilities-2012.jsp .

JAMES R. WILLIAMS is the president and chief executive officer of iOR Partners, a company in Kansas City, Missouri, that develops and manages office-based surgical suites. He can be reached at info@iorpartners.com.