As office-based surgery (OBS) becomes an increasingly common choice for refractive cataract practices, the next-level autonomy and elevated patient experience tend to spark the interest of more surgeons. But they still have questions: Is OBS just as safe as an ASC? What are the advantages? And how does one actually go about adding a cataract surgery suite to their office?
We talked to three ophthalmologists who have made the transition. Here, they share why they chose OBS, how it’s changed cataract surgery for their patients and themselves, and how iOR Partners helped make it happen.
The Highest Safety Standards
OBS is performed in a full OR with accreditation standards, protocols, and sterility as you would find at an ASC. “My first concern was safety,” says Lance Kugler, MD, who offers OBS at Kugler Vision in Omaha, Nebraska. “I thought surgery would happen in a clean room or a procedure room, but when I learned it was a complete accredited OR that we can build to be as safe or safer than an ASC, I began to feel very comfortable with the idea. Now safety is something we feel really good about—I feel safer operating in our practice than I do at an ASC.”
In a 2016 Kaiser group study that compared 21,000 office-based cataract procedures to comparable ASC procedures, patients with ophthalmic OBS actually fared better than those who had surgery at an ASC.1 Rates were lower for endophthalmitis (none vs. 0.012-1.3%), retinal detachment (0.14% vs. 0.26-0.27%), and vitreous loss (0.3% vs. 3.5%). Adverse events were negligible for both. Later data from iOR Partners reinforced these findings with even lower rates of adverse events in more than 5,000 OBS cataract procedures.
“I think there’s a misconception of what in-office surgical suites are all about—it’s not like we open a closet, pull out a phaco machine and a scope, and start doing surgery! A lot of planning goes into setting up an iOR surgery suite. We followed many of the same safety standards seen in a hospital OR or ASC,” explains Inder Paul Singh, MD, of the Eye Centers of Racine and Kenosha. “Architectural plans were designed to meet every parameter for a safe operating environment in the in-office suite—not just where to place the phaco machine and 3D monitor, but also the best choices for the OR’s size, flow, flooring, walls, sterile processing, and airflow. We know that we have the same standards of safety and surgical outcomes we’re accustomed to. There is no compromise on patient safety.”
Both surgeons relied on iOR Partners throughout the OBS process. “It was clear I would need the help of someone with experience, and iOR is a leader in the field,” says Dr. Kugler. “They not only guided the design, but they also completely handled the training of my staff, who had never done any intraocular surgery. Now they’re the best OR team I’ve ever worked with. iOR has also handled accreditation and ongoing compliance support so we can focus on what we do best.”
Better Experience for Patients, Surgeons, and Staff
OBS places every aspect of the patient experience under the surgeon’s control. Cataract patients can have the same experience as LASIK, with all the benefits of a familiar, comfortable environment.
“With OBS, cataract patients have surgery in our practice, just like LASIK patients. Our ASC was fine, but this is a very relaxed, comfortable experience that our patients greatly prefer,” says G. Brock Magruder, Jr., MD, of Magruder Laser Vision in Orlando. “We can offer personalized care from a staff patients have already come to know. The ability to control all aspects of the patient experience is so important—the experience has been remarkable.”
Dr. Kugler agrees. “Our patients’ experience at the ASC was never quite as good as our LASIK patients had in our office,” he says. “Now, instead of making a special trip to a place they’ve never been before, with people they’ve never met, they can come to our familiar office. We even control the schedule, so we can choose a convenient arrangement for everyone.”
Dr. Singh noticed that his patients are much more calm when they come to his office for surgery, compared to other surgery centers. “The facility is the same as their consult, so they have familiarity with their surroundings and fewer unknowns. All the touch points are the same as the pre-op consultation—the same staff welcomes them, circulates them through the process, and assists during surgery. We want patients to walk in and remain calm and comfortable, and OBS certainly makes them feel calmer.”
When patients feel calm, it not only contributes to a better experience, but it also influences decisions about anesthesia. Dr. Singh explains, “Because patients are already calm, oral sedation has been more than enough for them to be comfortable and alert enough to follow commands, which is not always the case with IV anesthesia. I think they’re actually more comfortable with oral sedation. Getting an IV can create stress, causing patients to feel more anxious, resulting in the need for more sedation.”
Dr. Singh also points out that the patient isn’t the only one who gets a better experience from OBS. “I control the OR design and the instrumentation I use—the phaco machine, scopes, digital overlays, 3D heads-up, etc.—without going through committees and red tape. That’s a huge boost for everyday surgery as well as for surgical studies. I’m also in complete control of my schedule, and I can see clinic patients as needed to help maximize my office time. I’m truly happy with the decision to start OBS.”
“I was worried we’d need to add more staff, but we’ve been delighted to find that everyone stepped up to support OBS and actually became significantly more engaged in their work,” Dr. Magruder says. “Because patients have surgery in the practice, staff members are now present for the entire continuum. They feel more connected and satisfied through the new process, and there’s a whole new area of the practice where they can grow their careers, which is so important because it's harder and harder to find good people to hire. OBS has been a wonderful experience for our staff and a great team-building experience.”
Financial Control and Advantages
There are financial advantages to OBS as well. iOR Partners has been successful with reimbursements from commercial, private pay, Medicare Advantage, and Medicare. Furthermore, efficiency increases as surgeons save time by creating their own schedules and lose no time traveling to ASCs. With everything taking place under one roof, billing is also streamlined.
“Before we decided to transition cataract surgery and other lens procedures to OBS, our throughput was limited at the ASC because of the time we were allotted. Our surgical volume was capped by the ASC’s capacity to host us,” explains Dr. Magruder. “In the first year of OBS, we slightly raised our conversion rate for refractive cataract surgery (we were already around 80%), and we were also able to increase our throughput over 30%. We also got a handle on everything that goes into the cost per case, and we're able to control it. In any ASC with multiple partners, the benefit is much less tangible—here in the office, we know exactly what's impacting the P&L.”
Dr. Kugler’s ability to control the schedule meant he could maintain his patient volume during the pandemic while spacing appointments. He sees ongoing financial advantages in premium surgery and other areas. “Using oral sedation alone, which accounts for about 80% of my OBS cases, saves my patients a lot of money. The savings, combined with the ability to offer conveniently scheduled, comfortable surgery in our home environment, makes more patients choose premium cataract surgery,” Dr. Kugler says. “The combination of improved efficiencies, increased conversions, and cost savings adds greater value to the practice with the OBS model.”
1. Ianchulev T, Litoff D, Ellinger D, et al. Office-based cataract surgery: population health outcomes study of more than 21 000 cases in the United States. Ophthalmology. 2016;123(4):723-728.
For more information about office-based surgery suites, please visit iOR Partners.com.