Outpatient settings like office-based laboratories (OBLs) have attracted increased scrutiny in recent times amid efforts to shine greater light on appropriateness in care. During the COVID-19 pandemic, they have been among some of the hardest-hit private vascular surgery practices as the virus wrought havoc on healthcare delivery and economic vitality across the U.S. They also encompass a major portion of the Society for Vascular Surgery (SVS) membership ranks: The vast majority of SVS members are associated with practices that include outpatient care options such as OBLs and ambulatory surgery centers.
But just how crucial a setting are OBLs to the vascular surgery universe? The recently concluded virtual annual meeting of the Eastern Vascular Society (Oct. 7–Nov.18) sought to provide an answer for this fundamental sector of vascular practice as they ran through topics from how to start an OBL and how to make one a success.
“One question that remains is whether OBLs are a necessity to survive?” moderator Philip Paty, MD, a vascular surgeon at Vascular Health Partners of Community Care Physicians in Queensbury, New York, told attendees listening in on a special community surgeons session and panel. “Regardless, in the United States nearly 70% of vascular procedures are performed in an outpatient setting. Market share analysis data show that the OBL market size was $8.5 billion in 2019 and is expected to have a compound annual growth rate of 9% from 2020 to 2027. On the other hand, the hospital industry is expected to grow at an annualized rate of 3%, and it is the outpatient services within the hospitals that are forecasted to experience the most growth, approximating 8%.”
When compared to in-hospital settings, Paty added, procedures in OBLs “not only reduce the overall cost of vascular procedures to the healthcare system but are also reported to result in better patient and healthcare provider experience and satisfaction.”
The increasing presence of OBLs was something acknowledged by Kim Hodgson, MD, the immediate past president of the SVS, in an October interview with Vascular Specialist as he discussed appropriateness in care and the specter of practice outliers both among members of other specialties carrying out vascular procedures and vascular specialists themselves.
Which recalls a key question posed by Paty to the panel of community surgeons: What should and shouldn’t be done in the OBL setting? Jonathan Levinson, MD, a partner in the Cardiovascular Care Group in Springfield, New Jersey, and a member of the panel, provided an answer.
“It’s really those patients that, No. 1, are nursing home patients that require attendants to be with them, that can’t communicate with us,” he said.
“So they have to be somewhat walkie-talkie patients. With regards to the patients that have multiple comorbidities that are out of control, such as significant renal insufficiency, with our lower-extremity revascularization cases, those are ones that would be better suited to optimize in the hospital.”
Yet, complications are an omnipresent consideration. The specter of planning in the face of a disaster in the OBL bears description. Clifford Sales, MD, managing partner of the Cardiovascular Care Group, another panelist, points first to the need for Advanced Cardiovascular Life Support (ACLS) certification. “And really ACLS-certified, not just going on the course—you’ve got to know what you’re doing,” he said. “Our patients are sick as hell, as everyone knows. Two days ago, we had a patient come into the office—not even the suite—who coded in the exam room.”
Often, Sales highlighted, tending to nonpatients in the vicinity is an important function. “We run a drill a couple of times a year where one person goes outside to flag down and wait for the ambulance,” he explains. “Another person takes care of the waiting room, and another person takes care of the people in the pre-op and post-op area. All the medical stuff goes on at the bedside, obviously. You’ve got at least two or three people, a doc and two nurses, an X-ray tech. Just having that drill, even though it’s a verbal drill, [is important].”
Elsewhere on the panel, Michael Schwartz, MD, a partner at Rockland Thoracic & Vascular Associates in Pomona, New York, ran through some financial realities.
“In an OBL, you’re basically getting one payment for every procedure,” he said. “You want to do what’s best for the patient, but at the end of the day, using a bunch of balloons and stents, you’re losing money—and that’s not the goal. The goal is to take care of the patients, and then do well financially. To that end, we really don’t monitor each doctor individually; we don’t have protocols, either. But what we do is audit everyone occasionally, just to see if there are any outliers.”
Back at the baseline, the idea of an OBL dimension to medical training was put to the last remaining panel member, Sean Wengerter, MD, also of Rockland Thoracic & Vascular Associates. “It’s hard to add another thing like contract negotiations [but] I think OBL would be great,” he said. “Looking at the numbers presented here—the number of OBLs, the percentage of cases that are done of vascular cases in them, and the good patient care that I’ve experienced being able to give in the OBL setting—I think the key is good training, good case selection, good case management, good skillset.”
As for the OBL overall direction of travel? Moderator Paty produced a snapshot in his session introduction.
“The rising trend of endovascular procedures coupled with the increasing prevalence of vascular disease, favorable outcomes in OBLs, patient preference, physician autonomy and ownership, and substantial reductions in the overall healthcare cost for procedures done in OBLs, are responsible for driving the increased demands for office-based procedures. Its longevity will center on our ability to prioritize patient safety and outcomes,” he said.