Chair, Scientific Subcommittee for Ambulatory Anaesthesia, ESA
Euroanaesthesia 2017 will be taking place over the first weekend in June in Geneva. While the programme promises to provide a contemporary update on every aspect of anaesthetic care, one component in the field of Ambulatory Anaesthesia reviews the concept of Office Based Anaesthesia (OBA), and whether the concept is worthy of further development in Europe. Speaking to both of these remits will be Professor Beverly Philip and Professor Johan Raeder. Beverly is Vice-President of Scientific Affairs of the American Society of Anesthesiology, based in Boston, Massachusetts, while Johan hails from the Ullevaal University Hospital as well as holding a chair at the University of Oslo.
OBA has a long history of development in the United States of America, where, over a period of 10 years from 1995 to 2005, the number of procedures carried out doubled to ten million per year. There has been a progressive movement away from hospital-based procedures to Ambulatory Surgery Centres, and from there to physician facilities, where the percentage of procedures has risen from less than 5% to 17%. The primary driver for this change seems to be cost based, with office surgery yields being 60% to 75% lower than hospital-based settings. Non-hospital environments also offer patients a more friendly environment with greater scheduling convenience as well as a perceived improvement in personal attention.
There have been a number of potential concerns raised by regulatory agencies about the developing concept, with the increasing complexity of patient case mix, the differing types of surgery, and potential staff and equipment limitations. On this basis, there seemed to be value in evaluating the safety of the office environment for complication and mortality rates. Early reports suggested the relative risk of complications (including death) to be more than 10 times higher for office-based procedures than for those performed in Ambulatory Surgery Centres. These figures have been criticised for numerator and denominator inaccuracies, and further studies have suggested that office-based procedures have mortality rates similar to those conducted in the hospital environment, namely 0.035%.
Patient selection and choice of operative procedure are other relevant considerations for office-based anaesthesia that will be addressed in these lectures. Are there any limitations to suitability for care compared with the hospital environment? Are there any embargoes on particular procedures or suggestions for safety optimisation? What staffing mandates are required? Should anaesthesia providers be accredited to specialist status? If so, what training opportunities are recommended for the environment? All these questions (and more) will be addressed by Professor Philip in her talk.
What facilities are available in Europe and how do they compare with those of their transatlantic colleagues? In the United Kingdom, non-hospital-based facilities are relatively rare outside of the National Health Service, and the provision of community dental services involving general anaesthesia are now carried out within the auspices of a hospital, where access to critical care facilities are guaranteed if required. There are a number of community facilities undertaking hernia repairs under general or local anaesthesia where the implementation of services has developed in concert with those hospitals with day surgery services.
Germany reports that the majority of ambulatory surgery (69%) is performed in specialised doctors’ offices, with costs per case approximately 30% less than hospital care, and provision by specialists rather than by more junior staff. However, the reimbursement for ambulatory care is about 25% that of the same procedure carried out as an inpatient, perhaps explaining why proportions of ambulatory surgery are comparatively lower for this country.
Italy has developed a comprehensive portfolio of standards for office-based anaesthesia dictating minimum organisational standards; protocols for admission, treatment, and discharge; structural remits particularly for operating theatres; and minimum competencies for staff working in such areas. Within the specification is the recommendation that OBA is restricted to local anaesthesia with general anaesthetic procedures available in hospital-based models.
Professor Raeder has described the organisation In Norway where about 95% of all surgery is done in public hospitals, with some of the rest performed in office-based premises. The practice is regulated, with a standard for anaesthesia care, covering aspects of location, equipment, staff education, safety, and performance of anaesthesia and sedation. Some plastic surgeons and general surgeons perform office-based surgery using local anaesthesia, whereas involvement of general anaesthesia is mainly seen in dental and ENT areas. Since both involve airway intervention, there are additional safety issues requiring staffing, equipment, and location for the ‘worst case scenario’ that for ENT may be uncontrolled bleeding necessitating transfer to a nearby hospital department.
So, make a date for this symposium to learn about current and future trends in Office Based Anaesthesia. It is scheduled to take place on Sunday 4 June between 09.30 and 10.30hrs in Hall 1, Room 1. I look forward to seeing you there.