In 2005, the Centers for Medicare & Medicaid Services established a fee schedule that provided reimbursement for selected peripheral endovascular procedures. During the next few years, office-based labs (OBLs) that performed these procedures slowly opened around the country. More recently, as an increasing number of endovascular procedures became reimbursable in the office setting, OBLs opened in record numbers, shifting many procedures that were once performed in a hospital to the outpatient setting. The shift of practice into the office-based setting offered significant cost-effective solutions to surgical care (60%–75% lower),1 as well as increased patient comfort and satisfaction in many cases. However, increases in the number and complexity of office-based cases posed significant concerns with regard to patient safety and standard of care. In fact, a recent New York Times article questioned the increase of peripheral arterial and venous interventions that coincided with the rise in OBLs.2 The article further speculated that some doctors, motivated by the higher reimbursement of office-based procedures, perform unnecessary procedures.

These concerns were precisely why a group of five interventional cardiologists, five interventional radiologists, and five vascular surgeons convened in Dallas, Texas, in September 2013 to form the Outpatient Endovascular and Interventional Society (OEIS). Since then, the OEIS has had two annual meetings and has established a set of practice standards focused on patient safety and quality, successful outcomes, appropriateness criteria, education, and fiscal responsibility.

OEIS FIVE PILLARS OF QUALITY

As the mission of the OEIS is to promote excellence in the outpatient management of patients with vascular disease, five pillars of quality were created to help foster innovation in our field, protect the patient-physician relationship, and promote improved care coordination and communication with office-based interventional centers.

The five pillars of quality are:

1. Highest commitment to patient safety and quality (see the Safety in the OBL sidebar)

2. A commitment to excellence in outcomes

3. A commitment to selecting and performing clinically appropriate procedures in all cases

4. A commitment to continuing education

5. A commitment to fiscal responsibility and
transparency

Our commitment to the highest quality standards is of paramount importance to our members. Through this commitment, we are able to establish premier levels of trust in our profession among our patients, constituents, and regulatory entities.

ACCREDITATION: A FOCUS ON SAFETY AND QUALITY

To facilitate the previously stated goals, the OEIS strongly recommends that each OBL obtain accreditation. External accreditation introduces an objective third party to monitor and validate the activities of an office-based practice and provides national acknowledgment of quality. This level of standardization provides confidence that the office-based surgery center has the same level of safety as that of ambulatory surgery centers or hospitals. Furthermore, accreditation validates all aspects of an OBL: administrative, clinical, and surgical. The administrative points include facility and equipment maintenance, medical records documentation, and credentialing of personnel. Clinical considerations include patient rights management, approval of procedures in the office, and nursing services. Surgical issues include preoperative testing requirements, medication administration, and risk management.

There are currently three major, nationally recognized accrediting organizations: the Accreditation Association for Ambulatory Health Care, The Joint Commission, and the American Association for Accreditation of Ambulatory Surgery Facilities. The Accreditation Association for Ambulatory Health Care is one of the more popular agencies for accreditation and has developed an accreditation handbook with guidelines that were specifically designed for office-based surgery. The handbook has been developed to assist organizations seeking accreditation in the review and application of the standards for an office-based surgery practice, with the intention of ensuring that the highest level of health care services is provided.3 The Joint Commission is traditionally known to be hospital based, but as of 2001, it has also introduced standards and a survey process for office-based surgery practices, currently providing accreditation for more than 400 office-based surgery practices.4 The American Association for Accreditation of Ambulatory Surgery Facilities, founded in 1980, provides accreditation for more than 2,000 outpatient facilities, with the mission to standardize and improve the quality of medical and surgical care while ensuring high standards of patient care.5 Although nearly 30 states already require some form of accreditation,6 there is an increasing movement in other states to require OBLs to obtain accreditation. The OEIS fully supports this national trend.

CONCLUSION

The growth in volume and complexity of cases, in addition to increased comorbidities, will continue to create challenges for office-based safety. The OEIS believes that OBLs can benefit all parties involved provided that proper safety measures and quality of care are upheld. An unwavering commitment to patient safety and quality is vital to the success of office-based surgery; thus, the OEIS highly recommends external accreditation of OBLs. Accreditation will, in turn, facilitate fulfillment of the OEIS five pillars of quality, which is vital to the success of OBLs and exceptional patient care. The OEIS is also actively working to establish a peer review process, clinical outcome registry, and guidelines for appropriate indications.

Sam S. Ahn, MD, FACS, is President Elect of OEIS and is with University Vascular Associates in Los Angeles, California, and DFW Vascular Group in Dallas, Texas. He has disclosed that he is the founder and CEO of Vascular Management Associates, a business designed to help doctors set up and manage OBLs. Dr. Ahn may be reached at ssahn100@gmail.com.

1. Lapetina EM, Armstrong EM. Preventing errors in the outpatient setting: a tale of three states. Health Aff (Millwood). 2002;21:26-39.

2. Creswell J, Abelson R. Medicare payments surge for stents to unblock blood vessels in limbs. The New York Times. January 29, 2015. http://www.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html?_r=1. Accessed August  11, 2015.

3. Accreditation Association for Ambulatory Health Care (AAAHC). Accreditation Handbook for Office-based Surgery Including Review Guidelines. Skokie, IL: AAAHC; 2014.

4. The Joint Commission. Facts about office-based surgery accreditation. http://www.jointcommission.org/assets/1/18/Office_Based_Surgery_Accreditation_7_10.pdf. Published November 2013. Accessed on August 11, 2015.

5. The American Association for Accreditation of Ambulatory Surgery Facilities. Inspecting and accrediting for over 30 years. http://www.aaaasf.org/aboutus.html. Accessed August 11, 2015.

6. Osman BM, Shapiro FE. Safe anesthesia in the office-based setting. American Society of Anesthesiologists Newsletter. 2014:78:14-17.