Office-based Ambulatory Setting Research Articles

PC140 Safety and Effectiveness of Antegrade Superficial Femoral Artery Access in an Office-Based Ambulatory Setting

PC140 Safety and Effectiveness of Antegrade Superficial Femoral Artery Access in an Office-Based Ambulatory Setting

American Association of Oral and Maxillofacial Surgeons' Anesthesia and Third Molar Extraction Benchmark Study: Rationale, Methods, and Initial Findings

Benchmark statistics are used in quality assurance/quality improvement processes. The purposes of the present report are to 1) review the rationale for a new specialty-specific benchmark study, 2) summarize the methods to create a practice-based research collaborative (P-BRC) designed for collecting data to create benchmarks, and 3) describe the characteristics of the P-BRC surgeon participants. The study was designed as a prospective cohort study. We created a P-BRC composed of randomly selected American Association of Oral and Maxillofacial Surgeons (AAOMS) members in private practice in the United States, who agreed to enroll patients scheduled to receive anesthesia of any type in the office-based ambulatory setting. The study variables included clinician demographics and their P-BRC status, grouped as 1) invited, active participants, 2) invited, inactive participants, and 3) uninvited AAOMS members. The P-BRC participants collected data for dozens of variables from their patients related to anesthesia. If the procedure was third molar (M3) surgery, additional M3 procedure-specific data were collected. Data analyses were composed of computing descriptive and bivariate statistics. Preliminary sample size estimates suggested that the P-BRC should include 300 surgeons to produce estimates with a ±5% error. During the 1-year study interval, 642 surgeons (11.8%) were invited to join the P-BRC from a population of 5,455 eligible AAOMS members. The 124 active participants in the P-BRC contributed 6,344 subjects to the anesthesia data set and 2,978 subjects who had had 9,207 M3s removed to the M3 data set. The active participants in the P-BRC were younger and more likely to be board-certified than were the inactive participants (P < .05). Details of the anesthesia and M3 variables will follow in future reports. Despite vigorous efforts, we did not achieve our stated goal of creating a P-BRC composed of a random sample of 300 AAOMS members. With the current P-BRC sample, variables with very high (>93%) or very low (<7%) frequency estimates will produce estimates with the desired range of ±5% error. The P-BRC includes a sample of self-selected, not random, participants and is well-characterized in terms of age, gender, board-certification status, academic degrees, and geographic distribution.

What Costs Are Associated With the Management of Third Molars?

The purpose of this study was to estimate the treatment costs directly related to operative and nonoperative management of asymptomatic, disease-free, third molar (M3) teeth. The data reviewed were limited to claims submitted by oral and maxillofacial surgeons. The data collected included charges for consultations, radiographs, surgical removal of bony impacted teeth, and general anesthesia, using the 2009 data extracts from Delta Dental of Virginia. The median charges were used as a proxy for the actual costs attributable to the removal or retention of M3 teeth. Three clinical scenarios were executed using the available claims data to calculate the treatment costs associated with nonoperative and operative M3 management. An assumption made in the computation of expenses was that for subjects who elected to retain their M3s, the recommended management strategy was active surveillance. Active surveillance is a prescribed treatment to monitor the retained M3s characterized by performing a clinical examination and panoramic imaging every 2 years. The author assumed a 3% increase in charges per annum. The 3 scenarios were as follows: scenario 1 (nonoperative management), retention of asymptomatic, disease-free M3s and monitoring for 20 years from age 18 to 38 years; scenario 2 (operative management), removal of 2 asymptomatic, disease-free, bony impacted M3s for 18-year-old patients using general anesthesia (30 minutes) in an office-based ambulatory setting; and scenario 3 (failure of non-operative management), removal of 1 previously asymptomatic, disease-free, bony impacted M3 after 10 years of follow-up in a now 28-year-old patient using general anesthesia (30 minutes) in an office-based ambulatory setting. The estimated charges for managing M3s were $2,342, $1,184, and $1,997 for scenarios 1, 2, and 3, respectively. A simplified financial analysis derived from the dental claims data suggests that during the course of the patient's lifetime, the charges associated with non-operative management of asymptomatic, disease-free M3s will exceed the charges of operative management. The difference in costs might be important to patients when choosing between operative and non-operative management of their M3s.

Comparison of Methohexital and Propofol Use in Ambulatory Procedures in Oral and Maxillofacial Surgery

Short-acting anesthetic agents, such as propofol and methohexital, are commonly used for ambulatory procedures in the practices of oral and maxillofacial surgeons (OMS). This study compares the safety and anesthetic outcomes of propofol and methohexital. In addition, the study compares the safety and outcomes of these agents when administered either by an OMS who simultaneously provides anesthesia and performs the procedure (anesthetist/surgeon), or by a non-OMS provider of anesthesia (anesthesiologist or certified registered nurse anesthetist; CRNA) whose sole obligation is to provide anesthesia. This is a prospective study of anesthesia techniques used in an office-based ambulatory setting by OMS throughout the United States, in which either propofol or methohexital was used for sedation/anesthesia. The study variables included demographic information, anesthetic agent, adverse outcomes related to anesthesia, operative procedure, and provider of anesthesia. These variables were compared with the patient group that received a benzodiazepine/narcotics regimen for sedation (control group). Bivariate (contingency tables) and multivariate (logistic regression) analyses were conducted. P < or = .05 was considered statistically significant. The study included 47,710 patients who met the inclusion criteria: 26,147 (54.8%) patients were in the propofol group, 15,859 (33.2%) were in the methohexital group, and 5,704 (12.0%) were in the benzodiazepine group. Among all study patients, 333 (0.7%) had an adverse event. The most common complication was nausea and vomiting without aspiration. Of the patients in the propofol group, methohexital group, or benzodiazepine group, 0.4%, 1.1%, and 0.8% had an adverse event, respectively. The higher number of complications among patients in the methohexital group compared with patients in the other 2 groups was statistically significant. Of 26,147 patients in the propofol group, 23,799 (91.0%) received anesthesia from an anesthetist/surgeon (OMS), and 2,368 (9.1%) from an anesthesiologist or nurse anesthetist (non-OMS). A total of 109 patients (0.4%) had an adverse event. The majority of patients who received anesthesia from a non-OMS were in the propofol group (2,368 of 2,404 patients; 98.5%). There was no statistically significant difference in the occurrence of adverse outcomes when comparing patients in the propofol group who received anesthesia from an OMS with those who received anesthesia from a non-OMS (P = .24, bivariate analysis; P = .33, multivariate analysis). There is a statistically significant increase in adverse events related to methohexital compared with propofol or benzodiazepine/narcotics for anesthesia. Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist. It remains critical that our specialty maintains the highest standards, to provide safe anesthesia and to reduce adverse anesthetic events.

Safety of Propofol and Methohexital Use in Office-Based Procedures

Statement of the Problem: Oral and maxillofacial surgeons (OMSs) are trained to provide anesthesia and perform surgical procedures in an office-based ambulatory setting. Propofol and methohexital sodium are often administered as anesthetic agents because of their rapid onset, effectiveness, and short duration. However, the propofol package insert states that it “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.” The purpose of this study is to compare the safety and anesthetic outcomes of propofol, methohexital, and benzodiazepines during oral and maxillofacial surgery outpatient procedures in which the OMS is both the anesthesia provider and the surgeon working with a team of assistants. Materials and Methods: This prospective cohort study, conducted by the AAOMS Outcomes Assessment Project, included a consecutive series of patients who underwent oral and maxillofacial surgery outpatient procedures in office-based ambulatory settings between January 2001 and December 2004. The procedures were performed by OMSs who volunteered to submit studyrelated data to a specialty-specific data repository. To be included in this study, the patient underwent conscious sedation or deep sedation/general anesthesia (DS/GA) and received a benzodiazepine, methohexital, or propofol. Patients given other sedative agents, such as ketamine, or a combination of sedative agents were excluded. Demographic information of the patient population included age, gender, and anesthetic risk classified according to the ASA system. Additional study variables included operative procedure, anesthetic monitoring, adverse events, and patient-oriented outcomes. Method of Data Analysis: Fisher’s exact test was used to compare the complications between each of three sedative regimens. The level of statistical significance was set at p 0.05. Results: Ninety-four volunteer OMSs submitted data for 27,162 patients who met the study criteria. Mean patient age was 29.2 years (range 1-101). The patients were relatively healthy with 20,551 (75.5%) classified as ASA I and 5,997 (22.0%) as ASA II. Over 70% of the procedures were third molar extractions, while the rest were other dentoalveolar procedures, implants, trauma, reconstruction, and pathology. Patients were categorized on the basis of the sedative regime they received: 15,428 (56.8%) received methohexital (with or without a benzodiazepine), 7,625 (28.1%) received propofol (with or without a benzodiazepine), and 4,109 (15.1%) received a benzodiazepine but no methohexital or propofol. Overall, 318 (1.2%) patients developed a complication from the anesthesia. The most common was postoperative nausea and vomiting without aspiration (68 patients, 0.3%). There were no deaths, but 6 patients required hospitalization. No patient in the study suffered any long-term effects. When comparing the anesthetic agents and the number of complications with each agent, propofol regimens resulted in 58 complications (0.8% of the patients receiving propofol), benzodiazepines resulted in 37 (0.9% of those receiving benzodiazepines without propofol or methohexital), and methohexital incurred 223 complications (1.4% of patients receiving methohexital). There was no statistically significant difference between the number of complications when using propofol than when using benzodiazepines without propofol or methohexital. However, there was a statistically significant difference between methohexital and benzodiazepines without propofol or methohexital (p 0.007), and between methohexital and propofol (p 0.0001). Methohexital demonstrated a higher number of complications in both comparisons. Conclusion: The overall proportion of patients who experienced complications was found to be extremely low (1.2%) and the complications that did occur were minor without any long-term effects. In addition, the number of complications while administering propofol, or benzodiazepines is statistically significantly less than methohexital. These results support the use of propofol by OMSs when administering the anesthetic and performing the procedure.

Office-based ambulatory anesthesia: Factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia

The purpose of this report was to analyze data collected in an outcomes study in an attempt to identify factors that may be significant predictors of either patient satisfaction or dissatisfaction with deep sedation/general anesthesia (DS/GA) administered in an office-based setting. To address the research purpose, we used a prospective cohort study design and sample of patients undergoing procedures in the office-based ambulatory setting of oral and maxillofacial surgeons practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or DS/GA. The predictor variables were categorized as demographic, anesthetic technique, adverse events, and patient-oriented outcomes (satisfaction/dissatisfaction). Appropriate descriptive and exact P values were completed as indicated. Statistical significance was set at P < .05. Multivariate analyses were performed to support the interpretation of univariate findings. The sample was composed of 34,191 patients, of whom 71.9% patients received DS/GA. There were 20,455 patient satisfaction forms completed, of which 14,912 forms were from patients undergoing DS/GA. Of patients who received DS/GA, 95.8% were extremely or moderately satisfied, 3.1% were neutral, and 1.1% moderately or extremely dissatisfied. Increased age and memory of postoperative instructions were identified as factors, which predicted satisfaction. The addition of nitrous oxide to some regimens also appeared to increase satisfaction. Young age, anxiety, pain, vomiting, and being awake during the procedure were predictors of dissatisfaction. The findings of this study indicate that patients are overwhelmingly satisfied with DS/GA provided in an office-based ambulatory setting. Items identified as significant predictors of dissatisfaction (anxiety, pain, vomiting, being awake) generally confirm preexistent suppositions. Surprisingly, patient age (<10 years old) and memory of postoperative instructions appear to have relevance to dissatisfaction as well. Lack of specific regimens and controls prevents confirmation that nitrous oxide improves patient satisfaction rates. Although statistically significant, the variations, which resulted in a higher or lower satisfaction rate, are of questionable clinical significance in many cases.

Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons

Purpose: The delivery of office-based ambulatory anesthesia services is an integral component of the daily practice of oral and maxillofacial surgeons (OMSs). The purpose of this report was to provide an overview of current anesthetic practices of OMSs in the office-based ambulatory setting. Materials and Methods: To address the research purpose, we used a prospective cohort study design and a sample composed of patients undergoing procedures in the office-based ambulatory setting of OMSs practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or deep sedation/general anesthesia (DS/GA). The predictor variables were categorized as demographic, anesthetic technique, staffing, adverse events, and patient-oriented outcomes. Appropriate descriptive and bivariate statistics were computed as indicated. Statistical significance was set at ≤.05. Results: The sample was composed of 34,191 patients, of whom 71.9% received DS/GA, 15.5% received CS, and 12.6% received LA. The complication rate was 1.3 per 100 cases, and the complications were minor and self-limiting. Two patients had complications requiring hospitalization. Most patients (80.3%) reported some degree of anxiety before the procedure. After the procedure, 61.2% of patients reported having no anxiety about future operations. Overall, 94.3% of patients reported satisfaction with the anesthetic, and more than 94.7% of all patients would recommend the anesthetic technique to a loved one. Conclusion: The findings of this study show that the office-based administration of LA, CS, or DS/GA delivered via OMS anesthesia teams was safe and associated with a high level of patient satisfaction.