Office-based Surgery Research Articles

The Association of Surgical Setting With Opioid Prescribing Patterns Following Wide-Awake Trigger Finger Release.

Wide-awake and office-based hand surgeries are increasingly common. The association of these techniques with postoperative pain and pain control has garnered recent attention. A prior study demonstrated that office-based trigger finger release (TFR) were associated with decreased perioperative opioid prescriptions compared to those performed in the operating room. The current study provides an in-depth analysis of the association between surgical setting and perioperative opioid prescriptions for wide-awake TFR. Patients undergoing TFR between 2010 and 2021 were identified in PearlDiver, a national administrative claims database. Exclusion criteria were age <18 years, <6 months of preoperative data, <1 month of postoperative data, bilateral TFR, and concomitant hand surgery. To identify wide-awake cases, patients with procedural codes for general anesthesia, monitored anesthesia care, sedation and regional blocks were excluded. Patients were stratified by surgical setting (office or operating room), then matched based on age, sex, Elixhauser Comorbidity Index score, and geographic region. Patients with prior opioid prescriptions, opioid dependence, opioid abuse, substance use disorder, chronic back/neck pain, generalized anxiety, and major depression were identified. Perioperative opioid prescriptions (those filled within 7 days before or 30 days after surgery) were characterized. There were 16,604 matched wide-awake TFR patients in each cohort. In the cohort of office-based patients, 4,993 (30%) filled a prescription for perioperative opioids, in contrast to 8,763 (53%) patients who underwent surgery in the operating room. This disparity was statistically significant in both univariate and multivariate analyses. Univariate analysis indicated that office-based surgeries were linked to lower morphine milligram equivalents (MME) in opioid prescriptions than those performed in operating rooms (median of 140 vs 150, respectively). However, multivariate analysis demonstrated that opioid prescriptions for office-based surgeries were actually associated with greater MME. Patients undergoing office-based TFR were less likely to fill perioperative opioid prescriptions but were prescribed opioids with greater MME. In wide-awake TFR, it appears that a disparity may exist in patient and provider beliefs about postoperative pain control. Future patient- and provider-level investigations may produce insights into perceptions of postoperative pain and pain control, which may be useful for reducing opioid prescriptions across surgical settings.

Academic visualization study of aesthetic medicine management and related legal research since 2000.

Aesthetics medicine, a controversial branch of clinical medicine known for its high degree of commercialization, faces numerous conflicts, particularly in some developing countries. The global aesthetics medicine industry requires enhancements of its legal and supervision framework and risk management systems. This paper aimed to provide a comprehensive visual analysis of academic achievements related to regulatory and legal issues in the field of aesthetic medicine and to identify its development trends and research hotspots. The Web of Science Core Collection was employed to retrieve relevant studies, resulting in a total of 602 research articles after selection. Utilizing bibliometric methods and CiteSpace, this study analyzed the primary countries, institutions, authors, journals, hotspots, frontiers, and trends in this domain. The findings indicated rapid increases in the number of published papers. The United States emerged as the leading contributor with 131 research papers and the highest intermediate centrality. Eleven keyword clusters were identified, with "adolescence" and "office-based surgery" being the most recent topics. We also analyzed the trends and frontiers of legal research in medical aesthetics. The importance of informed consent has been increasingly emphasized, and research in the field of medical aesthetics has been gradually expanding beyond individual cosmetic procedures. The management system has become more comprehensive, moreover, guidelines and medical laws have been continually published, with research shifting toward a holistic perspective that encompasses patients, medical aesthetic providers, and regulatory authorities in the study of medical aesthetics regulation and legislation. This paper also proposes some innovative directions for future research and applications.

The Correlation of Surgical Setting With Perioperative Opioid Prescriptions for Wide-Awake Carpal Tunnel Release.

Prior studies have compared perioperative opioid prescriptions between carpal tunnel release (CTR) performed wide-awake and with traditional anesthetic techniques, but the association of opioid prescriptions with surgical setting has not been fully explored. The current study assessed the association of opioid prescriptions with surgical setting (office or operating room) for wide-awake CTR. Patients with open CTR were identified in an administrative claims database (PearlDiver). Exclusion criteria included age less than 18 years, preoperative data less than 6 months, postoperative data less than 1 month, bilateral surgery, concomitant hand surgery, and traditional anesthesia (general anesthesia, sedation, or regional block). Patients were stratified by surgical setting (office or operating room) and matched by age, sex, Elixhauser Comorbidity Index, and geographic region. Prior opioid prescriptions, opioid dependence/abuse, substance use disorder, back/neck pain, generalized anxiety, and major depression were identified. Opioid prescriptions within 7 days before and 30 days after surgery were characterized. Each matched cohort included 5713 patients. Compared with patients with surgery in the operating room, fewer patients with office-based surgery filled opioid prescriptions (45% vs 62%), and those prescriptions had lower morphine milligram equivalents (MMEs, median 130 vs 188). These findings were statistically significant on univariate and multivariate analysis. Following office-based CTR, fewer patients filled opioid prescriptions, and filled prescriptions had lower MME. This likely reflects patient and provider attitudes about pain control and opioid utilization. Further patient- and provider-level investigation may provide additional insights that could aid in efforts to reduce perioperative opioid utilization across surgical settings.

Office-based anesthesia: a contemporary update on outcomes, incentives, and controversies.

The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies. Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates. The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery.

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting.

Office-based surgery can increase logistical and financial efficiency for patients and surgeons. The current study compares wide-awake, office-based carpal tunnel release to wide-awake operations performed in the operating room in terms of volume, financial burden, narcotic prescriptions, and adverse events. Operations performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region. Primary endpoints included total disbursement and physician reimbursement, and 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSIs). Before matching, there were 303,741 operating room operations and 5463 office operations. From 2010 to 2020, the percentage of operations in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 operating room operations and 5459 office operations. Office surgery was associated with lower total disbursement and physician reimbursement for patients with commercial insurance, Medicaid, and Medicare. Linear regression modeling indicated that office-based surgery was significantly associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSIs. Compared with operating room surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and a similar incidence of SSIs. These findings, together with literature showing greater efficiency in the office, suggest that office-based operations are safe and cost-effective and should continue to grow. Therapeutic, III.

Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients.

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures.

Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities. The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications. A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events. This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments. Therapeutic, III.

Aktuelni hirurški modaliteti lečenja polipa glasnica - mini-pregled

Vocal fold polyps represent one of the most common benign organic disorders affecting the larynx in the general population, and a relatively frequent cause of long-standing hoarseness. The exact etiology is unclear, but poor vocal behavior has been suggested as the principal etiologic factor. Histopathologically they are characterized by various structural alterations in the vocal fold superficial lamina propria, and typical clinical finding is of a solitary, unilateral and well-defined vocal fold lesion. Vocal fold polyps usually require surgical removal using microlaryngoscopy with cold steel excision in general anesthesia, which has been the practice standard for the last 60 years. Microlaryngoscopy offers the surgeon an unparalleled magnified view of the vocal folds and very precise work on a still operative field without a specific time limit. The introduction and technological development of ambulatory endoscopy and various laser systems provided the surgeon with ample therapeutic opportunities, including operating some of the patients in the office setting in local anesthesia. These outpatient procedures are technically simple and cost-effective, require fewer medical personnel, exclude general anesthesia-related risks, and are less time-consuming both for the patient and the physician. Nevertheless, the contemporary laryngologist should be able to perform both conventional microlaryngoscopy and office-based surgery for vocal fold polyps, depending on the clinical situation.

Sublimation of Benign Conjunctival Nevi Using Plasma-Assisted Noninvasive Surgery: A Clinical Case Series.

Conjunctival nevi (CN) are common benign ocular tumors. Given their low risk of malignancy, surgical removal of nevi is primarily requested by patients. Herein, we introduce Atmospheric Low-temperature Plasma (ALTP) as a novel noninvasive method for the removal of CN. A clinical case series was conducted from 2020 to 2021 at the Vision Health Ophthalmic Center in Tehran, Iran. CN in one of the eyes of seven patients was treated. In all patients, the benignity of CN was confirmed by ocular oncologists. The white handpiece of the Plexr device, which generates plasma with the lowest output, was used to apply plasma spots on the nevi. In addition, the Ocular Surface Disease Index (OSDI) questionnaire was completed by all patients before and six months after the treatment. In all patients, the nevi outside the limbus area completely disappeared. The mean size of pre- and post-operative nevi was 3.89×11.7 and 0.54×1.69 mm, respectively. Results of the OSDI questionnaire showed significantly lower scores after the surgery in all patients. The ALTP method is a simple, cost-effective, and office-based surgery to remove CN safely and effectively.

Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines.

Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.

Radiofrequency ablation of varicose veins in combination with ultrasonic-assisted wound debridement and platelet-rich plasma as well as platelet-rich fibrin technologies in treatment of lower extremity venous ulcers in office-based surgery.

Introductionfor the treatment of varicose ulcer performed clinical and laboratory reasoning of the use of ultrasonic-assisted venous ulcer debridement and Platelet-rich plasma with radiofrequency ablation in an outpatient setting, was carried out.Methodsultrasonic-assisted debridement of trophic ulcer were performed for 50 patients with lower extremity varicose veins at decompensation stage. The effectiveness of ultrasonic-assisted debridement was evaluated by indicators of bacteriological, morphological, cytological study and assessment of trophic ulcers according to the MEASURE system. After ultrasonic-assisted debridement, the patients were divided into two groups: 30 patients, who underwent combined Platelet-rich plasma to stimulate wound regeneration and 20 patients, for whom the Granuflex hydrocolloid bandage was applied for the same purpose.Resultsa comparative analysis of ulcer regeneration in two groups of patients proved that in cases of platelet rich plasma the time of transition from inflammatory-regenerative type to regenerative one is much shorter than when using a hydrocolloid dressing. In 28 patients undergoing Platelet-rich plasma (PRP) and Platelet-rich fibrin (PRF), the radiofrequency ablation of the principal superficial and perforating veins was performed. Another 22 patients performed autodermoplasty of trophic ulcers after radiofrequency ablation.Conclusionour experience has shown that in a one-day inpatient surgical clinic such a multidisciplinary approach to treatment of venous ulcers, including ultrasonic-assisted debridement that is stimulation of wounded process by Platelet-rich plasma with further surgeries to remove the causes of decompensated chronic insufficiency, is promising regarding low costs of treatment and rehabilitation of these patients.

Comment on: Purifying air over the operating field with a new mobile laminar airflow device to reduce the possibility of airborne contamination.

We were interested to read the recent article by Osher et al.1 We had also previously reviewed the poster by Osher and Figueiredo, “A New Technology for Purifying the Surgical Field”, at the 2019 ASCRS Annual Meeting in San Diego that had a nice picture of the Operio System located adjacent to the patient and the surgical field. Point 1, we wish that photograph had been included in this article and the reason for the orientation or of the machine discussed further in the article. Prior to the San Diego meeting, we became concerned with the plethora of lint-like fibers on the surgical field at our institution, both clear and blue, particularly after visualizing one in Bela Lugosi-like horror in the anterior chamber on the first postoperative day (Figure 1). After recovery and ensuring that the patient did not develop endophthalmitis, we initiated a Quality Assurance Project that sought to identify the number, risk factors, and location of these fibers during a senior resident's 3-month surgical rotation (A.H.). Eighty-nine surgeries were performed between the attending and the senior resident, and 15 fibers were identified. Most fibers were seen on the approach to the eye as an instrument was inserted, but 7 were seen in the eye during nucleus manipulation, capsulorhexis, and cortex removal. Similar to the article by Osher et al., we had no episodes of toxic anterior segment syndrome, chronic uveitis, or endophthalmitis (Table 1).Figure 1 Table 1. - Fiber Location During Phacoemulsification Surgery. Cataract procedure step Cases, n Intracameral moxifloxacin injection 3 Cortex removal 3 Capsulorhexis 2 Nuclear cracking and manipulation 2 Wound closure 2 IOL injection 1 Viscoelastic removal 1 Trabecular microbypass device 1 Regarding Table 2, the denominator is 99 in the laminar flow group and 50 in the control group. We noted on initial review that the total number of fibers seen in the laminar air flow group was 13 in 99 eyes vs the control group of 16 in 50 eyes, which is only a difference of 3, which if we increased the denominator to 100 in the control group, the total number of fibers would probably double. In personal communication with the primary author, it became clear that the salient point that the article conveyed is that in the laminar air flow group, the number of fibers directly on the field was zero. In other words, all fibers in the laminar air flow group were brought onto the surgical field by an instrument that is similar to our small series, which had a very high fiber rate of 16.9%. Watson et al. in their comment on this article focus on the trend to move toward office-based surgery and they discuss a laminar downflow hood that they have been using for 1 year.2 As such, Osher et al. and Watson et al. should be complimented for addressing important factors in our surgical microenvironments including air flow, ventilation systems, the revolving door-like atmosphere in a teaching environment, and our drapes and gowns. Point 2, we would go further, like our orthopedic colleagues, to attempt to close our operating rooms to transit to protect the laminar flow, locate our automated medication dispensing systems inside our operating rooms, and recommend that we seek to eliminate or find alternatives to article and cloth-based drapes and towels. We support the efforts by Osher et al. to eliminate what we aptly defined in our Quality Assurance Project as “Fibers, Fibers, Everywhere!”

Office-based management of Bartholin cysts and abscesses: a comparison of three surgical methods

Aim: In the present study, we aimed to compare the effectiveness of incision + drainage alone, marsupialization, and incision + drainage followed by silver nitrate application for the office management of Bartholin cysts/abscesses.&#x0D; Material and Method: A total of 128 women who presented to our clinic, diagnosed with Bartholin cysts/abscesses and underwent Bartholin gland sparing office-based surgery were included in this retrospective study. Patients’ demographic data, laterality and size of the cyst, surgical method performed, operational time, presence of recurrence, and treatment method of recurrent cysts/abscesses were recorded. Patients were divided into three group according to the operation they have undergone as incision + drainage alone, incision + drainage followed by silver nitrate, marsupialization. &#x0D; Results: The mean cyst diameter was found as 3.00±1.05 cm. Eighteen (14.1%) patients developed recurrence. Of all patients, 37.5% underwent incision + drainage alone, 8.6% incision + drainage followed by silver nitrate application and 62.5% marsupialization. The mean operational time was significantly longer in the marsupialization group compared to incision + drainage alone and incision + drainage followed by silver nitrate groups (both, p

The assessment of a growing mobile anesthesia practice from 2016 to 2019: A retrospective observational cohort study of 89,999 cases comparing ambulatory surgery (ASC) and office-based surgery (OBS) centers using a high-fidelity, anesthesia-specific electronic medical record (EMR).

Office-based surgery (OBS) has emerged as a significant subspecialty of ambulatory surgery. There are few clinical trials and limited published data on patient characteristics, anesthesia, or outcomes distinguishing OBS from ambulatory surgery centers (ASCs). We examined retrospective data from a large mobile anesthesia practice for 89,999 procedures from 2016 to 2019. Data was abstracted from billing and an anesthesia-specific electronic medical record, segregating procedures performed in ASCs versus OBS. The number and breadth of procedures increased substantially. Compared to ASCs, OBS patients were more likely male (52% vs. 48%), older (61 years vs. 55 years), and to have a higher American Society of Anesthesiologists (ASAs) status (33% vs. 20% ASA 3 or higher). The procedure mix varied substantially between the two settings. The major complication rate was 0.07% for the ASCs and 0.24% for OBS (p=0.2, confidence interval [CI] -0.15 to 0.04). Minor complications were 11.2% in OBS versus 17.3% the ASCs (p<0.0001, 95% CI 5.2-7). The practice demonstrates a low rate of complications, and despite the limitations of this study, the organization and structure of this large mobile anesthesia practice serves as a template for effective risk mitigation and patient safety.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review.

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Comparative Efficacy of the KTP Laser and Cold Steel in Office-Based Surgery for Oropharyngeal Papilloma.

Objective: This study aims to compare the efficacy of the potassium-titanyl-phosphate (KTP) laser and cold steel surgery in treating oropharyngeal papilloma. Methods: Between 2017 and 2020, we enrolled 242 patients with oropharyngeal papilloma who were treated with either the KTP laser (n = 160) or cold steel surgery (n = 82). Patient charts were reviewed for demographic data (age and gender), pathology, anatomical location of lesions, operative duration, pain rating, residual disease, and recurrence. Results: The oropharyngeal papillomas were successfully removed in all patients, except one with a significant pharyngeal reflex. There was no significant difference in the average time for lesion resection between KTP laser and cold steel group (18.11 ± 13.96s vs 19.43 ± 16.91s, P > .05). However, all patients who underwent cold steel surgery experienced bleeding during the operation and required postoperative observation (about 20min), making the total procedure time longer than that of the KTP laser procedure, which did not cause any intraoperative bleeding or require postoperative observation. After KTP laser treatment, the pain rating was .49 ± .98, whereas after cold steel surgery, it was .74 ± 1.12 (P = .058). Twenty-five samples were sent for human papillomavirus (HPV) testing, and one tested positive for both HPV 6 and 11 strains, while another tested positive for HPV 16. No residual disease or recurrence was observed at the treatment sites after a long period of follow-up (M = 15.35 ± 10.79mo; range = 6-39mo). Conclusion: The KTP laser provided a better hemostasis effect and a good surgical field of vision during the operation, allowing the surgeon to complete the procedure in less time. No significant difference in terms of pain rating, incision recovery, and postoperative recurrence between the KTP laser treatment and cold steel surgery.

27828 Oxygen-enriched operating rooms and surgical fires: An underestimated risk of ambulatory dermatologic surgery

Dermatologists perform a number of office-based surgical procedures; therefore, they are faced with a unique challenge to create a safe and controlled operative setting. Oxygen-enriched environments created by nasal cannulas, nebulizers, or oxygen cylinders complicate the set-up of an ambulatory operating room (AOR), as the gas can accelerate combustion and facilitate fire ignition. While the risk of surgical fires is low, the risk can be diminished with proper education and preoperative risk assessments.

Quality, Safety, and Standards Organizations COVID-19 Impact Assessment: Lessons Learned and Compelling Needs.

The stark reality of the COVID-19 pandemic challenged the very systems established to ensure the nation’s safety and quality. The pandemic resurfaced long-endemic challenges within the health care quality and standards ecosystem and identified novel challenges that cannot be ignored. This paper examines: 1. the health care quality and standards ecosystem pre-pandemic; 2. vulnerabilities in quality and standards organizations exposed by COVID-19; 3. quality and standards organizations’ responses during the pandemic; 4. opportunities to improve the national response to improving quality and safety overall with a particular focus on readiness in the case of disasters, pandemics, or other national emergencies; 5. sector-wide policy, regulatory, and legal changes that might be transformative; and 6. priorities moving forward. The quality and safety focus of the American health care system has a long history, dating back to the 19th and early 20th centuries. Quality of care is generally understood as providing the right care for the right person at the right time—every time. Several seminal laws and publications over the last 60 years have shaped the current quality landscape in profound ways and have been cataloged in numerous publications [1,2,3,4]. These publications generally point to several landmark occurrences that have shaped the evolution of quality measurement, improvement activities, and safety standards over the years. The evolution has centered around four main levers (see Figure 1): Open in a separate window FIGURE 1 Key Levers for Care Quality and Safety 1. survey, certification, and accreditation of facilities, laboratories, health plans, and providers; 2. quality measurement, incentives, and payment reforms; 3. public ratings of providers and facilities; and 4. quality improvement learning and action networks. Survey, Certification, and Accreditation The role of government in establishing quality and safety standards for the health care system became prominent with the implementation of the 1965 Medicare legislation, in which Congress explicitly tied payment to the achievement of minimum health and safety standards, commonly known as conditions of participation (CoPs). Initially, the CoPs focused on medical staff qualifications, nursing services, and utilization review, but have since evolved to include minimum standards for various other important safety issues, including infection control, emergency preparedness, quality assurance, performance improvement, and medication management. States also established health and safety requirements for facility licensure. State standards for health and safety must, at a minimum, align with the CoPs but may go above and beyond the federal requirements. While the state government and federal surveyors perform inspections for many facilities (primarily nursing homes), the Centers for Medicare and Medicaid Services (CMS) has approved several national accreditation organizations (AOs) to perform survey functions [5]. One of the largest AOs is the Joint Commission. Founded in 1951, the “Joint Commission accreditation can be earned by many types of health care organizations, including hospitals, doctor’s [sic] offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services” [65]. In 1990, the National Committee for Quality Assurance (NCQA) was established as a nonprofit organization that accredits quality programs for health plans, physicians, and other providers. NCQA developed the first set of standards for health plan quality using a set of evidence-based requirements and measurements.

Iliac vein stenting is safe when performed in an office based laboratory setting

BackgroundVenous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting. MethodsData were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm. ResultsBetween January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died. ConclusionsMajor complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

Ambulante Phonochirurgie

Wesentliche und neue Impulse, die das Behandlungskonzept für ambulante phonochirurgische Eingriffe am unsedierten Patienten betreffen, stammen aktuell aus dem angloamerikanischen Sprachraum. Die dort etablierten „office-based procedures“ werden als eine Alternative zu vielen konventionellen operativen Larynxeingriffen in Vollnarkose propagiert. Maßgeblich für diese Entwicklung ist der Einsatz neuer endoskopischer Techniken in Kombination mit photoangiolytischen Laserverfahren (KTP-Laser und blauer Laser), die eine sichere und effiziente ambulante Phonochirurgie ermöglichen. Die Akzeptanz seitens der Patienten ist hoch, da ambulante Eingriffe als risikoärmer gelten. Ungeachtet der verbreiteten Euphorie fehlen weiterführende Studien, welche die medizinischen Entscheidungskriterien und das Sicherheitsmanagement bei dieser neuen ambulanten Ausrichtung der Kehlkopfchirurgie bewerten.