Outpatient Endovascular Suites: Are They Good for the Patient or the Doctor?
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Vascular surgeons, as well as related specialists, have increasingly become involved in the ownership of outpatient endovascular suites as proprietors (individual or partnered with other physicians or hospitals) or through lease arrangements. As such they would be responsible for the operation of the entity including any accreditation requirements, the financial aspects, quality, and patient safety.
There are some compelling reasons for physicians to become involved in these ventures. However, some have suggested that many of these suites will be established with minimal patient safeguards, outdated or inefficient technology, and ill-prepared or insufficient staff. Further, competition from these suites would reduce inpatient angiographic volume and experience as well as negatively impacting the finances of nearby hospitals. The main argument advanced by detractors of physician ownership has been that the profit motive may result in unnecessary testing or procedures and ?cherry picking? the less complicated and insured patient.
Accordingly, the Clinical Practice Council of the Society for Vascular Surgery (SVS) requested that a white paper be written to provide guidelines on the establishment and function of outpatient endovascular suites. However, there was a considerable debate as to what should be included in this white paper with some even suggesting that these outpatient suites should not be supported. Consequently, the Council requested the authors to initiate debate on the subject. Eventually the SVS may have sufficient information from its membership to produce a definitive statement as to the role and function of these outpatient facilities. Therefore, this editorial is based on the opinion of the authors. It is not a product of a systematic review nor is it a comprehensive analysis of the subject. Neither is it a product of the Society for Vascular Surgery. Readers are encouraged to consider the information presented, evaluate other material and reach their own conclusions. The authors would appreciate feedback in the form of letters to the editor of "Vascular Specialist" or directly to the authors. Their emails accompany this editorial.
What we think!
Diagnostic arteriography, venography, venous ablation, balloon angioplasty, atherectomy, vena caval filters, filter extraction, and stenting can all be performed in an outpatient setting and have been shown to be safe provided that standard quality controls are in place.
Compared to in-hospital centers, these free-standing outpatient suites may offer more efficient clinical operations, saving time and money for the patient, the surgeon and the insurance provider. Patients could benefit from the convenience and consistency of on-time appointments, convenient locations, shorter wait times, easier scheduling, onsite parking and less intimidating surroundings. The location and space allotted to the suite will vary. However, every effort should be made to assure that these positive attributes of outpatient endovascular suites are incorporated. The insurance carrier may benefit by reimbursing the center less than if the procedures were performed in a hospital. This would then result in lower co-pay for the patient and reduce overall premiums and the cost of healthcare. Vascular surgeons would have the convenience of working in a familiar facility usually in proximity to their clinic or private office. Importantly, they would work in an environment where they have direct control over safety, quality, personnel, equipment and cost.
Some endovascular suites are directly affiliated and attached to hospitals whereas others are independent and located at variable distances from hospitals or emergency facilities. Irrespective of ownership or location considerations, the prime concern for the vascular surgeon should be patient safety. Accordingly, special considerations may be required when these procedures are performed in locations at a distance from hospitals. Foremost, only procedures and technology proven to be safely performed as an outpatient should be considered for that setting. Newer technologies and procedures should probably not be utilized until their safety has been established. For example, although diagnostic carotid arteriography may be safely performed, stenting of carotid lesions probably should not be performed in these outpatient facilities at this time.
Procedures to prevent wrong side interventions, incorrect medication administration and other safety precautions, standard in hospital environments, must also be followed. Timely production of complete procedure reports and hard copy (digital or other media) of the images is strongly encouraged since these will most often be reviewed offsite.
Nowadays "cloud" storage of data may allow easy access to images although privacy concerns must be safeguarded. Tracking of complications such as hematoma formation, allergic reactions and other quality parameters such as contrast dosages, fluoroscopy time etc., should be performed on a regular basis.
In many states, complications must be reported to the relevant State Department of Health usually within 48 hours for their review. Most importantly, the endovascular suite should have in place a plan to deal with emergencies that may arise during or soon after a procedure such as cardio-pulmonary arrest, retroperitoneal bleeding, access site bleeding, false aneurysm, anaphylaxis etc. Standard care should incorporate having ACLS certified personnel present at all times with the ability to perform aggressive CPR including intubation, cardiac defibrillation etc.
