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May 1996
Volume 60 |
Number 5
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| The Anesthesiologist
in the Ambulatory Surgical Care Setting |
Rebecca S. Twersky, M.D., Chair
Committee on Ambulatory Surgical Care
The paradigm shift to the expanded role of the anesthesiologist
as a perioperative physician, as recently espoused by respectable
colleagues,1-3 is not a new concept at all for those clinicians
who have engaged in the specialty of ambulatory surgery and anesthesia.
Since the rapid growth of ambulatory surgery started in the 1980s,
anesthesiologists have become an integral part of the infrastructure
that has led to the success of outpatient facilities. This shift
could not have been achieved without the availability of newer
anesthetics and pharmaceuticals coupled with our expertise in
meeting these changing needs. Our recognized role as perioperative
physicians has provided us with a competitive edge to meet the
needs of a changing marketplace and will continue, especially
as newer noninvasive surgical technology expands the possibilities
of outpatient procedures.
The majority of the medical directors of ambulatory surgical care
facilities are anesthesiologists who have assumed both clinical
and managerial roles. Although the increase in ambulatory surgery
is less dramatic than 15 years ago [Figure 1], there continues
to be a shift of procedures from inpatient to outpatient setting,
including the increasing segment to freestanding centers and physicians'
offices.4,5 It is within this capacity as physician-manager that
the anesthesiologist has gained recognition as a perioperative
physician. We have guided our facilities in the development of
policies and protocols that utilize our expertise as perioperative
physicians. These have included preoperative screening clinics,
integrated health delivery systems and anesthesia outside the
operating room, including sedation and analgesia.
Perhaps the most noticeable activity of the perioperative physician
in ambulatory surgical care is in the establishment of preoperative
screening clinics. Although there is no registry of how many of
these facilities exist, continued demand by health and managed
care networks to consolidate the preoperative preparation of the
patient has led many surgeons and ambulatory surgery facilities
to turn to anesthesiologists as the most obvious leaders of this
process. While staffing needs vary among preoperative screening
clinics, the common patients are suited for surgery, determining
what testing may be needed6 and setting the tone for evaluating
and educating patients prior to surgery and anesthesia.
Unfortunately, the role of the perioperative physician-anesthesiologist
still has not achieved universal acceptance, especially because
there is a lack of uniformity among clinicians. In fact, through
its Task Force on Preoperative Evaluation, ASA is in the process
of establishing consensus guidelines that could facilitate some
standardization of preoperative assessments within and outside
our specialty.
Nonetheless, the anesthesiologist in the preoperative screening
clinic is a clear example of our perioperative physician challenges.
Future opportunities exist for the perioperative physician to
link information systems and to increase online communication
with physicians' offices and other providers involved in preoperative
and postoperative care to further enhance this process.
Some of the market is shifting to facilities that are part of
integrated delivery systems and ambulatory service networks, joint
ventures or formal contractual arrangements. In addition, surgical
services are provided by multispecialty freestanding ambulatory
care centers. Among the most common outpatient services is ambulatory
surgery with emergency and laboratory services.4 As such, our
visibility as perioperative physicians becomes even more important
when establishing the value of our professional services.
As the perioperative physicians in ambulatory surgery, we are
sensitive to the need for operating room efficiency, cost-containment
and patient satisfaction. Our leadership abilities as physicians
and managers have enhanced our role as perioperative physicians.
By 1997, hospitals will have lost one-third of their share of
the ambulatory surgery market. At that time, they will provide
only 45.5 percent of all procedures compared to the 75 percent
they provided in 1992.5 Effective management of these facilities,
especially the close examination of how overhead costs are assigned
to outpatients and the attention to improving how patients perceive
these facilities, will enable hospitals to remain competitive
in the current market. Many perioperative physician-anesthesiologists
have taken the leadership role and are actively involved in the
fiscal and administrative management of operating rooms.
While health care systems and integrated networks accepting capitation
will be able to direct patients to the most appropriate setting
and may use subcontracts with lower-cost providers, the competition
by ambulatory surgery centers (ASCs) becomes great. Hospitals
are moving ambulatory surgery out of the high-cost operating suite
into affiliated outpatient centers. ASCs will experience competition
from hospitals as they augment their satellite operations and
develop multipurpose ambulatory care centers.
In order to both treat higher acuity patients and package their
services for managed care companies, ASCs are expanding their
preoperative and postoperative services. Because our services
span the perioperative period, this may be an opportunity to become
more vocal about the role that anesthesiologists play and to delineate
that role during contractual negotiations. With the expansion
of services into 23-hour or recovery care centers, we may be further
responsible for managing the patient's postoperative course, including
but not limited to postoperative pain.
Although not limited to ambulatory surgical care, providing guidance
and personnel for sedation and analgesia outside the operating
room follows the model of the perioperative physician. The Joint
Commission on Accreditation of Healthcare Organizations has clearly
acknowledged our expertise and requirements for establishing policies
within hospitals. Numerous opportunities have arisen for clinicians
in the outpatient setting to facilitate noninvasive and diagnostic
procedures in remote and nonoperating room settings.
By providing appropriate sedation and analgesia, monitoring, and
recovery parameters, we have firmly established ourselves as professional
consultants in areas that extend beyond the traditional operating
room. That is the goal of the paradigm shift.
References:
1. Alpert CC, Conroy JM, Roy RC. Anesthesia and perioperative
medicine: A department of anesthesiology changes its name. Anesthesiology.
1996; 84:712-715.
2. Longnecker DE. Planning the future of anesthesiology. Anesthesiology.
1996; 84:495-497.
3. Saidman LJ. What I have learned from 9 years and 9,000 papers.
Anesthesiology. 1995; 83:191-197.
4. American Hospital Association. 1994-95 Hospital Statistics.
Chicago, IL: AHA; 1995.
5. SMG Forecast of Surgical Volume in Hospital/Ambulatory Settings:
1994-2001. Chicago, IL: SMG Marketing Group, Inc.
6. Mangano DT, Goldman L. Preoperative assessment of patients
with known or suspected coronary disease. N Engl J Med.
1995; 333:1750-1756.
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