‘Bright future’ or ‘immense loss’? Interventionalists split over shift towards ambulatory practice

Aaron Mauck

A number of speakers took to the stage at the International Symposium on Endovascular Therapies (ISET; 16–19 January 2023, Miami Beach, USA) to debate the ‘ambulatory shift’ that is currently taking place in the interventional space.

Aaron Mauck (Advisory Board, Washington DC, USA), began with a keynote lecture describing the factors driving the migration of procedures away from the hospital towards ambulatory surgery centres (ASCs) and office-based labs (OBLs)—describing this as a “seismic shift” that “everyone is preparing for”. New reimbursement policies and regulations, provider competition and innovation are among major drivers of this trend. However, Mauck stated that “the future is not etched in stone” when it comes to the ambulatory shift, adding that industry investment and purchaser/referrer steerage are among factors that could accelerate this shift, while certain data indicating poorer outcomes with peripheral vascular procedures performed in the OBL—as well as US state legislatures not being amended—constitute barriers that may slow the process.

Jeffrey Carr

For ambulatory practices
Several key points extoling the virtues of more ambulatory, office-based practices were delivered by Jeffrey Carr (CardiaStream, Tyler, USA). Drawing on a 15-year experience of cardiac and vascular procedures in the ambulatory environment, Carr averred that greater control of their (his team’s) schedule and patients’ clinical care was among the initial motivations behind establishing an OBL in 2008, which was then transitioned to a hybrid lab—an OBL-ambulatory surgery centre (ASC)—in 2014. Here, the speaker cited the possibility for diversification and optimisation of revenue, a minimised impact on reimbursement cuts, and “higher standards” for existing OBLs as among the most important benefits.

After detailing the myriad peripheral vascular, cardiac and venous interventions that can currently be performed in his centre’s office-based settings—and touching on other future possibilities, such as aortic repairs and carotid stent placements—Carr concluded that it is “vital” to follow standardised processes/protocols, while also exercising transparency and reporting outcomes accurately. He further stated that “the future is bright” for expanding procedures, reducing costs and creating high value in office-based and ASC settings.

Jason Greis

This session also yielded additional tips for those wishing to establish outpatient practices—Jason Greis (Benesch, Friedlander, Coplan & Aronoff, Cleveland, USA), advised prioritising “quality of care, not volume of cases”; maximising the number of interventionalist owners and the percentage of equity they hold; and taking patient, payer and investor complaints seriously.

Against ambulatory practices
This talk was immediately followed by Dipankar Mukherjee’s (INOVA Fairfax Hospital, Falls Church, USA) presentation entitled: “Why I chose not to work in an outpatient lab”. Mukherjee noted that, since the 2011 approval of atherectomy codes for peripheral vascular interventions, migration of talent has become a problem, as “some of our best interventionalists” have moved from hospitals to OBLs. In addition to leaving some of the sickest hospitalised patients in the hands of less experienced operators, and contributing to a “serious manpower crisis” across much of the USA, the speaker stated that these interventionalists have “abandoned their responsibility” in educating future generations as well.

Dipankar Mukherjee

On top of this “immense loss” facing trainees, surgeons working exclusively in OBLs are also likely to “lose all open repair skills”, according to Mukherjee, who asked the ISET audience, ‘where would you and I be now’ if pioneering interventionalists of the past had gone to work in these ambulatory settings? He further called for the “rules of the game” in OBLs to change and for the restoration of “the values that attracted us to the profession and specialty”.


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