Determining the Optimal Location for Minor Procedures—Goldilocks Medicine and the Just-Right Surgical Setting | Orthopedics | JAMA Network Open | JAMA Network
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Invited Commentary
Surgery
October 13, 2020

Determining the Optimal Location for Minor Procedures—Goldilocks Medicine and the Just-Right Surgical Setting

Author Affiliations
  • 1Department of Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 2Division of Plastic Surgery, Stanford University, Palo Alto, California
JAMA Netw Open. 2020;3(10):e2016127. doi:10.1001/jamanetworkopen.2020.16127

This study by Billig et al1 provides information on the optimization of the surgical setting for minor surgical procedures. The study used large national claims data to evaluate the settings and outcomes of more than 400 000 minor hand operations. The authors found that procedures performed in offices had similar rates of complications and substantial decreases in costs compared with procedures completed in formal operating rooms.

The surgical setting has evolved over the centuries. Early on, procedures were often performed outside, such as in military tents. By the end of the 19th century, germ theory and sterile technique were accepted, and procedures moved to more controlled indoor settings, such as the operating theater seen in the iconic Thomas Eakins paintings. Since World War I, integrated high-technology operating rooms have become the norm for most procedures. However, the question has arisen recently: are these high-technology operating rooms the right setting for more minor procedures?

This study by Billig et al1 focused on the benefits of the office setting for minor hand procedures. However, this transition to office settings has also been occurring for a variety of other surgical disciplines.1,2 All of this emerging literature should reassure patients and stakeholders about the utility of the office setting for minor surgical care.

It is interesting to consider the various forces that have had the opposite influence, pushing minor procedures into the operating room. First, US medical culture often defaults to a philosophy of maximal medicine. In this view, an operating room is seen as the ultimate site of care and therefore better and safer. However, the study by Billig et al1 and others3,4 have shown that the office is equally safe for many minor procedures. Second, patient preferences could be driving the choice of the operating room, but that is unlikely, as offices are used commonly for minor procedures in many other countries. In addition, other disciplines, such as dermatology and dentistry, perform major procedures in the office, and patients have been satisfied with their care.5 Third, surgeon preferences are important in the choice of procedure location. The surgeon’s experience with an awake patient in the office is quite different from the experience with a sedated patient in the operating room. In the office, the surgeon must interact with the patient while simultaneously focusing on the surgical task. Little research is available on the role surgeon attitudes play in the choice of surgical setting. Surgeons must be amenable to the change to office-based procedures if widespread implementation is to occur. Finally, a powerful force pushing the use of the formal operating room is finance; office-based procedures often receive no facility fees. This is a strong financial disincentive, especially if the professional fee does not cover the costs of the procedure.

Despite the demonstrated benefits of the office setting, most minor procedures are still performed in the operating room. Indeed, the study by Billig et al1 found that only 5% of procedures studied were performed in the office. To encourage change and the use of the right setting for procedures, the patient, the system, and the surgeon need to be engaged. Our own experience transitioning to a minor procedure room in 2007 went smoothly, with widespread patient acceptance. A study by Davis et al6 also found that patients likely represent a minimal barrier to implementation of this change. At the system level, change has already begun. Several companies offer a bundled payment model for carpal tunnel care. If there is a fixed reimbursement for a procedure, the facility fee disincentive disappears and the system is incentivized toward efficiency. Finally, the biggest barrier is likely that surgeons and physicians can be resistant to change.7 However, evidence-based pathways can provide surgeons and specialty societies with a framework to implement this change widely.

Choosing the right setting should be part of all clinical care, not just in deciding the location of minor surgery. The study by Billig et al1 and those by others highlight the transition of medical philosophy from maximal medicine to Goldilocks medicine, in which the goal is to get the care just right.

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Article Information

Published: October 13, 2020. doi:10.1001/jamanetworkopen.2020.16127

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Curtin CM. JAMA Network Open.

Corresponding Author: Catherine M. Curtin, MD, Department of Surgery, Veterans Affairs Palo Alto Health Care System, Ste 400, 770 Welch Rd, Palo Alto, CA 94304 (ccurtin@stanford.edu).

Conflict of Interest Disclosures: None reported.

Disclaimer: The contents do not represent the views of US Department of Veteran Affairs or the US government.

References
1.
Billig  JI, Nasser  JS, Chen  JS,  et al.  Comparison of safety and insurance payments for minor hand procedures across operative settings.   JAMA Netw Open. 2020;3(10):e2015951. doi:10.1001/jamanetworkopen.2020.15951Google Scholar
2.
Ianchulev  T, Litoff  D, Ellinger  D, Staverton  K, Packer  M.  Office-based cataract surgery: population health outcomes study of more than 21 000 cases in the United States.   Ophthalmology. 2016;123(4):723-728. doi:10.1016/j.ophtha.2015.12.020 PubMedGoogle ScholarCrossref
3.
Leblanc  MR, Lalonde  DH, Thoma  A,  et al.  Is main operating room sterility really necessary in carpal tunnel surgery: a multicenter prospective study of minor procedure room field sterility surgery.   Hand (N Y). 2011;6(1):60-63. doi:10.1007/s11552-010-9301-9 PubMedGoogle ScholarCrossref
4.
Lalonde  D, Bell  M, Benoit  P, Sparkes  G, Denkler  K, Chang  P.  A multicenter prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.   J Hand Surg Am. 2005;30(5):1061-1067. doi:10.1016/j.jhsa.2005.05.006 PubMedGoogle ScholarCrossref
5.
Perrott  DH, Yuen  JP, Andresen  RV, Dodson  TB.  Office-based ambulatory anesthesia: outcomes of clinical practice of oral and maxillofacial surgeons.   J Oral Maxillofac Surg. 2003;61(9):983-995. doi:10.1016/S0278-2391(03)00668-2 PubMedGoogle ScholarCrossref
6.
Davison  PG, Cobb  T, Lalonde  DH.  The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.   Hand (N Y). 2013;8(1):47-53. doi:10.1007/s11552-012-9474-5 PubMedGoogle ScholarCrossref
7.
Ubel  PA, Asch  DA.  Creating value in health by understanding and overcoming resistance to de-innovation.   Health Aff (Millwood). 2015;34(2):239-244. doi:10.1377/hlthaff.2014.0983 PubMedGoogle ScholarCrossref
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