Performing minimally invasive procedures in the office is the new standard of care in hysteroscopic medicine.1
The shift from hospital-based to in-office hysteroscopic procedures began in the 1980s because evidence demonstrated higher success rates, lower complication rates, lower cost, and greater diagnostic accuracy with in-office hysteroscopic procedures than with hospital-based procedures.2,3 By the early 2000s, it was estimated that 20% of gynecologists were performing hysteroscopies in their offices.3,4 The most recent American College of Obstetricians and Gynecologists Workforce Report indicates that many physicians are performing a variety of procedures in their offices.4
In my practice, 75% of hysteroscopic procedures are performed in the office. I am committed to providing quality care while also staying on the cutting edge of new technology; when it is right for the patient, I prefer to perform diagnostic and operative hysteroscopic procedures, including hysteroscopic myomectomy and endometrial ablations, in the office.
As I talk to colleagues about the importance of moving procedures to the office setting and how it is beneficial to my practice, I refer to the four “Ps.” The first of the four is “Procedures,” an awareness of which procedures you can perform in your office, and how the technology today makes it possible. Smaller hysteroscopes with better visualization enable greater accuracy and more surgical control, advances in electrosurgical technology make it more comforatable for patients and improvement in additional devices, has dramatically enhanced the speed and accuracy of tissue removal.
Then there are the remaining three “Ps”:
Patient
Physician
Practice of Medicine
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Benefit for patients Doing procedures in the office absolutely benefits our patients. Coming to the office is more convenient for the patient, eases much of their anxiety about surgery, and is often less expensive than it would be had the procedure taken place in a hospital or surgery center.Research shows that women tend to be more comfortable when procedures are performed in the setting where they receive routine gynecologic care, by a physician they already know and trust.2,5 Short procedure length—about an hour from arrival to completion—in a familiar setting allows patients to come and go quickly, minimizing interruptions to their daily lives. Convenience and comfort could decrease the anxiety that many women say they experience before hysteroscopy.6
The high cost differential between OR and office-based care yields a dramatic difference in cost savings for procedures not covered by insurance.2 Women also typically pay less in copays and deductibles in the office.7 Shortened wait and procedure times reduce the number of work hours patients miss, in turn minimizing income loss for patients and offering even more savings.7
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Benefit for physicians Performing procedures in the office setting benefits us as physicians in terms of convenience of scheduling, increased revenue, and overall efficiency of our practice. A quick learning curve for the staff ensures the whole team can participate and an optimal experience for the patient.Bringing procedures into the office doesn’t mean hiring more staff, but it does require training your existing staff to develop an efficient workflow.
When the care team is working effectively and efficiently together, in-office procedures afford the doctor the opportunity to devote more time to their other patients while surgical patients are being prepped for or are recovering from their procedure.7,8 This increase in doctor-patient time can be beneficial to the practice’s reputation and gives the physician greater control over their schedule.8
Due to improved reimbursement for in-office procedures, physicians are also realizing the financial benefit of moving surgical cases to the office setting. Recently, reimbursement rose a remarkable 237% for hysteroscopic endometrial biopsy and/or polypectomy performed in the office—compared to a decrease of 11% to 19% for the same procedure in a hospital or ambulatory surgical center.7,9 This in-office fee increase has been coupled with increased coverage of procedure-related practice expenses, such as the cost of hysteroscopic fluid management and tissue resection systems. This financial support signals that the Center for Medicare & Medicaid Services is encouraging the shift to in-office procedures.7
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Better for practice of medicine and the healthcare system Everyone, including physicians, needs to be aware of the financial impact of surgical procedures on the healthcare system. By performing procedures in the office, practices have an opportunity to reduce the cost burden of gynecologic procedures through optimized care, value, quality, and efficiency. The total cost of a surgery performed in the office is significantly less than the same procedure performed in a hospital or ambulatory surgical center. For this reason, costs don’t trickle down to patients.We, as physicians, can be a part of the solution to reducing health costs.
With today’s technology, integrating hysteroscopic procedures into the practice is easier than ever before.
As physicians, we all want to provide the highest level of quality care. Establishing our practices as office-based centers of care is crucial to our future as obstetrician-gynecologists. It is about staying at the leading edge by providing the highest quality of care, doing what is right for our patients, and helping to improve the practice of medicine.
1. Mairos J, Martino PD. Office hysteroscopy. An operative gold standard technique and an important contribution to patient safety. Gynecol Surg. 2016;13:111-114. 2. Emery JD, Paraiso MFR, eds. Office-Based Gynecologic Surgical Procedures. New York, NY: Springer Science+Business Media; 2015. 3. Hidlebaugh D. A comparison of clinical outcomes and cost of office versus hospital hysteroscopy. J Am Assoc Gynecol Laparosc. 1996;4(1):39-45. 4. Rayburn WF. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications. Washington, DC: The American Congress of Obstetricians and Gynecologists; 2017. 5. Cholkeri-Singh A. The benefits of integrating in-office hysteroscopy. MDedge web site. Accessed February 19, 2019. 6. Gambadaueo P, Navaratnarajah R, Carli V. Anxiety at outpatient hysteroscopy. Gynecol Surg. 2015;12:180-196. 7. Cholkeri-Singh A. Payment changes drive hysteroscopy to the office. MDedge web site. Accessed February 19, 2019. 8. Data on file. Hologic, Inc. 2017. 9. Witt M. In-office hysteroscopy procedures: reimbursement jumps 237%. OBG Management. 2017;29(7):26-29.
Dr. Miller is a paid consultant of Hologic. Hologic provided editorial support for this article.
Dr. Miller completed medical school at Loyola University Stritch School of Medicine and a residency in Obstetrics and Gynecology at Rush University Medical Center in Chicago. She spent part of her childhood in Naples and returned to join A Woman's Place in 2009 after spending time in private practice in Jackson, Tennessee. Dr. Miller's interests lie in minimally invasive surgery including daVinci hysterectomy, myomectomy and endometriosis resection; laparoscopy; in-office procedures; high risk obstetrics; and adolescent gynecology. Outside of the office, she enjoys spending time with her husband and four children, reading and running.
Dr. Miller is Board Certified by the American Board of Obstetrics and Gynecology. She is a Fellow of the American College of Obstetrics and Gynecology and a member of the American Medical Association (AMA) and the Collier County Medical Society (CCMS).