Dr St. Amour, Interventional Radiologist at CARTI Cancer Center in Little Rock, Arkansas, spoke with IO Learning and shared his unique perspective on transitioning from a hospital setting to treating patients in an outpatient setting.
Why did you choose to practice in the outpatient setting?
I did my residency at Columbia, and I actually worked very closely with Dr. David Sperling, who is an advocate of performing interventional radiology procedures in the office-based lab (OBL). He has mentored a number of residents and fellows in that setting, and I thought it sounded great. The idea of greater autonomy, better work-life balance, and a more consistent schedule was intriguing. Then, one of my father’s partners, who has been a mentor to me as well, was hired to an oncology group to start an OBL back home. Needless to say, I’ve been fortunate to have joined him at CARTI.
What are the advantages and disadvantages of the outpatient setting?
The obvious advantages are you have no call, there are no weekends, and essentially set hours, which is fantastic, but you also get pigeonholed into what procedures you can perform. There are certainly procedures you are not going to do in an OBL that are possible in a hospital. For example, I was trained to do endovascular aneurysm repair (EVAR). There may be people who would do EVAR in an OBL, but I’m not one of them, at least with currently available devices. These are procedures that I love to do, that I was trained to do, but realistically from a safety perspective, it’s just not appropriate.
It all comes down to comfort level. What do you feel comfortable doing in an outpatient setting? For instance, as much as I would love to treat superior vena cava syndrome, there is a very small but real risk of causing a severe cardiac tamponade, and that’s just a risk I’m not willing to take. With something like a foreign body retrieval — say an intracardiac catheter fragment from a fractured port — I feel comfortable doing that because I feel like I can manage an arrhythmia if it were to happen. Fortunately, it hasn’t, but I feel much more comfortable treating that than something that would require a much higher level of care rapidly.
How do you handle complications that cannot be resolved in the OBL?
I have admitting privileges at the closest hospital to our OBL. I don’t have procedural privileges, but if there are any issues with one of my patients, I can always send them over there. Typically, I’ll admit them to a hospitalist. I’ll contact the hospitalist on call, tell them I’m sending a patient over, and get the patient admitted to them. Then I follow the patient during their hospital course and help with management of any complications. Almost all of the complications I’ve had that required transfer to a hospital are because of lung biopsies, usually for chest tube management, and I’ll do that chest tube management myself.
Are there any procedures that you used to do outpatient that you stopped doing or vice versa?
There is nothing I have stopped doing. I’m always willing to try something new if I think it can be done safely, but I have modified my techniques to make it a more safe experience and more appropriate experience for an OBL. For instance, for lung biopsies, I do a blood patch on every patient, which I hadn’t done in a hospital setting. Also, I almost exclusively do distal radial access because it’s an easier recovery and arguably less risk of complications than femoral access. And, these are techniques I had to learn after my training.
Radial access is continuing to grow in popularity.
Absolutely. We hear a lot about interventionalists doing more and more radial access. I personally do all distal radial access. Not only is it more comfortable for the patient, but it is also for my own personal comfort, because I find it easier to work from the right side of the table, and my patient can put their hand across their stomach as I work.
Are there any particular types of equipment, staff, or technology that you would like to highlight?
We had the first combined CT/fluoroscopy machine in the United States at our facility, which is great. All equipment is going to have pluses and minuses, but the real beauty of this equipment (the Toshiba Infinix 4D CT; now Canon Infinix-i 4D CT) is that I can go back and forth between one modality and the other in a single room. I have one room that I can do all my procedures in, which saves space, overhead, and costs. I found that very helpful. Moreover, we have certified registered nurse anesthetist (CRNA) coverage for most of our cases.
How is pre- and postprocedure care handled in your outpatient clinic?
We have a preprocedure/recovery area that currently has 4 bays, and we’re moving up to 10 bays. Our patients come in, go into a preprocedure room, and are prepped by our excellent nurses. Then, we do the procedure and they go immediately back to that room for recovery. It’s pretty seamless. As you grow, obviously 4 beds is definitely not going to be enough, especially when you start doing bigger procedures or you need to monitor patients longer than expected, as we have learned. We’re also in the process of adding another procedure room to cover greater demand.
How are tasks delegated to different team members in the OBL?
This is probably one of the most exciting things that I didn’t even know existed until I started this job. We have a contract with a local anesthesia group. They provide CRNAs, and those CRNAs do all the sedation for our cases. We discuss what would be the most appropriate level of sedation, and then the CRNA performs all of the monitoring and sedation.
Did you previously need an anesthesiologist to do that in the hospital?
It depended on the level of anesthesia, although an anesthesiologist or CRNA is required for anything beyond moderate sedation. Most IR and IO cases are done with moderate sedation, which is essentially led by the attending physician in the room and monitored by a nurse. So, as the physician, you are tasked with both doing the procedure and making sure that the patient is comfortable from a sedation standpoint. Having the CRNA on my team takes that out of the equation and allows me to focus more on the procedure. When I started relinquishing the responsibility of sedation, it was actually kind of hard to get used to. It took me time, but now I can’t imagine doing it any other way. Now I don’t even have to think about it unless there’s an issue. I have a great working relationship with our anesthetist. Even though we’re working with a group, we have one anesthetist who’s essentially assigned to us unless she’s out, and then we have someone that’s covering for her. But, for the most part we have a single anesthetist who works with us on a daily basis. Now, not only do I have techs and nurses who know how I do my procedures and how I do my work-up and recovery, I have an anesthetist who knows how I like patient sedation level as well.
The CRNA group does their own billing as well. The anesthetist is not employed by us, which also cuts out overhead from a business perspective. You don’t have to worry about all the costs associated with having another employee.
Are there any future trends you see emerging with outpatient centers?
I personally feel that outpatient centers are going to become more common. There is cost savings associated with it. I think insurance companies have historically preferred to have patients treated in the hospital. In fact, Medicaid still only allows their patients to be treated in the hospital. I think as time goes on and more data come out showing the cost benefit of doing procedures in an outpatient setting, more patients are going to be done that way. I also truly believe that it’s a much more comfortable and easier experience for the patients, and patients are going to want it.
Can you share some of the procedures you do in an outpatient lab setting?
We do everything from infusaport placements and biopsies to embolizations and ablations. We even do some pain management, including vertebral augmentation, as well as biliary and renal interventions. A large part of my practice is Y-90 radioembolization and obviously it is all done on an outpatient basis. My partner actually did the first complete Y-90 from mapping to treatment in an outpatient facility in the world.
How many years ago was that?
That was 3 years ago. In the past year alone, we’ve done approximately 75 outpatient Y-90 dosings, not including the mappings.
Roughly what percentage of your practice is made up of Y-90?
It’s probably 15%. The majority of what we do is going to be ports and biopsies. We do multiple biopsies every day. We do ports almost every single day and most days we do multiple ports. Y-90 dosing is our next most common procedure.
Do you perform transarterial chemoembolication (TACE)?
We do TACE periodically. The vast majority of what we do, though, is Y-90, largely because it tends to be better tolerated and I have more experience with it. We do some TACE, and rarely we will do bland embolization, but the vast majority of my patients receive Y-90.
Is ablation performed frequently?
Interestingly, we can only perform ablations in the kidney, lung, and bone in an outpatient setting. Insurance won’t pay for it to be done in the liver. Therefore, ablation is not quite as big a part of our practice as it would be in a hospital setting. We’re also a multispecialty group, so we have radiation oncologists, and as you can imagine, there is definitely some overlap with their treatments and ablation.
Any final thoughts?
I would say choose your procedures wisely, do them safely, and don’t be afraid to break the mold. You’re going to do things differently than you have in the past. I think outpatient therapy is going to be more commonplace and it does require a little bit different mindset. Embrace that mindset.
What do you mean when you say “do things differently”?
I think the techniques are going to evolve. And, I think the technology is going to evolve, including both the devices and the equipment itself. I expect this evolution to make things easier for the patient and the physician, to make procedures safer, and ultimately, change the way healthcare is delivered, namely, in an OBL setting.