Jaime B. Hyman, MD

Measuring Quality in Ambulatory Anesthesiology:

Challenges and Opportunities

1. Assess safety in current ambulatory anesthesiology

practice

2. Apply recent consensus statements relevant to ambulatory

anesthesiology into practice

3. Formulate a patient-centered approach to high-quality

perioperative care of the ambulatory surgical patient

Learning Objectives

History of Ambulatory Anesthesiology

1900s

James Henderson Nicoll

~9000 peds procedures

Glasgow, Scotland

1910s

Ralph Milton Waters

Downtown Anesthesia Clinic

Sioux City, Iowa

Hyman JB, Goren O, Wilson S, Philip BK. Ambulatory (Outpatient) Anesthesia. In

Miller’s Anesthesia, 10th edition. Gropper MA, Eriksson LI, Fleisher LA, Cohen NH,

Leslie K, Johnson-Akeju O, editors. Elsevier, New York, NY. 2024; 2149- 2184

History of Ambulatory Anesthesiology

1951

First HOPD

Grand Rapids,

Michigan

1970

First ASC

Phoenix,

Arizona

Hyman JB, Goren O, Wilson S, Philip BK. Ambulatory (Outpatient) Anesthesia. In

Miller’s Anesthesia, 10th edition. Gropper MA, Eriksson LI, Fleisher LA, Cohen NH,

Leslie K, Johnson-Akeju O, editors. Elsevier, New York, NY. 2024; 2149- 2184

1970s - 1980s

Rapid increase

in ASCs

across U.S.

1982

Medicare approved

payments to ASCs

for ~200 procedures

2006

>60% surgeries in

U.S. ambulatory

Epstein RH, et al. Since the COVID-19 pandemic, approximately 90% of elective

anesthetics have been ambulatory: A retrospective analysis of statewide data in

Florida from 2010 through 2022. J Clin Anesth. 2024 Nov;98:111596.

Percentage of Ambulatory Cases

Ambulatory Anesthesiology in 2025:

• >4,000 CMS approved procedure codes for ASCs

https://www.cms.gov/medicare/payment/prospective-

payment-systems/ambulatory-surgical-center-asc/asc-

regulations-and-notices/cms-1809-fc

Variable

Surgical

Complexity

Variable

Patient

Complexity

Consensus Statements

Reflect on safety

Beyond Morbidity…

Thoughts for the future

Remainder of Talk:

•NSQIP database 2005-2010; N = 244,397

•100 most used CPT codes for outpatient surgery claims

•General or neuraxial anesthesia

•Primary outcome: 72h major morbidity/ mortality

•Occurred in 0.095%

Mathis MR, et al. Kheterpal S. Patient selection for day case-eligible surgery: identifying

those at high risk for major complications. Anesthesiology. 2013; 119(6):1310-21

Mathis MR, et al. Kheterpal S. Patient selection for day case-eligible surgery: identifying

those at high risk for major complications. Anesthesiology. 2013; 119(6):1310-21

•NSQIP database 2016 – 2020; 14 procedure types

•N = 848,468

•Inpatient 37%

•Outpatient 63%

•30d adverse events:

•Outpatients: 2 - 9%

•Inpatients: 3 - 13%

•Outpatient vs inpatient:

•aOR 0.38 (95% CI: 0.37–0.39)

Zhang C, et al. Outpatient surgery benchmarks and practice variation

patterns: case controlled study. Int J Surg. 2024; 110(10):6297-6305.

Hernia repair:

MIS groin

MIS ventral

Open groin

Open umbilical

Parathyroidectomy

Thyroid lobectomy

Total thyroidectomy

Same Day

Discharge

Surgeries

Hernia repair:

MIS groin

MIS ventral

Open groin

Open umbilical

Parathyroidectomy

Thyroid lobectomy

Total thyroidectomy

Same Day

Discharge

Surgeries

Adverse Events:

Breast

Lumpectomy

Mastectomy

Minimally

Invasive

Adrenalectomy

Minimally

Invasive

Cholecystectomy

Same Day

Discharge

Surgeries

Breast

Lumpectomy

Mastectomy

Minimally

Invasive

Adrenalectomy

Minimally

Invasive

Cholecystectomy

Same Day

Discharge

Surgeries

Adverse Events:

Minimally

Invasive

Colectomy-

Malignancy

Minimally

Invasive

Colectomy-

Benign

Minimally

Invasive

Fundoplication

Next Day

Discharge

Surgeries

Minimally

Invasive

Colectomy-

Malignancy

Minimally

Invasive

Colectomy-

Benign

Minimally

Invasive

Fundoplication

Next Day

Discharge

Surgeries

9% 4%

Adverse Events:

Consensus Statements to

support our Practice…

•MI within previous 30-60 days

•Recent PCI (without stenting 14 days, with stents 30 days)

•Significant arrhythmias with hemodynamic compromise (VT,

afib/RVR)

•Decompensated CHF

•Acute pulmonary conditions (active pneumonia, URI, PE in past 3

months)

•Acute neurologic conditions (AMS, CVA within 3 months,

uncontrolled epilepsy, increased ICP)

•DKA or hyperosmolar hyperglycemic nonketotic syndrome

•Malignant hypertension with acute end-organ damage in at least 3

target organs

Cataract surgery should likely be delayed to allow optimization:

Sweitzer B, et al. Preoperative Care for Cataract Surgery: The Society for Ambulatory

Anesthesia Position Statement. Anesth Analg. 2021; 133(6):1431-1436.

SAMBA Consensus Statement on

Perioperative Blood Glucose Management

Rajan N, et al. Society for Ambulatory Anesthesia Updated Consensus Statement on

Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing

Ambulatory Surgery. Anesth Analg. 2024; 139(3):459-477.

SAMBA Consensus Statement on

Perioperative Blood Glucose Management

Rajan N, et al. Society for Ambulatory Anesthesia Updated Consensus Statement on

Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing

Ambulatory Surgery. Anesth Analg. 2024; 139(3):459-477.

SAMBA Consensus Statement on

Perioperative Blood Glucose Management

Rajan N, et al. Society for Ambulatory Anesthesia Updated Consensus Statement on

Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing

Ambulatory Surgery. Anesth Analg. 2024; 139(3):459-477.

Moving Beyond Morbidity…

Month before surgery:

•53% had at least one preop test

Compared to preceding 11 months:

•Expenditures on testing $4.8m higher

•Expenditures on visits $12.4m higher

Chen CL, et al. Preoperative medical testing in Medicare patients

undergoing cataract surgery. N Engl J Med. 2015; 372(16):1530-8.

•Medicare beneficiaries

undergoing cataract surgery

in 2011 (N = 440,857)

2006-2014 Medicare claims

Chen CL, et al. Preoperative Medical Testing and Falls in Medicare Beneficiaries

Awaiting Cataract Surgery. Ophthalmology. 2021; 128(2):208-215.

Biometry

Cataract Surgery

2006-2014 Medicare claims

Chen CL, et al. Preoperative Medical Testing and Falls in Medicare Beneficiaries

Awaiting Cataract Surgery. Ophthalmology. 2021; 128(2):208-215.

Biometry

Cataract Surgery

•Single-center retrospective

review of cases cancelled

on the day of surgery

Tewfik GL, et al. Outcomes and Disposition of Patients After Case Cancellation on

Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective

Cohort Analysis. Anesth Analg. 2022; 135(4):845-854

•Single-center retrospective

review of cases cancelled

on the day of surgery

•Single-center retrospective

review of cases cancelled

on the day of surgery

•Cases cancelled for

medical reasons (n = 877)

•Single-center retrospective

review of cases cancelled

on the day of surgery

•Cases cancelled for

medical reasons (n = 877)

•72% rescheduled

•Single-center retrospective

review of cases cancelled

on the day of surgery

•Cases cancelled for

medical reasons (n = 877)

•72% rescheduled

•83% of these had underlying

issue resolved

•Reason for cancellation

not

addressed in 102

rescheduled cases

Tewfik GL, et al. Outcomes and Disposition of Patients After Case Cancellation on

Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective

Cohort Analysis. Anesth Analg. 2022; 135(4):845-854

•Reason for cancellation

not

addressed in 102

rescheduled cases

•Several cases planned to

be moved from ASC/GI

suite to main OR ultimately

performed at ASC/GI suite

Tewfik GL, et al. Outcomes and Disposition of Patients After Case Cancellation on

Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective

Cohort Analysis. Anesth Analg. 2022; 135(4):845-854

Case Presentation

•Telephone survey 5,703 patients 24h after surgery

Acute Pain after Ambulatory Surgery

McGrath B, et al. Thirty percent of patients have moderate to severe pain 24 hr after

ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004; 51(9):886-91.

•Telephone survey 5,703 patients 24h after surgery

•30% reported moderate/severe pain

Acute Pain after Ambulatory Surgery

McGrath B, et al. Thirty percent of patients have moderate to severe pain 24 hr after

ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004; 51(9):886-91.

•Telephone survey 5,703 patients 24h after surgery

•30% reported moderate/severe pain

Acute Pain after Ambulatory Surgery

McGrath B, et al. Thirty percent of patients have moderate to severe pain 24 hr after

ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004; 51(9):886-91.

Bryson GL, et al. Patient and caregiver experience following ambulatory surgery: qualitative

analysis in a cohort of patients 65 yr and older. Can J Anaesth. 2014; 61(11):986-94.

•There were 105 patient-caregiver dyads:

•90 patients & 64 caregivers offered at least one response

Bryson GL, et al. Patient and caregiver experience following ambulatory surgery: qualitative

analysis in a cohort of patients 65 yr and older. Can J Anaesth. 2014; 61(11):986-94.

•

“The impact of physical disability on home life was vividly described”

•

“Patients and caregivers ardently described real challenges during

convalescence”

•

“Paramount for participants was the need for clear communication

and a commitment to ongoing support following discharge”

Bryson GL, et al. Patient and caregiver experience following ambulatory surgery: qualitative

analysis in a cohort of patients 65 yr and older. Can J Anaesth. 2014; 61(11):986-94.

Quality in ambulatory anesthesiology

Reducing waste and

cancellations in less

complex procedures

Quality in ambulatory anesthesiology

Reducing waste and

cancellations in less

complex procedures

Reducing adverse events

and improving post-

discharge recovery in

more complicated

procedures

•ASC-21 and OP-42: THA/TKA PRO-Based Performance Measures

•PRO data collected

•HOOS, JR for THA recipients and KOOS, JR for TKA recipients

•Success defined as improvement from pre-op

•Risk-adjustment:

•PROMIS Global (mental health subscale items) or VR–12 (mental

health subscale items)

•Single Item Literacy Screener (SILS2) questionnaire

•Voluntary reporting started CY2025

•Mandatory reporting beginning CY2028

Ambulatory Surgical Center Quality

Reporting (ASCQR) and Hospital

Outpatient Quality Reporting Program

(Hospital OQR)

https://qualitynet.cms.gov/asc/ascqr

Endpoints:

•Supplementary analgesic use

•Subjective analgesic effectiveness

•Pain intensity (at rest, during

movement, at 12, 24, 72 h)

•PONV at 0–6 h, 6–24 h, overall

•PDNV

•Severe PONV

•Time to mobilization

•Quality of Recovery (QoR-15)

Myles PS, et al. Quality of patient-centred recovery trajectories after different types of

surgery: a prospective cohort study. Br J Anaesth. 2025: S0007-0912(25)00346-0.

Upper endoscopy Cardiac surgery

Knee, hip, shoulder

arthroplasty,

single-level spine

surgery,

laparoscopic

cholecystectomy

Myles PS, et al. Quality of patient-centred recovery trajectories after different types of

surgery: a prospective cohort study. Br J Anaesth. 2025: S0007-0912(25)00346-0.

Upper endoscopy Cardiac surgery

Knee, hip, shoulder

arthroplasty,

single-level spine

surgery,

laparoscopic

cholecystectomy

QoR-15

•Patient support, Comfort,

Emotions, Physical

Independence, and Pain

Myles PS, et al. Quality of patient-centred recovery trajectories after different types of

surgery: a prospective cohort study. Br J Anaesth. 2025: S0007-0912(25)00346-0.

80% willing to

participate

33% ineligible

199 underwent surgery

94% complete follow-up

Nadir QoR-15 median (IQR):

•EGD= 128 (93–145)

•Intermediate surgery= 87 (70–102)

•Cardiac surgery= 70 (60–81)

Myles PS, et al. Quality of patient-centred recovery trajectories after different types of

surgery: a prospective cohort study. Br J Anaesth. 2025: S0007-0912(25)00346-0.

Conclusions:

1. A patient-centered approach to quality in ambulatory

anesthesiology includes reducing waste and delays for less

complex procedures.

Conclusions:

1. A patient-centered approach to quality in ambulatory

anesthesiology includes reducing waste and delays for less

complex procedures.

2. Minimizing adverse events remains important for increasingly

complex ambulatory surgery.

Conclusions:

1. A patient-centered approach to quality in ambulatory

anesthesia includes reducing waste and delays for less

complex procedures.

2. Minimizing adverse events remains important for increasingly

complex ambulatory surgery.

3. Patient-reported recovery metrics represent the standard we

should ideally aspire to in measuring quality improvement in

ambulatory anesthesiology.

Thank you!

jaime.hyman@yale.edu