In the ever-changing healthcare environment, there is constant economic pressure placed on healthcare providers from payers to lower the cost of care. Health care systems administrators are constantly seeking effective ways to lower cost while preserving the quality of care and the service experience.  As healthcare costs continue to rise, payers favor every opportunity to shift care to Ambulatory Surgical Units (ASU's). The shift towards ASU's offers a lower cost site while maintaining patient safety, quality of care, and overall patient satisfaction.  However, hospital-based ASU's costs are high due to the same overhead costs that are seen within the main hospital operating rooms. When possible, shifting procedures to an office-based setting can reduce costs without a negative impact on outcomes. The movement of inpatient and ambulatory surgical procedures to the office-based setting has been proven to be safe, and effective, and can result in direct and indirect cost savings, as well as, improve patient and provider satisfaction.1 One example of this safe cost-effective shift has been achieved with office based hysteroscopic surgery, which is associated with reduced health system costs versus the institutional environment. 2 In the continued transition of procedures towards office-based ASU's (O-ASU), one procedure that has been shown to be comparable in outcomes is the mid-urethral single incision sling (MSIS).3 Literature has provided evidence that M-SIS placement in an ambulatory surgical unit is both safe and effective.4,5,6 However, there is relatively limited data comparing MSIS placement performed in an office-based Ambulatory Surgical Unit (O-ASU) setting versus a hospital-based ambulatory surgical unit (H-ASU).

Mid-urethral slings (MUS) have become the accepted standard of care for the surgical treatment of female stress urinary incontinence. 7 They are considered to be the most cost-effective option with the highest success rate in the surgical treatment of SUI. 9 Historically the majority of MUS were first performed in hospital-based settings under general anesthesia. Over time, the site of care for MUS has shifted from main Operating Room (OR) settings to H-ASU's (Hospital based Ambulatory Surgical Units). 3 Although there has been an overall increase in MUS procedures performed in ambulatory surgery centers 3, there still has been a failure to capitalize on the opportunity to fully transition the site of care for MUS procedures from the hospital OR to either H-ASU or free-standing ASU settings. The barriers to this transition continue to exist are mostly perceived concerns around patient safety. The paucity of evidence-based medicine supporting the patient's safety and efficacy in these lower acuity settings creates a backdrop for physician apprehension.

Identifying the optimal site of care in terms of both patient satisfaction and overall value-based care (quality cost) is best achieved through careful comparative analysis. Office-based procedures often, but do not always, provide patients with a more cost-effective means to surgical care with the additional comfort and convenience of having an outpatient procedure performed in a more familiar setting. 1 Patient convenience is achieved through ease of physical access to the facility itself, and availability of scheduling. These conveniences and others may lead to increased satisfaction for both the patient and the provider. Currently for most USA based urogynecology centers, office-based procedures have been limited to diagnostic cystoscopy, urodynamics, bladder instillations, chemodenervation of the bladder, and periurethral bulking performed in a standard “procedure room”. There has been a recent trend towards creating a hybrid ASU model, blending segments of an integrated AAHC (Association for Ambulatory Health Care) certified ASU with an office-based procedure room. There is a known historical safety of regulated or certified ASUs accomplished through standards of care that must be consistently maintained. This integrated model of a certified ASU, within an office-based setting, would provide a safe and reliable site of care to perform more “advanced” urogynecology procedures. Over the past 20 years there has been a substantial increase in the number of surgical procedures for stress urinary incontinence (SUI). In fact, in women aged 18-64, there has been a 27% increase in the rate of surgical management of SUI since 2000. 8 This significant increase has been attributed to the widespread adoption of the MUS procedure, which has now become the standard of care. 7

Although standard 3 incision MUS procedures have been established to be both safely and effectively performed in an ambulatory surgical setting, relatively few descriptive studies have examined the safety and feasibility of performing MSIS procedures in an O-ASU6. Identifying the optimal site of care is best achieved through careful comparative analysis. While there are many factors that can be considered in comparing the differences between two surgical sites of care, we selected those of most relative importance: cost, patient safety and satisfaction. Therefore, the purpose of this study was to compare charges and reimbursements associated with MSIS placement within traditional H-ASUs versus an O-ASU setting. We hypothesized that cost savings would be associated with O-ASU based procedures without differences in perioperative details, adverse events, or patient satisfaction. To our knowledge, there have been no prior comparative analysis reported in peer review journals between MSIS performed in an O-ASU vs. H-ASU.