In the last decade, we have witnessed a dramatic upsurge in the number of independent surgery centers across the country. These centers offer an alternative to hospitals when an overnight recuperative period in a hospital setting is deemed unnecessary.
Surgery centers may perform medical procedures such as colonoscopies, cataract removal, joint repairs and spinal injections. More than two-thirds of operations performed in the United States now occur in outpatient centers, some of which are owned by hospitals. The number of centers that qualify for Medicare reimbursement increased by 41 percent between 2003 and 2011, from 3,779 to 5,344, according to federal statistics. In 2006 nearly 15 million procedures were performed in surgery centers; by 2011 the number had risen to 23 million.
Most of these surgery centers are owned at least in part by doctors who have financial incentives to refer their surgical patients to them.
The recent death of Joan Rivers brought increased scrutiny to these facilities. In that particular case, the surgery center was cited for numerous medical errors and failure to follow established surgical policies and procedures.
So, how safe are these surgery centers? In an interview with the Daily Herald Baltimore internist Matthew DeCamp noted
Are surgery centers safe?
Wendy Salo was alarmed when she learned where her doctor had scheduled her gynecologic operation -- at an outpatient surgery center.
"My first thought was 'Am I not important enough to go to a real hospital?'" recalled Salo, 48, a supermarket department manager who said she felt "very trepidatious" about having her ovaries removed outside a hospital.
Before the Sept. 30 procedure, Salo drove 20 miles from her home in Germantown, Md. to the Massachusetts Avenue Surgery Center in Bethesda, Md., for a tour. Her fears were allayed, she said, by the facility's cleanliness and its empathetic staff. Salo later joked that the main difference between the multi-specialty center and Shady Grove Adventist Hospital -- where she underwent breast cancer surgery last year -- was that the former had "better parking."
Salo's initial concerns mirror questions about the safety of outpatient surgery centers that have mushroomed since the highly publicized death of Joan Rivers. The 81-year-old comedian died Sept. 4 after suffering brain damage while undergoing routine throat procedures at Yorkville Endoscopy, a year-old free-standing center located in Manhattan.
Federal officials who investigated Rivers' death, which has been classified by the medical examiner as a "therapeutic complication," found numerous violations at the accredited clinic, including a failure to notice or take action to correct Rivers' deteriorating vital signs for 15 minutes; a discrepancy in the medical record about the amount of anesthesia she received; an apparent failure to weigh Rivers, a critical factor in calculating an anesthesia dose; and the performance of a procedure to which Rivers had not given written consent. In addition, one of the procedures was performed by a doctor who was not credentialed by the center.
Rivers' gastroenterologist, who was the clinic's medical director, has left the center. The clinic, which remains open, faces termination from the Medicare program in the wake of Rivers' death; it must correct deficiencies and pass an unannounced inspection. Yorkville officials have said they have corrected the deficiencies and are cooperating with the investigation.
"Anytime there is a major or minor accident, people begin to question the safety record," said anesthesiologist David Shapiro, past president of the Ambulatory Surgery Center Association, a national trade group and member of the board of an organization that accredits surgery centers. Rivers' death, Shapiro said, is an aberration.
"We have an exceptional, exceptional success rate," he said, adding that his industry is "very, very tightly regulated." Since 2006, he noted, an industry group called the ASC Quality Collaboration has been reporting aggregate data on complications including burns, falls and surgery on the wrong site or wrong patient.
A 2013 study by University of Michigan researchers who analyzed 244,000 outpatient surgeries between 2005 and 2010 found seven risk factors associated with serious complications or death within 72 hours of surgery. Among them: overweight, obstructive lung disease and hypertension. The overall rate of complications and deaths was 0.1 percent -- about 1 in 1,000 patients -- and involved 232 serious complications, such as kidney failure, including 21 deaths. Comparable statistics could not be obtained for hospitalized patients because most studies involve specific procedures.
Another study found that about 1 in 1,000 surgery center patients develops a complication serious enough to require transfer to a hospital during or immediately after a procedure.
Lisa McGiffert, director of Consumers Union's Safe Patient Project, has a significantly less rosy view than Shapiro. Surgery centers, she said, largely operate under a patchwork of state laws of varying strictness. Detailed information about outcomes and quality measures is lacking, she said, and the Rivers case raises questions about "the relaxed attitude that might have prevailed."
"There's not much known about what happens within the walls of these places by regulators or by the public," McGiffert said. "Hospitals are more tightly regulated" than outpatient surgery centers. "They have to report on many more aspects of what they do, such as errors and certain infections.
The unusual thing about Rivers' death, she added, is "that she was a famous person and everyone found out about it."
The number of ambulatory surgery centers or ASCs -- which perform procedures such as colonoscopies, cataract removal, joint repairs and spinal injections on patients who don't require an overnight stay in a hospital -- has increased dramatically in the past decade, for reasons both clinical and financial. More than two-thirds of operations performed in the United States now occur in outpatient centers, some of which are owned by hospitals. The number of centers that qualify for Medicare reimbursement increased by 41 percent between 2003 and 2011, from 3,779 to 5,344, according to federal statistics. In 2006 nearly 15 million procedures were performed in surgery centers; by 2011 the number had risen to 23 million.
Advances in surgical technique and improved anesthesia drugs have allowed many procedures to migrate out of full-service hospitals to free-standing centers, which offer doctors greater autonomy and increased income. Patients say the centers are cheaper, require less waiting and offer more personalized care.
Surgery centers are "a much more convenient, safe place to get quality health care," Shapiro said, enabling patients to avoid exposure to "the infections, chaos and delay" that he said pervade many hospitals.
Nearly all ambulatory surgery centers are owned wholly or in part by doctors who refer patients to them. These doctors earn money by performing procedures and receive a share of the fee charged by the facility.
Recently some centers, including the Massachusetts Avenue facility, which is owned by 30 doctors, a third of whom are orthopedists, have begun performing total hip and knee replacements on selected patients, sending them home the same day. Such operations typically require several days in the hospital. Center officials say that a new drug they use to control postoperative pain has made expedited discharges possible.
Baltimore internist Matthew DeCamp, interviewed by the Daily Herald, said that as a result of Rivers' death, patients have asked him whether they should avoid surgery centers.
"I don't think there's necessarily one answer for all patients," said DeCamp, an assistant professor of bioethics and internal medicine at Johns Hopkins. "There is no doubt that these facilities can be more convenient and valuable for patients (and offer) a pleasant experience of care." But DeCamp said he has advised prospective patients to ask about safety equipment. "I would say you would want to have what is colloquially known as a crash cart," a wheeled cart containing a defibrillator, medicines and other lifesaving supplies that is standard in hospitals."
According to the Daily Herald, "Postoperative infections in hospitals have been a source of concern for years, but little is known about the rates in surgery centers.
A 2010 report by CDC researchers examined 68 centers in three states, and found that two-thirds had one or more lapses in infection control. These included improper cleaning and sterilization of surgical equipment and the failure to wear gloves. The following year, the federal agency issued infection control guidelines for outpatient settings similar to those that apply to hospitals. Researchers estimate that on any given day about 1 in 25 hospitalized patients has one health-care-associated infection."
Rates of infection may be a good place to start when determining if a surgery center is the optimal place to undergo a surgical procedure. It would also be wise to ask how many procedures are performed at the facility on a daily basis? Is the staff properly trained and credentialed to perform the specific surgery?
In evaluating the quality of any medical facility, the same questions should be asked in order to ensure that a procedure is performed properly and the recuperative period is safe and properly monitored.
Contact Jared Green:
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