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Researcher says surgery centers are 'pushing the envelope'
ASC leaders say their data don't support his concerns
"We know about 1 in 200 patients get admitted to hospital following outpatient surgery, but that rate can easily vary. Outpatient surgery centers are going to continue pushing the envelope, and it is imperative that patients and physicians take control back. We have some steps in place now that can help in the decision-making process. We need to carefully review them and make sure we do what's best for our patients regardless of the convenience factor."
These words, from Lee A. Fleisher, MD, Dripps professor and chair of anesthesiology at the University of Pennsylvania School of Medicine in Philadelphia,1 were included in a press release announcing a study he and his colleagues recently published in The Archives of Surgery.2 The study identified risk factors that may be associated with increased rates of hospital admission immediately following outpatient surgery. Each risk factor was given a score of 1 to 2 points. Patients with at least a score of 4 or higher were more than 30 times more likely to require hospitalization than those with a score of zero or 1, Fleisher reported. Risk factors were assigned a score of 1 or 2 each.
Physicians and patients should consider these risk factors when deciding whether a procedure should be performed on an outpatient basis, the researchers suggest. "This is not to suggest that patients with an outpatient surgery admission index of four or higher should universally undergo inpatient surgery," they wrote; "rather, clinicians should consider performing surgery on these patients in a setting where there is additional medical support to treat acute adverse events and to permit rapid transfer to an inpatient hospital."
The study consisted of 783,558 ambulatory surgery patients, of which 4,351 were sent directly to hospital following surgery (1:180) and of which 19 died (1:41,240). This equates to one death per approximately 50,000 patients. Most of the procedures were done in outpatient hospital settings. The researchers excluded cardiac catheterizations, endoscopies, cataract operations, and discharges other than routine or short-term hospitalization.
The researchers' conclusions drew criticism from leaders in the ambulatory surgery center (ASC) field. "My argument, if he is saying ASCs have been pushing the envelope to provide the absolute best care and offer anyone to go home the same day and save money, I'd say, 'Yes, we're pushing the envelope,'" says Kathy Bryant, president of the Federated Ambulatory Surgery Association (FASA). "But what it seems he appears to suggest, that procedures are unsafe, totally is not true."
Craig Jeffries, Esq., executive director of the American Association of Ambulatory Surgery Centers (AAASC), adds, "Physician-led ambulatory surgery centers appear to have a very strong safety record based on internal and industry benchmarking efforts." With increasing efforts by federal and state government, as well as payers, to collect and publish the patient safety experience of all providers, including surgery centers and hospital outpatient departments, "consumers will increasingly have the opportunity to compare the safety of alternative surgery settings," he says.
You can provide safe care and convenience, says Bryant, who adds that the argument to suggest otherwise is used by providers who don't offer care that is convenient for patients. "ASCs are based on the fact that you shouldn't have to make that choice," she says.
For his part, the author says there is little in the way of evidence-based guidelines on which to make decisions about settings for surgery. In the absence of such evidence, the decision often falls to facilities or insurance companies making decisions based on contracts, he says.
Study: ASCs may increase morbidity/mortality
The study claims that "surgery in locations distant from a hospital, such as freestanding ambulatory surgical centers or physicians' offices, might result in increased, avoidable morbidity or mortality" however, the study adds "such findings are difficult to demonstrate given our predominantly outpatient hospital data set."2 To back up this claim, Fleisher points to an earlier study he conducted that found surgical performance at a physician's office or outpatient hospital, along with other factors, identified those patients who were at increased risk of inpatient hospital admission or death for elderly patients within seven days of surgery at an outpatient facility.3
Whether low-risk surgery performed in a location distant from a hospital results in increased morbidity and mortality compared to the same operations performed in hospital requires study, says William P. Schecter, MD, FACS, chair of the American College of Surgeons Committee on Perioperative Care. However Schecter, who also is professor of clinical surgery at the University of California, San Francisco, and chief of surgery at San Francisco General Hospital, says, "When an unexpected event occurs in a hospital, the resources of the hospital may be rapidly mobilized to support the patient. I believe that mobilization of such resources is more difficult in an out-of-hospital facility."
Bryant's response? "If there were deaths occurring as a result of this, we would know." Instead, data collected by FASA indicate otherwise, she says. In fact, the most recent data from the organization's outcomes monitoring project indicates 41.1% of ASCs that responded had zero complicate rate. "None of the data we have suggest there is a particular problem in ASCs," Bryant says.
Schecter is quick to defend surgeons' motives. "Surgery is a moral community, the members of which agree to place the patient's best interests above their own parochial interests," he says. Different individuals may have an honest disagreement regarding what represents the patient's best interests, Schecter says. "However, the individual responsible surgeon should make a decision based on his or her assessment of the patient's best interests."
Bryant agrees and adds, "Perhaps the great results we have in ASCs suggest physicians in consultation with ASCs are making exactly the right choice," she says.