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Popularity of Outpatient Surgery Centers Leads to Questions About Safety

Comedian Joan Rivers’ death spurs increased scrutiny

According to a report from Kaiser Health News, questions about the safety of ambulatory surgery centers (ASCs) have mushroomed since the highly publicized death of Joan Rivers. The 81-year-old comedian died September 4 after experiencing brain damage while undergoing a routine throat procedure 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.

In 2013, researchers at the University of Michigan analyzed 244,000 outpatient surgeries between 2005 and 2010 and found seven risk factors associated with serious complications or death within 72 hours of surgery. These factors included overweight, obstructive lung disease, and hypertension. The overall rate of complications and deaths was 0.1% (about 1 in 1,000 patients) and involved 232 serious complications, such as kidney failure, including 21 deaths.

Another study found that approximately 1 in 1,000 ASC patients develops a complication that is serious enough to require transfer to a hospital during or immediately after a procedure.

According to Lisa McGiffert, director of the Consumers Union’s Safe Patient Project, ASCs largely operate under a patchwork of state laws of varying strictness.

“There’s not much known about what happens within the walls of these places by regulators or by the public,” she said. “Hospitals are more tightly regulated [than ASCs]. They have to report on many more aspects of what they do, such as errors and certain infections.”

The number of ASCs — which perform procedures such as colonoscopies, cataract removal, joint repairs, and spinal injections in patients who don’t require an overnight stay in a hospital — has increased dramatically in the past decade, for both clinical and financial reasons, the Kaiser report says. More than two-thirds of surgical procedures performed in the U.S. now occur in ASCs, some of which are owned by hospitals. The number of centers that qualify for Medicare reimbursement increased by 41% between 2003 and 2011 (from 3,779 to 5,344), according to federal statistics. In 2006, nearly 15 million procedures took place in ASCs; by 2011 the number had risen to 23 million.

Advances in surgical techniques 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, the report says. Patients say ASCs are cheaper, require less waiting, and offer more-personalized care.

Nearly all ASCs 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 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. Officials say that a new drug used to control postoperative pain has made expedited discharges possible.

A 2010 report from the Centers for Disease Control and Prevention (CDC) examined 68 ASCs in three states and found that two-thirds of them 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 CDC issued infection-control guidelines for outpatient settings similar to those that apply to hospitals. Researchers estimate that on any given day approximately 1 in 25 hospitalized patients develops an infection related to health care.

Source: Kaiser Health News; December 16, 2014.



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