Betsy Shapiro, a lawyer in the Justice Department, is pretty tough. And not just at her job. She throws a mean fastball in a local softball league. And when one of those pitches was batted straight back at her this summer, smashing several small bones in her face, she was pretty tough about that, too. She quickly agreed to reconstructive surgery. But when she learned that the operating room was located in a small shopping center -- between a deli and a dry cleaner -- she balked.
"I was somewhat incredulous," she said, after her doctor told her to schedule an appointment at the River Road Surgery Center in Bethesda. "I had never heard of a surgery center, and it made me very nervous. Somehow it just didn't sound right."
The River Road Surgery Center sits in a strip mall in Bethesda, below a tailor shop and an Asian market.
(Jonathan Ernst - For The Washington Post)
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That was Shapiro's introduction to the rapidly growing world of the ASC, or ambulatory surgical center.
Picture a typical hospital operating complex -- the surgical suites with their steel operating tables, bright lights and sharp scalpels -- transported elsewhere. You can get your gallbladder removed, your broken bones set or your nose fixed, and never set foot in a hospital. Instead, you're in a downtown office building, inside a suburban industrial park or, yes, at the local strip mall.
Just as Midas Muffler broke away from traditional auto mechanics and H&R Block from general accounting services, changing those fields in the process, ASCs are transforming health care. Studies and patient experiences suggest some consumers may find ASCs more comfortable and convenient. Fears that the trend may compromise patient safety appear unwarranted -- as long as patients and procedures are selected carefully. A lack of rigorous regulation is a lingering concern. Hospitals could feel a financial squeeze as the upstarts siphon off healthier, better-paying patients. One thing appears clear: Strip-mall surgical centers are becoming established features of the 21st-century health landscape.
"Freestanding ambulatory surgery centers have become very common," said Lee Fleisher, an anesthesiologist and risk assessment researcher at the University of Pennsylvania who has studied ASCs and patient attitudes toward outpatient surgery.
In 1979, fewer than 10 percent of the nation's surgeries were performed outside the hospital setting, according to the Federation of State Medical Boards. Today, the figure is 65 percent. In 2002, there were 3,570 ASCs in the nation, nearly five times the number in 1986. The count will soon exceed 5,000 -- nearly equal to the number of hospitals nationwide, according to Verispan, a health care information company in Yardley, Pa.
Entering an ASC is nothing like entering most hospitals. The parking is easy, the reception area cheerful with modern lighting, a built-in television and a friendly receptionist. There is very little waiting around in half-open gowns. If you're scheduled for 11, you generally get started at 11.
Your surgeon will tell you that the typical ASC is also more doctor-friendly, too. "The type of things that go on in a hospital," said Philip Schoenfeld, the facial reconstruction surgeon to whom Shapiro was referred, make it "so difficult sometimes. . . . The level of administration it takes to get a patient from Point A to Point B. I can do double the cases in half the time in an outpatient center."
Jeffrey Doty, chairman of the Governor's Committee on Surgical Practice in Hospitals and Ambulatory Settings at the American College of Surgeons, and a general surgeon in San Jose, Calif., echoes this. At ASCs, he said, "the schedule tends to run a little more on time, patients don't get bumped by emergencies, the surgical suite turnover (cleaning and preparation for next surgery) tends to be quicker."
The one major health care player that's not pleased is your community hospital. Ellen Pryga, policy director of the American Hospital Association, said ASCs tend to draw away just the kinds of patients that financially pressed hospitals need to stay in business: people with relatively simple medical problems and the ability to pay. "If the community looked to you to be the provider for all the safety net services," she asked, "and your ability to generate the revenues to support these services was disappearing left and right, wouldn't you be nervous?"
But Is It Safe?
For Betsy Shapiro, all these issues were eclipsed by a bigger one: Is it safe?
Seeking reassurance, Shapiro phoned a surgeon at a hospital in the District who was recommended by a friend. "He wasn't the least bit concerned that I would get worse care in a surgery center than at a hospital," Shapiro said.
Several studies support the surgeon's confidence. One, published this year by Fleisher in the journal Archives of Surgery, compared patient outcomes at surgery centers with those at hospitals and doctors' offices. The study concluded that ASCs appeared to be the safest of all options. "Our data suggests that ASCs have among the lowest adverse outcome rates of the three sites of care, even after controlling for factors associated with patients with higher risk," wrote Fleisher.
