To reach that conclusion, Fleisher and colleagues looked at more than 500,000 outpatient medical procedures. They found that the mortality rate (measured within seven days of the procedure) was as high as 35 per 100,000 procedures for surgeries performed at physician's offices, and 50 per 100,000 for surgeries at outpatient hospitals. ASCs came in with 25 deaths per 100,000 procedures.
Another study, published in 2000 in the Annals of Surgery, examined subsequent hospital admittance rates for patients who'd undergone outpatient surgery. (Admission within 30 days of surgery is suggestive of a surgical complication.) The study found the rate of admissions within 30 days of surgery to be less than two-tenths of a percent (0.15 percent) for ACSs.
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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The rate of illness and death after ASC surgeries, likewise, is "very low," according to a 1994 study published in the Journal of the American Medical Association. This study looked mostly at healthy patients 18 and older, but other studies suggest similar results with patients who had preexisting conditions or with older patients. In fact, the data show that an increasing number of people over 65 are opting for outpatient surgery, with no increase in negative outcomes for this age group.
But all surgery entails risk, and things can go wrong at ASCs, as a recent Medicare-sponsored survey made clear. Among cases cited by the study:
• An ASC patient who underwent a routine gynecologic procedure and died from complications during surgery.
• A patient whose bladder was punctured during surgery at an ASC; he was rushed six blocks by wheelchair to the nearest hospital ER, bleeding the whole way.
Shapiro was anxious to know what a complication would mean in her case. "I kept wondering, 'Where will they take me if something goes wrong?' " she recalled.
Fail-Safe
The answer -- you guessed it -- is the hospital. For all the advantages ASCs offer when things go right, they depend on the good, old-fashioned hospital for backup when a procedure goes amiss. A patient with serious post-surgery complications can require blood transfusions, lab tests, intensive care and 24-hour monitoring. This is what hospitals do -- not ASCs, where the staff generally aims to be home in time for dinner.
Minimizing the chances that staff will need to rush you from the ASC operating table to the ER requires "choosing the right patients" for off-site surgeries, said Schoenfeld. That means avoiding, generally, those at a higher risk of complications -- people who are over 85, who have already undergone multiple surgeries or who suffer from stroke, heart disease or diabetes.
The ideal patient might be, say, pro basketball player Richard Hamilton, who had his broken nose surgically repaired by Betsy Shapiro's surgeon at the same outpatient center a few months before her operation. Shapiro found this reassuring.
The other tactic used to minimize patient risks is choosing the right kind of surgery. Last month, the Center for Medicare and Medicaid Services (CMS) published a draft of its annual list of medical procedures Medicare will reimburse at Ambulatory Surgery Centers. There are some 2,500. But some experts advise more caution. [See "Which Surgeries Are Suited for Off-Site Centers?" below].
On Dec. 1, the Pennsylvania Department of Health sent a notice to the state's more than 170 ASCs to stop performing laparoscopic procedures -- such as gallbladder operations, appendectomies and tubal ligations -- that enter the abdomen.
This action was not prompted by any deaths or serious injuries. Rather, said Jessica Seiders, a spokeswoman for the Department of Health, "any procedure that requires the entrance of body cavities, whether by incision or tubes, may not be performed in the ambulatory surgical facility setting. The reason is that if there is an accident/emergency with this invasive procedure, a patient can be treated quicker and with a better quality of care in a hospital setting."
Pennsylvania learned of some ASC problems through Medicare, which has set minimum health and safety requirements for the facilities. Medicare relies on state agencies and private accreditors to ensure that ASCs meet the requirements. Once a center is certified as meeting Medicare standards, those standards apply to all patients who use the center.
