Number of office-based surgeries rivals surgery centers; are they safe?
Florida imposes 90-day moratorium after five deaths
Did you think the only competition you’d ever have to worry about was the hospital or surgery center down the street? In recent years, a new competitor has grown in strength. The number of procedures performed in office-based settings is now running neck and neck with ambulatory surgery centers, according to John A. Henderson, CEO of SMG Marketing Group in Chicago, who spoke at this year’s meeting of the Federated Ambulatory Surgery Association.
Physician-based surgery is a "competitive threat," Henderson said. "And there’s the opportunity that even more of them, perhaps, will move out of even the hospital and into their own office-based surgical environments."
And when the physicians leave, they’re taking the self-paid and insurance cases with them, says Larry Hornsby, CRNA, president of the American Association of Nurse Anesthetists of Park Ridge, IL, and vice president of Anesthesia Resources Management, a Birmingham, AL-based group practice of anesthesia providers.
"It’s not only the number of cases, but also the fact that you’re removing the better-paying patients or procedures from facilities," he says.
Rural surgery centers and physician offices, in particular, have taken cases from the hospitals, Henderson said at the meeting. "Many of the rural hospitals are losing their bread-and-butter cases and seeing significant losses in their operating environment."
According to SMG, the number of physician-office-based surgeons grew 23% from 11,710 in December 1997 to 14,358 in December 1999.
The reason for the tremendous growth in office-based surgeries is physicians can offer more efficiency, convenience, and privacy, says Marc E. Koch, MD, president and CEO of Resource Anesthesiology Associates, an anesthesiology practice, and physician director of the OR in St. Claire’s Hospital in New York City.
A significant amount of plastic surgery has moved into office settings where physicians can offer privacy in a setting that the patient already has become accustomed to, says Walter L. Erhardt, MD, president-elect of the American Society of Plastic Surgeons in Arlington Heights, IL. Thus, hospitals and surgery centers that perform a large number of plastic procedures might feel the impact more significantly than centers that perform other types of procedures.
As the amount of surgery performed in office-based settings has risen, so have concerns about the safety of surgery in this setting. And surgery centers and hospitals might feel some of the fallout from those concerns.
On Aug. 10, the Florida Board of Medicine enacted a 90-day moratorium on all Level III office-based surgeries. Level III office surgery is defined as surgery that involves, or reasonably should require, the use of a general anesthesia or major conduction anesthesia and preoperative sedation. The moratorium came after five patients died this year.
Are medical error rates actually higher in physician offices? Several people interviewed by Same-Day Surgery say no.
Koch contends that surgery in the office can be safe as long as the surgeon is highly qualified, skilled, and appropriately credentialed; the anesthesiologist has core resuscitative skills and experience and expertise in the office; and the facility has appropriate supplies, medications, staff, and safety features.
Hornsby uses this analogy: When an airplane crashes, the media cover the story extensively. Sometimes air travelers express concern about continuing to fly, but they are continually reassured that it’s safer to travel on an airplane than it is to get in a car and drive to the grocery store. The same is true of office-based surgery, Hornsby maintains.
The problem is the lack of quality assurance data to prove it, Koch points out. "There’s been no prospective or retrospective analysis done to show that the office setting is any less safe than the hospital setting when you have a skilled surgeon and skilled boarded anesthesiologist providing care," he says.
Others point to some safety concerns in the office setting. Synergy Healthcare Services, a Fort Washington, PA-based provider of anesthesia, has walked away from some contracts with office-based practices, says Larry B. Grossman, MD, chairman of the medical advisory board and medical director. The issues included adequate infection control and qualifications of staff; anesthesia providers who are handling multiple cases want to feel confident about the people to whom they are turning over their patients, he says.
"If you’re going to have someone handling the recovery period, you should have someone with appropriate credentials to handle it, such as a nurse with experience," Grossman says.
The safety concerns vary depending on who is voicing the concerns and what their motivation is, Koch says. Wary of losing patient volume, many hospital-based surgeons and anesthesiologists will shroud financial concerns under the veil of safety, he maintains. However, a small number of physicians perform surgery in their unaccredited offices because they’ve lost their credentials, Koch says, while a few others use their offices to perform specific surgery that otherwise might be prohibited in another setting.
So what can office-based settings do to ensure safe outcomes?
Provide the same standard of care as the hospital, Hornsby emphasizes. For example, the same quality monitoring equipment and the same drugs/pharmacology should be used in each setting, he says. "Anesthesia in the office is the same as anesthesia in a hospital."
That philosophy should carry over to credentialing, Grossman says. "We credential our people just like a hospital. We check with the state licensing boards and the physician data bank to make sure they have the qualifications." His firm also checks their current competency and training.
Here are some additional tips:
• Ensure that surgeons and anesthesiologists are board-certified. "To limit your legal exposure, don’t deal with fly-by-night people who couldn’t cut it in traditional settings," Koch advises. While hospitals typically have a large number of specialists and others to assist if a patient’s condition worsens, in an office setting, "You’re by yourself on a desert island," he says. "You need the most competent, educated person there: board-certified surgeons and anesthesiologists."
• Ensure that staff are thoroughly educated in emergency protocols. Staff should have knowledge of emergency protocols that range from resuscitation to fires, Erhardt says. At least one person on staff should be certified in acute cardiac life support, and staff should know what medications to administer in the event of respiratory or cardiac distress, he adds.
• Have appropriate equipment and medications available. Even with relatively minor procedures, offices need emergency equipment and an alternate power source, Erhardt says. "There’s a huge responsibility that comes with having an in-office facility."
According to Erhardt, office-based surgeons who offer general anesthesia must have dantrolene (Procter and Gamble, Cincinnati) available in the event of malignant hypothermia. However, some physicians are reluctant to purchase the expensive drug, which has a very short shelf life. It doesn’t matter if the incidence of malignant hypothermia is low, he says. "The cost of having the drug and restocking would pale in comparison to the cost for not having it and needing it."
• Perform drills. Office-based facilities should perform fire drills, code 10 (code blue) drills, and malignant hypothermia drills, Hornsby says.
"Most anesthesiologists don’t see one single [malignant hypothermia case] their entire career," he says. "But you go through drills so everyone in the facility, all staff, knows clearly what defined role will be in an emergency." As staff change, and as you have new people, they should be acclimated to their specific roles, Hornsby says. "It’s good common sense and good practice."
• Become accredited. "If people want to do [office-based surgery] and avail themselves of the advantages, they also need to avail themselves of the responsibilities," Erhardt says. "The best way to do that is to be willing to be accredited."
In some states, office-based practices have no choice except to be accredited, he says. More states are considering an accreditation requirement. And the American Society of Plastic Surgeons is requiring all of its members to be accredited by 2002, he says.
"It’s a matter of maintaining a certain standard of excellence that they can demonstrate to patients," Erhardt says.
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