Ambulatory surgery centers can be risky for older patients

In the wake of the surgery-related death of comedian Joan Rivers, patient-safety leaders and some physicians are calling on outpatient surgery centers to carefully select elderly patients eligible for surgery and encouraging patients to question the qualifications of physicians performing the procedures.

Surgery carries risk for everyone, but older adults are more likely to have multiple health conditions that can affect how their body responds to even minor surgical procedures. If something goes wrong, they're likely to deteriorate more rapidly, so having access to emergency care is essential, geriatricians say. They also warn that not all ambulatory surgery centers are staffed to handle a crisis, and the patient's condition can worsen as they await transfer to a hospital, safety leaders warn.

“If something goes slightly wrong, it's much more likely to turn into a big problem in an older person than a younger person,” said Dr. Jonathan Flacker, chief of geriatrics and gerontology at Emory University and a spokesman for the American Geriatrics Society. Older patients often have less physiological reserve, and even relatively healthy older adults may have more difficulty coping with the stress of surgery.

In a hospital setting emergency teams can respond rapidly, but outpatient centers often need to call 911 and transfer the patient to a hospital. “You have to think about that risk seriously,” Flacker said.

Rivers, 81 at the time of her death, reportedly underwent an endoscopy that required anesthesia before suffering cardiac arrest and being rushed to a nearby hospital. An ear, nose and throat doctor, who was not authorized to practice medicine in the clinic, was present in the operating room last month, according to a New York Times report. A spokesperson for the clinic told the Times a board-certified anesthesiologist was present at the patient's bedside.

Hospitals are staffed to manage a variety of crises, from heart attacks to allergic reactions, while surgery centers tend to have a more narrow set of expertise, said Frank Federico, executive director of strategic partners at the Institute for Healthcare Improvement. “If the risk is really high, somebody needs to make a decision about not doing it in a surgery center but doing it in a place that might actually better manage the patient.”

A total of 5,357 ambulatory surgery centers treated 3.4 million fee-for-service Medicare beneficiaries in 2012, and the Medicare program and its beneficiaries spent $3.6 billion on ASC services, according to a report from the Medicare Payment Advisory Commission. The CMS required ambulatory surgery centers that receive Medicare payments to report on five safety metrics—including patient burns; patient falls; wrong site or wrong patient procedures; hospital admission and transfer; and prophylactic IV antibiotic timing for all ambulatory surgical centers. In 2013, they were also asked to report on use of safe surgery checklists and volumes for certain procedures. A facility that fails to report can have its Medicare payment docked by 2%, and the CMS aims to eventually begin publically reporting the data.

Because many of the high-volume procedures at ambulatory surgery centers are procedures that seniors undergo, those that perform them should be prepared to cater to the needs of the elderly as a part of their daily routines, according to the Ambulatory Surgery Center Association.

A recent study on care at outpatient surgery centers published in the journal Surgery found of the nearly 4 million patients who were sent home after having a procedure, an estimated 1 out of every 31 (3.2%) were admitted to the hospital or visited an emergency room for followup care within seven days of being discharged, and the need for visits varied widely depending on the procedure. Researchers reviewed records of about 3.8 million patients who had surgery at one of 1,295 ambulatory surgery centers in California, Florida and Nebraska between July 1, 2008, and Sept. 30, 2009.

Among the most common procedures, were colonoscopy (27%), upper gastrointestinal endoscopy (10%), lens and cataract surgery (10%), and pain management procedures (5%). About half of the total population of patients were 60 and older, with 22% between 60 and 69, 18% between 70 and 79, and 10% were 80 or older.

Among patients who were sent home, those receiving a diagnostic cardiac catheterization ended up at the hospital later, either in the emergency room or admitted for care, at the highest rate—1.9%. Other procedures with much smaller but still-high hospitalization rates included noncardiac vascularization (0.17%); replacement or removal of pacemakers and defibrillators (0.18%); and bunionectomies (0.16%). Those who had a breast biopsy were the least likely to be sent to the hospital (only 1 in 10,000 cases or 0.01%).

The keys to safety are the thoughtful application of the risks and benefits during a patient's assessment and then ensuring that the proper clinical staff are in the room when that procedure is performed, experts say.

For any patient undergoing surgery, particularly if anesthesia is involved, it's critical to know as much about their medical history as possible, including what prescription and over-the-counter medications they may be taking. These factors can affect how the patient's body will respond to anesthetic drugs, said Dr. Jane Fitch, president of the American Society of Anesthesiologists.

“You want to be sure you're picking the right procedure, for the correct location, for the correct patient,” she said. The pre-operation evaluation should not only assess the potential risks the surgery may pose for the patient, but it should also help to determine whether or not the facility itself is the right place for that patient to have the surgery.

Some worry, though, that may not always happen.

“I think some of the centers might be pushing the envelope a bit,” says Federico of the Institute for Healthcare Improvement. As ambulatory surgery centers expand the scope of procedures they conduct, clinicians may be getting away with doing tasks like administering anesthesia or intubation without having the specialized expertise to perform those tasks. “They are trying to do more,” he said, “and they are trying to do it at lower costs.”

It's not just money pushing risky procedures into outpatient settings, says Dr. Marc Siegel, clinical professor in the department of medicine at NYU Langone Medical Center. Use of ambulatory surgery centers may be convenient for both the physician and the patient.

“People want a shortcut. And I'm fine with that in uncomplicated younger patients,” he said. The older the patient and the more underlying medical problems they have, the more his concern level rises. It might trigger at least a “Hey, wait a minute,” he said.

The New York State Health Department told Modern Healthcare it is reviewing medical records and conducting interviews with staff at the Yorkville Endoscopy Center in New York City, but to date no complaints or violations regarding this facility.

Whether for an inpatient or outpatient surgery, patients are encouraged to check the credentialing and licensing of all physicians who may be a part of their outpatient care.

Four organizations accredit ambulatory surgery centers: the Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care and the Healthcare Facilities Accreditation Program. Ambulatory surgery centers that provide care to Medicare beneficiaries must meet CMS certification requirements. Virtually every state requires ambulatory surgery centers to obtain a state license, according to the Ambulatory Surgery Center Association, which provides a state-by-state database.

Additionally, 27 states have certificate-of-need programs, according to a report from the National Conference of State Legislatures. The programs govern the establishment, ownership, construction and change in service of specific types of healthcare facilities, including ambulatory surgical centers.

Follow Sabriya Rice on Twitter: @sabriyarice



Loading Comments Loading comments...