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Why Some Patients Face Higher Risks at Ambulatory Surgery Centers

March 27, 2018 BY Alanna Moriarty

Why Some Patients Face Higher Risks at Ambulatory Surgery Centers

Ambulatory surgery centers (ASCs) are outpatient facilities that offer surgical procedures to patients at reduced costs, often with greater scheduling flexibility than hospitals. Also known as same-day surgery centers, these facilities allow patients to undergo minor surgical procedures during the day and recover at home rather than remain at a hospital for overnight observation.

While this model has advantages for patients seeking routine procedures, it can pose serious safety risks for patients seeking more complicated procedures like joint replacements or upper spine surgery. This is where the lure of a surgery center can become its greatest liability. A recent study from the Kaiser Family Foundation, publicized by USA Today, revealed that more than 260 patients have died due to procedure complications at ASCs since 2013, primarily from “routine procedures” like tonsillectomies or colonoscopies. At least 10 percent of these patients died within 24 hours of being released from an ASC. 

According to Definitive Healthcare data, ASCs reported performing more than 9 million Medicare procedures in 2016, resulting in more than $5 billion in Medicare charges.

Top 10 Surgery Centers Using Safe Surgery Checklist by Medicare Charges

Surgery Center Name # Operating Rooms Total Medicare Charges (M) # Medicare Procedures
Tower Wound Care Center 3 $16.7 96,353   
Center for Cardiovascular Research and Education 20 $14.1 1,323   
Silicon Valley Interventional Surgery Center 1 $12.2 813   
River Drive Surgery Center 5 $10.2 11,175   
Ophthalmology Surgery Center of Dallas 8 $9.3 9,125   
Marshfield Clinic - Marshfield Center ASC 21 $8.8 19,114   
Fremont Ambulatory Surgery Center 11 $8.6 6,877   
University Surgery Center 5 $8.5 3,549   
Coronado Surgery Center N/A $8.4 872   
Santa Rosa Surgery and Endoscopy Center 6 $8.1 6,701   

Fig 1 Data from Definitive Healthcare based on self-reported data from 2016 (most recent reporting year). More than 4,150 ASCs currently use the Safe Surgery Checklist, approximately 48 percent of the total active surgery centers in the U.S.

Most surgery center procedures are performed without any difficulty, and physicians have access to the proper training and specialized equipment. However, in New Jersey alone, more than 1,200 “events” such as preventable injuries, comas, and deaths were reported between September 2008 and September 2017. ASCs may not have the tools necessary in a medical emergency due to high medical device costs or lack of specialized training. According to the study, hospital providers are more likely than surgery center providers to have experience with trauma patients and emergency measures.

ASCs do not legally have the same staffing and emergency equipment requirements as hospitals, which the Kaiser study indicated could lead to higher patient risk in life-threatening situations. In thousands of such cases, the Kaiser Family Foundation discovered that ASC personnel had to call 911 for an emergency hospital transfer. Currently, Medicare requires surgery centers to align with a local hospital to transport patients in an emergency, but this could mean a 15-mile journey or longer in rural areas. Even in an urban setting, 30 minutes or more can pass between calling 911 and patient arrival at an emergency department—which can be too late to save a patient.

Top 10 Surgery Centers with Highest Hospital Transfer Rate

Surgery Center Name Hospital Transfer Rate # Operating Rooms Total Medicare Charges
Eastwind Surgical LLC 42.5 3 $73,485   
Spokane Valley Ear Nose Throat and Facial Plastics 38.4 2 $71,387   
Plaza Ambulatory Surgical Center 25.6 1 $40,026   
Advanced Plastic Surgery Center 19.6 1 $150,931   
Oregon Ear Nose and Throat Surgery Center 19.6 4 $176,740   
Mile High Surgery Center 14.4 2 $586,356   
Gold Coast Surgicenter 12.8 4 $169,993   
Cape Cod Surgery Center Inc 12.1 2 $96,538   
HealthEast Surgery Center Maplewood 11.3 4 $311,311   
Interstate Ambulatory Surgical Center South 10.8 5 $110,465   

Fig 2 Data from Definitive Healthcare based on self-reported data from 2016 (most recent reporting year).

Despite the risk factors, surgery centers are not mandated to report how often or how many patients are transferred to hospitals in an emergency, and only one-third of ASCs voluntarily disclose how often patients are sent to an emergency department. The participating ASCs reported 7,000 cases of emergency patient transports between September 2016 and September 2017, bringing the total estimate to around 20,000. According to ASC reports, not all patients survive the transport.

The nature of an outpatient surgery means that a patient may be sent home too soon after a procedure without proper observation. Many surgery centers keep regular business hours unlike hospitals, which are open 24-hours. Patients undergoing procedures toward the end of the day may not be monitored for long enough to determine whether it is truly safe to discharge them. The Kaiser Family Foundation cites several cases in which patients were found unresponsive upon arriving home.

Though surgery centers do not have the same equipment and training requirements as hospitals, they still must follow strict patient safety guidelines. Since 2015, Medicare health inspectors found more than 230 lapses in in rescue equipment or training at ASCs across the U.S., with the potential to jeopardize patient health and safety. This does not mean that surgery centers are inherently less safe than hospitals. In fact, several studies have shown that ASCs are just as safe for patients as hospitals and other inpatient facilities, even for procedures like upper spine surgery

ASCs participating in ASC Quality ProgramFig 3 Active surgery centers (4,756) that report patient procedure data under the ASC Quality Program. Data and map from Definitive Healthcare.

Not all surgery centers in the U.S. are required to report to state or federal organizations. In New Jersey, for example, ASCs with only one operating room are not licensed by the state Department of Health, and therefore are not obligated to submit information on patient mortality or other events. These surgery centers are instead overseen by the licensing board for doctors.

Surgery Centers that do not report under ASC Quality ProgramFig 4 Active surgery centers (3,911) that do not report patient procedure data under the ASC Quality Program. Data and map from Definitive Healthcare.

The popularity of outpatient surgery centers with patients lies in their convenience and low costs, but physicians appreciate them for different reasons. Federal law allows physicians to refer patients to their own surgery centers, which offers much greater financial incentives than hospital referrals. Physicians who own surgery centers take a larger share of responsibility for patients, including risk assessment. However, experts worry that the financial incentives, particularly for complicated procedures like upper spinal surgery and joint replacements, will lead physicians to take on patients at a higher risk for complications simply for the money.

This isn’t to say that there are no mistakes or lapses in care at hospitals, and it is nearly impossible to say whether patients who died at an ASC would have seen better outcomes in an inpatient hospital setting. The Ambulatory Surgery Center Association (ASCA) recently published a response to the USA Today article, claiming that the data from the study was misrepresented, and indicates patients face higher mortality rates at ASCs than hospitals. Studies have shown that patients receiving care at a surgery center have lower risks of infection, most likely because neither the patients nor their providers are in the proximity of other patients for an extended period. 

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