Under the knife: The location of surgery matters

Millions of Americans undergo surgery each year, and many of the more minor surgeries take place in outpatient settings like ambulatory surgery centers (ASC), hospital outpatient departments (HOPD) and physician offices. Over the past few decades, the number of these procedures being done in physician offices has skyrocketed, going from about 110,000 surgeries in 1981 to 12 million in 2009. This growth, however, brings with it concerns about the safety of office-based procedures.

To gain a better understanding of this, a research team led by Regents Professor Robert Ohsfeldt, PhD, of the Texas A&M School of Public Health, compared surgical procedures performed in each of the three outpatient settings. The study, published in the journal Health Services Insights, outlined the researchers’ analysis of surgeries performed in different settings to determine how often complications arose for each procedure and type of location. They found significantly higher post-procedure hospitalization rates for physician office procedures compared to surgeries performed in ASCs or HOPDs. Hospitalization rates serve as an indicator of complications related to the outpatient procedure.

The growth of physician office surgeries can be attributed to many factors. A few of these are physicians seeking more autonomy in their practices and the fact that surgeries open a new revenue stream for physician practices. Two other likely contributors are technological advances that make office-based procedures more feasible and the fact that office-based surgery takes fewer resources.

“In-office procedures can make things more convenient for patients, but physician offices are not always regulated the same way as ASCs or HOPDs and often lack the staff and equipment that dedicated outpatient surgical facilities have,” Ohsfeldt said.

Previous studies have looked into differences in outcome between surgeries in physician offices and dedicated surgical centers, but most have not taken a rigorous approach that appropriately handled the varying levels of risk involved in different procedures. Riskier or more involved surgeries would be more likely to happen in an ASC or HOPD, so an assessment would need to weight those procedures differently than simpler ones.

Ohsfeldt and colleagues built on a previous study that used Medicare data and analyzed 16 surgical procedures, only now they examined one million private insurance claims for 88 types of relatively complex outpatient surgeries performed in Florida between 2008 and 2012. Despite the rapid growth in office-based procedures overall, little change in settings among the specific 88 procedures was observed during the study period. Ohsfeldt and colleagues attribute this in part to the fact that they focused on relatively complex procedures rather than very simple procedures often performed in an office setting.

Among these relatively complex surgeries, differences in complication rates were striking.

“The seven-day hospitalization rate for physician office surgeries was nearly twice the rates in ASCs and HOPDs and the 30-day rate was about 34 percent higher,” Ohsfeldt said. “These findings were consistent with the previous study using Medicare data, showing larger differences but in the same direction.”

Ohsfeldt and the other study authors caution that this work should not be taken as the final word on the subject. As the research was limited to surgeries in Florida, the results may not be representative of the entire country. Also, their research focused on hospitalization for all causes and not just surgery-related reasons. This could affect overall numbers of hospitalizations, but would likely have little effect on the differences between settings.

“These findings point to a need for continued in-depth research in this area,” Ohsfeldt said. “Studies with a focus on how safe and effective office-based procedures are will become more important as the number of surgeries done in physician offices continues to grow.”

Additionally, research should help to guide practitioners on which procedures are appropriate for an office setting and which ones should stay in ASCs and HOPDs.