Her hopes for a quick and easy experience were fulfilled: Within a half hour of arriving at Reiss's practice, Lively was on the operating table, sedated by a board-certified anesthesiologist. She awoke in a cozy recovery room and was home before lunchtime. "At a hospital, everything before and after an operation is a hassle," she says. "The office was so much faster and less stressful because everyone's focus was entirely on me."
Lively's experience is becoming increasingly common, as surgeries that were once performed solely in the hospital operating room migrate to physicians' offices. "The type and range of office-based surgeries—known as OBS—have exploded in recent years," says Lawrence S. Reed, MD, president of the American Association for Accreditation of Ambulatory Surgery Facilities, one of several groups that offer surgery certification for physicians' offices. According to the American Hospital Association, 16 percent of outpatient surgeries were performed in an office in 2005 (the most recent year for which statistics are available), compared with fewer than 10 percent in the early 1990s.
That number is only expected to rise. "By 2015 the majority of operations will be done outside hospitals—in both doctors' offices and freestanding surgery centers," predicts Michael Kulczycki, executive director of ambulatory care accreditation at the Joint Commission, an independent group that certifies hospitals and, increasingly, offices nationwide. But before you agree to forgo the OR, it's important to consider the risks as well as the benefits.
The Office Advantage
Experts point to several reasons for the upswing in OBS. Across the country, the financial downturn has led to a flurry of hospital closings, which means that many communities have fewer available operating rooms. "It has become tough for physicians performing nonemergency procedures to book OR time," says Reed.
Today's anesthetics are also faster and safer than they were in the past. The most popular wear off just a few minutes after surgery (compared with an hour or more for older drugs) and are less likely to trigger side effects like severe nausea, says Hector Vila Jr., MD, former chair of the committee on ambulatory surgical care at the American Society of Anesthesiologists.
Significant breakthroughs in the procedures themselves have also made OBS more popular. Sterilization, for example, no longer requires an incision to tie off or sever the fallopian tubes; instead, flexible metal coils are inserted to block the eggs' path. For endometrial ablation (a hysterectomy alternative used to control excessive menstrual bleeding), doctors can instantly vaporize the uterine lining using a heated balloon, rather than a more painful and time-consuming electrical current. Minimally invasive procedures using a laparoscope—a tiny video camera that allows the doctor to see what's happening as she works inside your body—are also transforming many operations.
And there are some compelling benefits to having surgery in an office:
1. You save money: OBS can be quite a bargain because the ancillary costs (such as use of the operating room) are about 70 percent lower, according to Reed. This is especially important if you're having a procedure that insurance doesn't cover, or if your plan carries a high deductible.
Two more benefits...plus a few drawbacks
3. You're exposed to fewer germs: Some 1.7 million infections occur in U.S. hospitals each year, including those caused by superbugs such as MRSA or C. diff, which are resistant to common antibiotics. Doctors' offices typically aren't breeding grounds for these types of bacteria in part because the very sick patients who harbor and spread them don't spend as much time there.
A Double-Edged Scalpel
Yet OBS has its drawbacks. One of the biggest is that because it's less heavily regulated than hospital-based procedures, it can involve additional risks for patients. "In many states, OBS is overseen by a medical board, and boards tend to be dominated by physicians, as opposed to the more consumer-focused state health departments that supervise hospitals and freestanding ambulatory surgery centers," Kulczycki says. When Vila examined data from the two years before Florida tightened its OBS regulations, he found that for every 100,000 OBS procedures, 66 serious complications and nine deaths occurred—a rate about 12 times higher than in the state's outpatient surgery centers.
Some states are working to implement greater oversight: In 2007, after a series of incidents including the death of a 42-year-old mother after having a facelift in a plastic surgeon's office, New York State passed one of the country's strictest laws governing OBS. Physicians using more than minimal sedation in offices there must now have much of the same safety equipment found in a hospital OR, they must report all serious complications to the department of health, and, most important, their offices must be inspected and accredited by an independent organization every three years. Doctors who don't comply risk losing their licenses. (Nearly 800 offices have been accredited since the law's passage.)
Still, 25 states don't regulate OBS facilities (to find out whether yours does, see https://www.fsmb.org/pdf/grpol_regulation_office_based_surgery.pdf), and patients who have surgery there are left without adequate government protection. Some of the risks:
1. The state doesn't check the doctor's credentials: Before being allowed to operate in a hospital or regulated OBS facility, doctors must provide proof of advanced training in their specialty. Not so with an unaccredited or unlicensed office: Any MD can legally hang out a shingle advertising a procedure he may not be properly trained to perform.
2. Trained anesthesiologists may not be present: With local anesthesia, this usually is not an issue, but it is a serious omission with more potent drugs, since the risk of respiratory or cardiac arrest is very real. (One in 200,000 patients dies on an operating table each year from a reaction to anesthesia.) "Some physicians think they can handle both the operation and the sedation, but it would be tough for a surgeon to manage complications on both fronts," says Richard Swanson, MD, a surgical oncologist at Brigham and Women's Hospital and chair of the American College of Surgeons' OBS committee.
Two more risks, plus 6 questions you need to ask before making your decision
4. Backup help may be insufficient: In the rare event of a serious medical complication requiring more emergency treatment than the office can provide, the biggest danger lies in the minutes before an ambulance arrives, says Arthur A. Levin, director of the Center for Medical Consumers, a New York–based patient advocacy group. But the staff at an unaccredited physician's office may not be trained or experienced in resuscitation care. In 2006 Kimberley Taylor, 53, went into respiratory arrest while having cosmetic surgery in her Tucson doctor's office. When paramedics arrived, they discovered that a breathing tube meant to revive her had erroneously been placed in her esophagus (leading to her stomach) rather than her windpipe. Although they moved the tube and whisked Taylor to the hospital, her brain had been deprived of oxygen for too long, and she died nine days later.
Making the Decision
Even if an office is regulated and all safety standards are in place, OBS is not for everyone—or for every procedure. If you have an underlying respiratory problem—severe asthma or chronic obstructive pulmonary disease, for instance—or sleep apnea or heart disease, you belong in a hospital, Swanson says. OBS is also not appropriate for complex or risky operations like neurosurgery.
If you do choose OBS, have a frank conversation with your doctor about the pain involved and her plan to minimize it. A 2007 Canadian review of more than 331,000 colonoscopies in Ontario, where the procedure is not regulated in office settings, found that doctors were three times less likely to complete the procedure when done at their practice. The authors hypothesize that office-based physicians may undersedate patients, resulting in too much discomfort for some to continue.
Still, patients whose doctors follow strict precautions can have a satisfying OBS experience. Until all states decide patient protection comes first, though, it's up to you to do everything you can to ensure that it's a safe one. "You should always ask your physician questions before undergoing surgery," Kulczycki says. "But when the surgery is happening in an office, it's even more crucial to make sure that you're fully informed."
Next: 6 questions you need to ask before undergoing surgery in your doctor's office