According to the article, it is estimated that approximately 60 percent to 70 percent of all surgical procedures are now performed in an outpatient setting (for example, a physician's office or specialized surgery center), and more and more high-risk patients, including the elderly, are having outpatient surgeries.
Lee A. Fleisher, M.D., who conducted his research while at The Johns Hopkins University, Baltimore, and colleagues examined the risk associated with 16 different surgical procedures among elderly (older than 65 years) Medicare beneficiaries from 1994 through 1999. Dr. Fleisher is now at the University of Pennsylvania School of Medicine, Philadelphia. (The procedures included cataract removal, prostate resection, hernia repair, laparoscopic gall bladder removal, dilation and curettage, vaginal hysterectomy, simple and modified mastectomy, hemorrhoidectomy, arteriovenous graft placement, knee arthroscopy, rotator cuff surgery).
The researchers studied 564,267 outpatient surgical procedures of which 360,780 were performed at a hospital-based outpatient center, 175,288 were performed at freestanding ambulatory surgery centers (ASCs), and 28,199 were performed in a physician's office.
There were no deaths on the day of surgery at a physician's office, four deaths the day of surgery at an ASC (2.3 per 100,000 procedures), and 9 deaths on the day of surgery at an outpatient hospital (2.5 per 100,000 procedures). The seven-day death rate was 35 per 100,000 outpatient procedures at a physician's office; 25 per 100,000 procedures at an ASC; and 50 per 100,000 procedures at a hospital-based outpatient center.
The researchers also found that the rate of admission to an inpatient hospital after outpatient surgery varied by surgical setting: admission to an inpatient hospital within seven days of outpatient surgery was 9.08 per 1,000 outpatient procedures at a physician's office, 8.41 per 1,000 procedures at an ASC, and 21 per 1,000 procedures at a hospital-based outpatient center.
More advanced age, prior inpatient hospitalization within the past six months, and invasiveness of the surgery performed were indicators of an increased risk of hospital admission or death within seven days of outpatient surgery.
The authors write that the study demonstrates that "patient outcomes are a function of patient characteristics independent of the surgical procedure, confirming the current perception of risk as a multivariate phenomenon," the researchers write. "The accelerated pace at which more complex procedures are being performed in locations increasingly removed from sophisticated support facilities requires that this effort be structured to permit appropriate assessment of these trends."
The authors also write that patients identified as high risk during preoperative evaluation should undergo surgery in locations with the best resources.
(Arch Surg. 2004;139:67-72. Available post-embargo at archsurg.com)
Editor's Note: This study was supported by an Outcomes Award from the Society of Ambulatory Anesthesia Patient Safety Foundation, Pittsburgh, Pa.
For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org .
Journal
Archives of Surgery