MONEY & MEDICINE

In-Office Surgery: Fewer Rules Apply

By MICHELLE ANDREWS


When Susan Houston needed a colonoscopy about five years ago, her doctor suggested doing the procedure in an operating room attached to his office. Before the procedure, she said, the doctor administered two shots - one of Demerol, a narcotic painkiller, and one of Valium, a sedative.

But Ms. Houston, 62, a psychoanalyst from New York, said the drugs did not work. "I was wide awake through the whole thing," she said, recalling how she watched on the video monitor as the scope snaked through her intestine. "It was painful; I had cramps. It was one of the most anxiety-producing experiences I've ever had."

Office-based surgeries and other procedures have become increasingly common - from colonoscopies to cardiac catherizations to cosmetic surgeries.

About one-quarter of the estimated 35 million outpatient surgical procedures performed last year took place in doctors' offices, up from 14 percent in 1990, according to Verispan, an industry research company in Newtown, Pa.

Many office procedures are completed without a hitch. Still, a hospital would entail fewer risks for difficulties like those experienced by Ms.

Houston. For example, anesthesiologists generally administer and monitor sedatives in hospitals.

To maintain state and federal licensing and accreditation, hospitals must have medical equipment and people in place to handle emergencies. But only 10 states, including New Jersey, California and Florida, now regulate office-based surgery, through state-mandated requirements or accreditation by one of three groups, according to a recent study in Health Affairs, a journal. (Most set standards for anesthesia, equipment and patient monitoring.)

"Office-based surgery is the Wild West of regulation," said Blair Horner, legislative director for the New York Public Interest Research Group, a research and advocacy organization.

Of course, regulations alone are no panacea. Dr. Rebecca Twersky, an anesthesiology professor at SUNY Downstate Medical Center in Brooklyn, says it's difficult to ensure that doctors performing procedures in an office have the proper credentials, particularly for some popular cosmetic procedures like liposuction.

"In a hospital there's a governing body that reviews a physician's credentials," Dr. Twersky said. "In a doctor's office, it's often the doctor himself who's deciding whether he's competent to perform."

Dr. Twersky also leads the American Society of Anesthesiologists' task force on office-based surgery, and she helped draft guidelines on behalf of the New York State Department of Health. Those guidelines were voided in a state court last November after a group of nurse anesthetists challenged the department's authority to impose such rules.

Medicare and some health plans, though, seem to favor office-based surgery, which costs a lot less than surgery in a hospital. Doctors, in fact, are often paid more to perform procedures in their offices than in hospitals. Under new payment schedules that took full effect in January, Medicare pays a doctor $459.37 if he does a colonoscopy in his office, but only $205.25 if he does the same procedure in a hospital.

The rationale? Physicians should get extra compensation to cover office personnel and overhead costs.

Yet even some medical groups are opposed to the payment system. "We're concerned about potential safety hazards," said Kathleen Teixeira, director of government affairs for the American Gastroenterological Association. "You're giving physicians an incentive not to do procedures in hospitals or ambulatory surgical centers."

When things go wrong in office-based surgery, it's often because of cardiopulmonary problems from the anesthesia. Hard data on safety is hard to come by, but one study published in the April 2000 issue of Pediatrics, the medical journal, found that in 95 pediatric cases in which there was a problem during sedation, the patient was three times more likely to die in a nonhospital setting.

"In some offices, the only backup they have is dialing 911," said Dr. Charles Coté, a professor of pediatrics and anesthesiology at the Northwestern University School of Medicine, who conducted the study.

Patients who have office-based surgery can take steps to ensure that they get the best care. For starters, Dr. Twersky suggests asking the doctor how many of the procedures he or she has performed in an office, and whether the procedure can and should be done elsewhere. Dr. Twersky also suggests learning the qualifications of the person who will be administering the anesthetic. An anesthesiologist is ideal, she says, but a nurse anesthetist supervised by a physician is an acceptable alternative. Ask, too, about emergency backup and who is responsible for watching patients in recovery.

When Ms. Houston went in for another colonoscopy this month, she told her new doctor about the painful experience during the last procedure. (She said her last doctor had told her that the Demerol did not work properly because she once smoked.)
Rather than administering the anesthesia himself, Ms. Houston's new doctor used an outside source, Resource Anesthesiology Associates in New Rochelle, N.Y. The company sends an anesthesiologist to the doctor's office with equipment in tow to sedate and monitor a patient.

This time, Ms. Houston's procedure was uneventful. "They put me out, and the next thing I knew I was lying there recovering," she said. "It was easy."Â*