Rise Seen in Surgeries, Surgery Centers more uneeded surgeries

As the number of outpatient surgery centers has increased, so has the number of potentially unnecessary surgeries, a new study finds.

The research focused on ambulatory surgery centers — medical facilities that perform surgeries not requiring an overnight stay. Visits to such centers have tripled in number within the last decade.

In areas that included ambulatory surgery centers, the researchers noted a significant increase in the number of so-called discretionary procedures, specifically colonoscopy and endoscopy to look for problems in the esophagus, stomach, and small intestine.

Specifically, they found that the yearly number of colonoscopies and endoscopies increased by 1,610 and 775, respectively, for every 100,000 residents after an ambulatory surgery center opened.

Overall, this increase translated into an additional 25,000 colonoscopies and 9,800 endoscopies between 2002 and 2006 within the state of Florida alone, the authors note in the journal Archives of Surgery.

The benefits of the centers, explained study author Dr. John Hollingsworth of the University of Michigan, is that they are more efficient than hospitals, which saves patients time — and money.

But the increase in potentially unnecessary surgeries following the introduction of an ambulatory surgery center suggests these added costs may somewhat offset whatever money is being saved, Hollingsworth noted.

"It is entirely possible that the increased healthcare expenditures associated with greater procedure use in markets where opened may mitigate some of the efficiencies related to."

The increase in some discretionary surgeries is probably not a result of ambulatory surgery centers reaching a backlog of necessary surgeries, Hollingsworth added. For comparison with discretionary procedures that are often optional and may be performed for screening purposes, he and his colleagues looked at the frequency of a type of surgery that is always medically necessary — breast surgery to remove cancerous tissue. No rise in those procedures was seen when ambulatory surgery centers came to an area.

That said, the researchers could not determine whether the additional colonoscopies and endoscopies were, in fact, medically necessary, or might end up saving money in the long-term by diagnosing diseases earlier, he cautioned. "We cannot say whether a given patient needed a particular procedure or not," he said in an e-mail.

Every year, 57 million outpatient surgeries take place in the United States. To handle the volume, many communities have opened ambulatory surgery centers, which now total more than 5,000 nationwide.

To investigate whether the appearance of an ambulatory surgery center changes surgery rates, Hollingsworth and his team reviewed the total number of outpatient surgeries among patients 65 and older that took place in Florida hospitals and ambulatory surgery centers between 1998 and 2006. They focused on regions in which an ambulatory surgery center opened during the study period, and those without one.

Most ambulatory surgery centers are owned — at least in part — by the doctors who staff them, which gives those doctors more control over scheduling surgeries and purchasing equipment, for instance, Hollingsworth noted.

But physician ownership also creates a conflict, he added, by encouraging doctors to schedule additional procedures.

Typically, colonoscopies at ambulatory surgery centers cost Medicare an average of $400 each, and slightly less for endoscopies.

Even if there is an increase in unnecessary procedures, ambulatory surgery centers are likely still a good thing, Dr. Steven Stain of Albany Medical College told Reuters Health in an e-mail.

"I think they are good for patients because of the efficiency, convenience, and lower costs of operation," said Stain, who wrote an accompanying editorial in the journal.

"However, physician-owned ambulatory surgery centers may reflect a conflict of interest between the physician's patient-care responsibilities and perceived personal financial interest," he added. "This may lead to an erosion of the public's trust in healthcare providers."

In response to the new paper, a spokesperson for the Ambulatory Surgery Center Association pointed to a 2009 study by KNG Health Consulting, which concluded that ambulatory surgery centers promote a shift of surgeries and screening procedures from hospitals to outpatient centers but do not increase the number of operations performed.