While the number of surgeries continues to increase annually in the US, and particularly the number of surgeries performed in ambulatory surgical centers (ASCs), so too does the proportion of patients with challenging conditions.
Researchers from UT Southwestern Medical Center analyzed 34,738,440 ambulatory surgery center visits in 2006 and 28,588,475 in 2010, and discovered an increase (12.8% to 13.9%) in the proportion of patients with a number of challenging comorbidities, including heart failure, chronic renal failure, and diabetes mellitus.
“This analysis suggests that sicker patients are increasingly being offered outpatient surgery in this country,” concluded Eric B. Rosero, MD, an assistant professor of anesthesiology and pain management at UT Southwestern Medical Center, in Dallas.
The problem, however, is not that more surgeries are being performed on sicker patients, or even that many of them are being done in the ambulatory setting. The real problem is the lack of consensus about which patients should be treated in the ASC, and which should be treated in an inpatient or outpatient setting at a full-service hospital.
A recent survey of anesthesiologists across the United States found a lack of consensus on appropriate patient selection criteria at ambulatory surgery centers for conditions like COPD, congestive heart failure, and even pregnancy. Only three risk factors garnered agreement by most of those surveyed. According to the report, more than 90 percent of respondents were willing to perform surgeries on patients with BMIs greater than 35 kg/m2, stable CAD, or insulin-dependent diabetes mellitus or cardiac pacemakers.
The study was conducted by researchers at the University of Nebraska Medical Center and was presented at this year’s Society for Ambulatory Anesthesia annual meeting. The idea for the survey emerged as the researchers were establishing an ASC in their area and began asking about appropriate patient selection criteria.
“Initially we thought to allow all ASA I and II patients, but then we realized we would have to look at allowing ASA III patients to have any significant volume and take pressure off of our main campus,” said Nicholas Heiser, MD, the director of anesthesia at Nebraska Medicine’s Fritch Surgery Center, who was one of the study’s authors. “Then we started digging around in the literature and talking to colleagues around the country about their practices. We found that there was not a great deal of guidance in the literature, and that when we talked to different colleagues, we were getting a wide variety of answers about a lot of different things, with no consensus we were able to discern.”
In their research, Heiser and Allyson Hascall, MD, the director of ambulatory anesthesiology at Nebraska Medicine–Bellevue, wanted to see if there might be more of a consensus than was being published. They also were looking for specific patterns about why various risk factors were included or not.
“But we didn’t find those kinds of differences,” Dr. Hascall said. “For instance, we expected criteria might tend to be looser at centers with overnight capacity, or at centers attached to an ambulatory center, as opposed to freestanding surgery centers. But we found no significant differences in that regard, which reinforces the idea that there’s a great deal of variability in patient inclusion/exclusion criteria at ASCs, regardless of setting.”
While the results of their research were not surprising, Drs. Heiser and Hascall do think the data highlights the need for greater consensus on evidence-based selection criteria, especially as the population ages, as obesity and other comorbidities increase, and as more and more surgeries are being performed in the outpatient setting.
“Anesthesiologists will be tasked with being the gatekeepers with respect to determining who is and who is not safe for outpatient surgery,” Dr. Heiser said. “We believe this to be a pressing issue that requires the attention of our profession.”
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