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Cost and convenience prompt more to choose surgery in doctors' offices

The next time your doctor says you need to go under the knife, chances are better than ever that you'll get the surgery in the same place you got the news — right in the physician's office.

Thanks to improved surgical techniques, the high cost of hospital care, and the comfort and convenience of staying in a familiar setting, both patients and practitioners increasingly prefer office surgery. Researchers say in-office procedures have doubled in a decade.

In addition to procedures, such as cataract removal, that long have been done in offices, many medical offices in the Tampa Bay region are expanding their offerings in areas such as gynecology, urology and gastroenterology.

Just 10 years ago, serious complications from in-office surgeries in Florida made national headlines, prompting stricter regulations. Today, experts say many procedures can be done just as safely in offices as in hospitals and outpatient surgery centers.

But some problems linger, especially with cosmetic procedures.

Deaths are rare, but more than half of the 46 office-surgery deaths reported in Florida from 2000 through 2009 involved cosmetic procedures, research found. And now the issue is again making news in South Florida, where since Christmas, three women have died at different Broward County medical offices after elective cosmetic surgeries.

Last year, three of the seven deaths that were reported in connection with in-office surgeries followed cosmetic procedures, a St. Petersburg Times review of state records found. Among them: a patient who had breast enhancement and a tummy tuck revision at a Pinellas County plastic surgeon's office and went home, but died the next day in a hospital of clots in the lungs.

Dr. Brett Coldiron, a dermatologist in Cincinnati, has studied in-office surgeries for medical journals, focusing on Florida since this is one of the few states that requires doctors to report on such problems.

He said overall, Florida's recent safety record is strong. He stressed that patients shouldn't let reports of cosmetic surgery deaths scare them away from needed procedures that are less expensive — and just as safe — in doctors' offices.

"You don't want to discourage any medically necessary procedures, like a colonoscopy, because you're worried about somebody dying from liposuction," he said.

• • •

Several years ago, Tampa anesthesiologist Dr. Hector Vila sounded national alarms with a report finding that office-based surgeries in Florida were 10 times more likely to be fatal than those in surgery centers.

The problem has largely dissipated, he said, crediting regulations adopted by the Florida Board of Medicine limiting the number of procedures that can be done in a single day and setting standards for the administration of anesthesia. Doctors were also required to report serious problems, including when patients had to be transferred to a hospital.

Done safely, office surgeries have a critical place in health care, Vila says. He is now the medical director of a mobile anesthesia practice that helps doctors administer what can be one of the most intricate aspects of surgery.

"There are good examples of how it can be done correctly," said Vila, an assistant professor at Moffitt Cancer Center. "And it saves a lot of money."

It is estimated that the cost of surgeries in doctors' offices could be as low as a third of the expense in a hospital, said Dr. Fred Shapiro, a Harvard anesthesiologist and president of the Institute for Safety in Office-Based Surgery in Boston.

Between 1995 and 2005, the number of office-based surgeries in the United States doubled to 10 million annually, he noted. The most common are cataracts removal, endoscopy and cosmetic surgery.

Procedures suitable for the office setting are those that do not call for a large incision, decreasing the risks of blood loss and infection.

Generally, cosmetic procedures are not inherently more dangerous than other surgeries, experts say. However, combining liposuction in which large volumes of fat are removed and a tummy tuck has been associated with a higher risk of death.

Some of the state's cosmetic surgery problems may just reflect how many of these procedures are being done relative to others. But experts say in some cases where there have been problems, practitioners were not well qualified, and may have cut corners, especially with the qualifications of those administering anesthesia.

Only 24 states regulate office surgeries at all. Even those that do, like Florida, can struggle with lack of resources to make sure rules are followed.

"It's still true that in physicians' offices there's the opportunity for less oversight," acknowledged Vila, who also is a leader of a national organization that accredits offices that voluntarily pursue key safety standards.

"A single physician, a general medicine doctor, could take a weekend course and start doing liposuction and using assistants to do anesthesia — and there's no one looking over their shoulder," he said.

• • •

Concern over in-office surgery has risen after several recent deaths in Broward County. In the latest, on June 18, a 38-year-old housekeeper and mother of two went to a Weston "rejuvenation institute" for liposuction.

Maria Shorthall was healthy, but she died on the operating table, said Michael Freedland, an attorney representing her family. Local authorities are investigating.

"Thirty-eight-year-old healthy women shouldn't die undergoing relatively safe cosmetic procedures," Freedland said.

In May, a 61-year-old woman, also in good health, died at another Broward County facility following a procedure to have her neck and eyelids tightened. And in December, a healthy 35-year-old woman died in yet another medical office during a liposuction with a fat transfer to the buttocks.

In those three deaths, problems emerged during surgery. But that wasn't the case in last year's death after procedures in a Palm Harbor plastic surgeon's office.

On March 31, 2010, a patient in good health went to the Palm Harbor Plastic Surgery Centre for breast augmentation and a revisional tummy tuck. Dr. Erel Laufer, a board certified plastic surgeon who performed the operation, reported that all went smoothly.

The patient recovered at the center, he told the state Department of Health, and was sent home.

But within 24 hours, the office learned that the patient suddenly experienced respiratory distress after going home. Taken to Community Hospital in New Port Richey the patient was diagnosed with pulmonary embolism, a complication that can happen after surgery anywhere. A major blood vessel in the lung becomes blocked, usually from a blood clot.

Later that night, the patient died.

Laufer reported the death to the state, as required. There is no record of disciplinary action against the doctor, whose state license is in good standing.

Laufer declined repeated interview requests from the Times.

• • •

Many experts see the acceleration in office-based surgery as the next step in a decades-old transition away from hospital-based care.

BayCare Health System — which operates the St. Joseph's hospitals, St. Anthony's Hospital and the Morton Plant Mease hospital network — now has about 20 ambulatory sites throughout the region.

CEO Steve Mason acknowledged that its hospitals' outpatient centers sometimes compete with doctor's offices over these surgeries. But outpatient surgery continues to grow at the BayCare facilities.

"We completely understand and appreciate the convenience point of view for the patients and for the physician," Mason said. "They can get much more done in their offices if they can see the patient there."

In the past 21/2 years, almost all of Women's Care Florida's locations in Tampa, St. Petersburg and Clearwater have begun offering surgical procedures. These include in-office endometrial ablation, an alternative to hysterectomy for women experiencing heavy bleeding, as well as some newer sterilization procedures.

Its practices follow safety protocols that exceed the requirements of the Florida Board of Medicine, said chief medical officer Dr. Robert Yelverton.

Anesthesiologists from Vila's practice come to the office when major sedation is required. High-risk patients are referred to the hospital. The practice has not had any bad outcomes, he said.

Neither has the Women's Group, now also offering some surgeries under similarly stringent guidelines at its north and south Tampa and Land O' Lakes clinics. Dr. Madelyn Butler can vouch for the experience as both a doctor and as a patient.

When she needed to have a polyp removed, she never left the office. She fell asleep talking to her colleagues and woke up in a recliner when it was all over.

"If it's good enough for the doctor," Butler said, "it's good enough for the patient."

Times researchers Shirl Kennedy, Carolyn Edds and Caryn Baird contributed to this report. Letitia Stein can be reached at lstein@sptimes.com or (727) 893-8330.

Tips for office-based surgery

• Research the credentials of the doctor performing the procedure. Is the physician certified by the appropriate medical board, signifying years of specialized education? How many procedures like yours has the doctor done?

• Ask about the qualifications of the person giving you anesthesia.

• Ask about recovery. Who will be monitoring you? For how long?

• Ask if the office is accredited to perform surgery and by whom. While this isn't mandatory, it's telling when an office elects to meet the standards of a nationally recognized organization.

Source: Dr. Richard Urman, a Harvard anesthesiologist and chief executive officer for the Institute for Safety in Office-Based Surgery in Boston

Cost and convenience prompt more to choose surgery in doctors' offices 07/04/11 [Last modified: Monday, July 4, 2011 11:58pm]
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