AMBULATORY CARE
One of the most significant trends affecting health care in the
last quarter of the 20th century was the development of ambulatory surgery (see Chapter
68
). Indeed, whereas 80% of surgery in the United States was performed
on inpatients in 1980, that same percentage of our national surgical workload is
now conducted on an ambulatory basis; moreover, the nation's surgery is now estimated
to comprise twice as many cases. This trend is expected to continue, albeit at a
slower rate ( Fig. 2-1
).
[25]
Many factors contribute to this trend, including
consumerism, especially because the public is increasingly eager to have an ever-larger
decision-making role in medical care; new technologies in anesthesia (fast-acting,
short-duration anesthetic drugs and adjuvants) and surgery (tools for minimally invasive
surgery such as endoscopic devices and lasers); and changes in health care economics.
However, judging from the temporal aspects of the transition depicted in Figure
2-1
, economic factors are by far the pivotal factor.
The phase-in of Medicare's prospective payment system, beginning
in 1983, limited payments for hospital inpatient care to predetermined resource costs
associated with
Figure 2-1
The growth of U.S. surgical procedures by site, 1980
to 2005. (Hospital data through 2001 from the American Hospital Association;
freestanding surgery center and physician's office data through 1999 and all estimates
after 1999 provided by Verispan, LLC, Chicago.)
a surgical procedure's diagnosis-related group. Suddenly, there was a potent financial
incentive to perform surgical procedures (and other care) out of the hospital to
escape the limitations imposed by these fixed rates. Thus, an increasing amount
of surgery was shifted to the hospital's outpatient surgery facilities, where payment
was based on the former, uncapped, cost-based system, which allowed the hospital
flexibility in setting charges. Once ambulatory care's safety and cost savings became
apparent, Medicare and other insurers covered an increasing array of procedures in
hospital-independent, freestanding surgery centers, providing a substantial incentive
for a further shift of hospital cases into the ambulatory setting.
Increasing cost-consciousness has encouraged the movement of surgery
to the setting with the lowest costs: the surgeon's office. What was once only
a site for biopsies and dental extractions has matured into freestanding, single-specialty
(e.g., hand and cosmetic surgery, cataract extractions, hernia repair) surgery centers.
Indeed, the surgeon's office has been the most rapidly growing surgical setting;
at present it accounts for about one quarter of the national caseload. Anecdotal
data report a similar movement of pain management to freestanding offices.
Although economics, enhanced technology, and a ready and willing
public account for the development and flourishing of ambulatory surgical care, the
main impetus of this transition in care is its apparent safety. The shift in locus
of care could not have occurred unless patient outcomes were at least comparable
to those associated with inpatient care, if not better. The corollary is that it
behooves anesthesiologists practicing in these various ambulatory sites to maintain
the same procedural and institutional safeguards required for high-quality care—including
policies and procedures regarding patient and procedure selection as well as practice
standards as they pertain to inpatient care. Mishaps occurring to high-profile persons
undergoing office-based plastic surgery (usually reported without detail) are evidence
of the potential danger of ambulatory procedures.[26]
Additionally, catastrophes involving liposuction,[27]
sedative drugs, and malignant hyperthermia in ambulatory procedure settings are poignant
reminders that high standards must be maintained in all clinical settings. The ASA
has prepared an information manual for all anesthesiologists administering anesthesia
in an office.[28]
The emphasis on ambulatory procedures has enticed many non-anesthesiologists
(emergency medicine and pediatric physicians, specially trained nurses) into the
sedation business. Anesthesiologists, however, are responsible for promulgating
guidelines for these groups. Burton Epstein, in his 2002 Rovenstein lecture, describes
the history and effectiveness of these efforts.[29]
