The Ups and Downs of Outpatient Procedures: What You Need to Know

Revolving doors: © Guntmar Fritz/zefa/Corbis, Patient: © Solus-Veer/Corbis

Thirty years ago, having surgery meant spending at least one night in the hospital. In fact you might find yourself spending days there, your doctor visiting the bedside on rounds, your greatest exertion to lift that spoonful of Jell-O to your lips.

How times have changed. Today, from 60 to 70 percent of surgeries are done on an outpatient basis—the patient heads home the same day, often within a few hours of surgery. It’s a dramatic shift that has brought distinct advantages in cost savings, patient comfort and, at least in some cases, quality of care. But this migration of post-surgical recovery from high-level medical facilities to the home has also put pressure on one of the weakest links in American health care—those moments when one provider hands you off to the next.

Driving the trend toward outpatient, or ambulatory, surgery is a potent combination of economic, medical and social factors. It is, first of all, an effort at cost-containment. As surgeons demonstrate that a particular surgery can be done safely without an overnight stay, insurers may balk at paying for a hospitalization deemed “medically unnecessary.” And physicians have indeed introduced innovations that lead to quicker recovery. Arthroscopic and laparoscopic surgery, for example, use keyhole incisions to insert miniature instruments and a tiny camera or scope to visualize the body’s interior, while short-acting, local anesthetic techniques let patients bounce back to alert functioning more readily.

Today’s medical zeitgeist emphasizes that patients who go home after surgery are able to avoid exposing themselves to the virulent infections spread in hospitals. And finally, most patients are more than happy to return to the privacy and comfort of home, says Ruth Tappen, a professor of nursing at Florida Atlantic University. “Our preference is not to be in a facility,” she says. “It’s a ‘let me out of here’ feeling.”

But all these advantages of outpatient surgery quickly unravel when something goes wrong. Josef Woodman, 56, of Chapel Hill, N.C., experienced excruciating urinary retention caused by the anesthesia in a routine outpatient hernia repair last December. The culmination, two days later, was a frightened, late-night dash to the emergency room.

An inability to empty the bladder is a common problem after hernia surgery. Woodman, who has an enlarged prostate, had even raised the issue with his surgeon. Yet the facility sent him on his way without making sure his system was up and running. As for the emergency department, staffers relieved Woodman of a liter and a half of urine, narrowly preventing his bladder from bursting. Then they discharged him with a catheter to use at home—with no instruction. “ ‘Okay,’ ” Woodman, a savvy publisher of consumer health guides, remembers thinking. “ ‘What am I supposed to do with that?’ I had to get on the Web.”

While serious events like heart attack or death are extremely rare in the aftermath of outpatient surgery, problems like Woodman’s are more common. According to Frances Chung, M.D., professor of anesthesiology at the University of Toronto, the rate of unexpected hospital admissions after outpatient surgery averages about one to two per 100 surgeries.

Chung also has reported that 3 to 12 percent of patients contact a doctor or emergency service about complications after outpatient surgery, the most common being post-surgical bleeding. Research led by Lee Fleisher, M.D., professor of anesthesiology and critical care at the University of Pennsylvania, showed that about 2 percent of outpatient surgeries on Medicare patients result in an emergency room visit within a week of the procedures.

Toronto’s Chung and other experts says that up to half of patients undergoing laparoscopic, orthopedic or other outpatient procedures report wound pain within 24 hours of surgery. And drowsiness, dizziness, headache, nausea and vomiting are common in the hours following surgery.

Notwithstanding the advent of minimally invasive techniques, many procedures increasingly performed on an outpatient basis—such as gallbladder removals, hysterectomies, mastectomies, prostate surgery, stomach reductions and orthopedic repairs requiring weeks of recuperation—are no walk in the park. “We are pushing the envelope at present,” Chung says. “And we are able to do that. But it doesn’t mean that the patient is very comfortable.”

It’s critical for patients to understand that they’ll be discharged when judged not “street fit,” as Chung puts it, but “home ready”—alert, vital signs stable and able to manage pain with oral medication and begin recovering at home. Outpatient surgical facilities typically won’t release patients without an escort. But most patients need someone to stay with them at least that first night. Depending on the procedure, some people need some assistance for days or even weeks.

Not everyone has a spouse or family member able to act as a post-surgical caregiver. Medicare and many private insurers will cover a visiting nurse if ordered by a doctor; this is something patients need to raise with their surgeons or the medical staff in the outpatient surgery facilities well before surgery.

In interviews Ruth Tappen and her colleagues at Florida Atlantic conducted at 10 same-day surgery units in southeastern Florida, the nurses reported little time, post surgery, for dealing with patients’ “last-minute” discharge needs. One recalled a case in which an elderly woman had undergone a breast lumpectomy that was more extensive than expected and required an implanted drain. The patient, like more than a third of women 65 and older, lived alone, and she had planned to go home unaccompanied. So at 4 p.m., the surgical center’s nurse spent two hours trying to locate a home health nurse, approved by the patient’s insurance, who would care for the woman after discharge. She succeeded, or so she thought. But the next morning, the home health nurse did not show up.

“If home health isn’t available or doesn’t show up, or if your friend or neighbor or family member doesn’t know how to help you, then what do you have?” Tappen asks. “Your backup is the ER.” In other words, you can end up where you didn’t want to be in the first place—the hospital.

Insurers typically do give doctors latitude to admit a patient who has certain health problems that make a surgery riskier, even if it’s normally deemed safe as outpatient treatment. But the case has to meet the insurer’s “medical necessity” test. Last year Medicare, as part of a retroactive audit program to curb erroneous billing, disallowed 1,610 New York claims totaling $17.1 million for surgical procedures the auditors said should not have required inpatient care.

In May a surgical instrument company, Medtronic Spine (formerly Kyphon Inc.), settled with the U.S. government, without admitting to wrongdoing, by agreeing to pay $75 million after being accused of defrauding Medicare. The company had recommended to doctors that a minor, typically in-and-out spinal procedure that typically cost $1,000 should be done on an inpatient basis, with an overnight hospital stay that usually cost about $10,000.

Stephen McCollam, M.D., an orthopedic surgeon in Atlanta, Ga., says a 23-hour overnight (technically an outpatient stay) in the hospital is also an option, one he relies on in cases where the procedure doesn’t typically require inpatient care but going home would be difficult for the patient. A good example, he says, is a person with a low pain threshold who faces a very long drive home after repair of a fractured ankle.

In most circumstances, though, one of the biggest attractions of outpatient surgery is that patients are less anxious about undergoing procedures precisely because they don’t have to stay in a hospital. As McCollam puts it, most of his patients are “thrilled they can sleep in their own bed.”

Katharine Greider of New York writes about health care and health policy.