Back Home by Sundown
For five years, Elizabeth Novoa's doctor recommended that she have a hysterectomy to end her painful, incapacitating periods. Novoa, who suffered from an enlarged uterus, kept stalling, fearful of an operation that would take her out of commission for six weeks. "There's no way I could be in recovery for that long," says Novoa, 39, a product educator for the Kerastase hair care line, who runs 7 miles each day. "For my personality, that would be slow torture."
From her Plano, Texas, home, Novoa searched the Internet for information on "hysterectomy" and "latest surgery," hoping to find a more palatable alternative. She hit upon the University of Texas Southwestern Medical Center in Dallas, where a new laparoscopic hysterectomy is being performed on an outpatient basis. Last month, Novoa's surgeon, Mayra Thompson, made four tiny incisions in her abdomen; inserted a thin, lighted tube called a laparoscope, whose tiny camera showed the way on a video monitor; snipped apart the uterus; and removed it. Just 13 hours after she was wheeled into the operating room, Novoa went home. "It was amazing," she says. "My mother, who came from Arizona to be with me, couldn't believe it. She had an old-fashioned hysterectomy 30 years ago. Here I was walking around a few hours after the surgery."
In and out. Thanks to new miniature tools and minimally invasive surgical techniques, operations long considered to be "major" are increasingly an in-and-out enterprise. You may not see the inside of a hospital at all but report instead to a free-standing "ambulatory" surgery center or a doctor's office. Between 70 and 90 percent of operations performed in the United States--from relatively simple gallbladder removal and hernia repair to more complicated operations like mastectomy and gastric bypass surgery--are now outpatient procedures, says Jack Egnatinsky, an anesthesiologist and president of FASA, an association of ambulatory surgery centers.
Many patients wonder: Is it risky to have surgery without a hospital stay? The less-is-more approach is certainly more convenient for patients than the old way. It's also less traumatic. By operating through small "keyhole" incisions instead of long cuts, surgeons can reduce postoperative pain, infection, bleeding, and other complications. Patients heal more quickly, require less pain medication, and can get up and move around almost right away--essential to a fast recovery.
Insurers, not surprisingly, are highly enthusiastic. An overnight in the hospital may no longer even be an option, unless you've got serious underlying health problems--a heart condition or diabetes or emphysema, for example--and your physician can certify that you require more postoperative care. Little wonder: An outpatient hysterectomy at UT Southwestern can cost as little as $8,400, compared with more than $12,000 for the conventional inpatient procedure.
Beyond the patient's overall health, the decision about where surgery is performed depends on the chosen surgeon's privileges. Many operate at two or more institutions, which may include a hospital and a free-standing surgery center. Heading to a hospital has pros and cons, notes Dennis O'Leary, president of the outfit that accredits them, the Joint Commission on Accreditation of Healthcare Organizations. On one hand, they have the experience, equipment, and personnel to deal quickly with life-threatening complications. But they also tend to be hotbeds of antibiotic-resistant infectious agents. Novoa admits to some trepidation about having her surgery in a teaching hospital, where she might be treated by young doctors in training. "I didn't want someone practicing on me," she says. But she was swayed by confidence in her surgeon, who trains other physicians in laparoscopic hysterectomy. "You have to be really good at what you're doing if you're teaching it," says Novoa.
"If I were having a simple, straightforward procedure, I probably wouldn't go to a hospital," says O'Leary. "But I wouldn't go to a doctor's office either."Surgery centers, he notes, are more tightly supervised than doctors' offices and don't harbor as many free-floating germs as hospitals. But if the procedure were complicated or if he had an underlying health problem, he'd opt for a hospital.
Hospitals may have an edge when it comes to quality control. "A patient who comes into a hospital for surgery can have a high level of confidence that the operating room and doctors and nurses involved are working under a set of standards and regulations that ensures at least a reasonable degree of safety," says Robert Wachter, chief of the medical service at the University of California-San Francisco Medical Center and coauthor of Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Hospitals aren't immune: Wachter and coauthor Kaveh Shojania found victims of error at hospitals and clinics around the country, from the transplant patient whose donor's blood type didn't match to the woman whose surgeon left a crowbar-size instrument in her abdomen. But the farther a patient migrates from the hospital setting, says Wachter, the less stringently regulated the setting will be.
Reined in. Indeed, until a few years ago, surgery centers were the Wild West of medical care: largely unregulated and unaccredited. Now that states are tightening up (14 so far require that outpatient facilities be accredited), about three quarters of surgery centers are accredited by JCAHO, the Accreditation Association for Ambulatory Health Care, or the American Association for Accreditation of Ambulatory Surgery Facilities. A stamp of approval from one of the three, while not a guarantee of excellence, says that the center has at least met certain basic industry standards for safety and quality, Wachter says. "The best analogy might be the health department inspection of a restaurant. Passing doesn't say the food is terrific, just that the place is clean and safe." In a 2005 report, the AAAHC found that nearly all outpatient surgery centers now have systems in place to prevent infection and wrong-site surgery and to check for drug allergies.
Next, the spotlight is moving to doctors' offices, home to an increasing number of tummy tucks, cataract operations, biopsies, and other procedures. Last year, an estimated 10 million surgeries were performed in doctors' offices, twice as many as in 1995, according to the American Society of Anesthesiologists. Some states do impose standards, but strictness varies considerably. Wachter, for one, worries about a lack of resuscitation equipment such as cardiac defibrillators and high-flow oxygen--and the know-how to use it. In a 2003 study of outpatient surgeries in Florida, researchers found that the incidence of death and injury, while still low, was 10 times higher when surgery was performed in an office compared with outpatient surgery centers. Wachter advises asking: "What happens if I stop breathing? What happens if my heart stops? What equipment and procedures are in place in case of an emergency? What if I need to go to a hospital?" He says, "You want to know if they've ever done that before or do they say, 'That's never happened to us; we cross our fingers and call 911.'"
Don't forget, too, to disclose any risks you bring to the operating table. For anyone whose body is stressed by other health problems, a top-ranked hospital might be the best choice of all.
This story appears in the July 17, 2006 print edition of U.S. News & World Report.