Texas legislators want to require that abortions in the state be performed in ambulatory surgery centers rather than licensed doctors’ offices or clinics, but will that make them safer?
Doctors are performing more procedures, from liposuction, vision correction operations and even abortions in the comfort of their own offices or private clinics. Since 1999, the number of these so-called ambulatory surgery centers (ASCs) has doubled [PDF], from 2700 to nearly 5400 in 2011, according to the Ambulatory Surgery Center Association (ASCA). The organization says that about 65% of these centers are owned by physicians, but hospitals are increasingly forming partnerships with them or establishing their own facilities. And as the volume of these centers continues to grow, more insurers, legislators and patients are asking about whether they meet safety standards and provide quality care.
The Texas abortion bill would require that all abortions in the state be performed at an ambulatory surgery center, and not in clinics that the state currently regulates. That may simply be a matter of semantics, since some physicians argue they don’t need the accreditation to perform procedures, and some states view licensed and ASC clinics as equivalent, and equally safe. (Some states don’t even require licenses for facilities that provide certain outpatient procedures.) Critics of the proposed legislation also say that abortion is not surgery, but a procedure, and that legal abortion is considered safe, especially during the early stages.
But supporters of the Texas bill argue that the surgery centers would provide better medical care for patients, not only during the procedure but in the event that patients would require emergency care to treat complications as well. Currently, 43 states and Washington, DC require that ASCs be licensed. Certification by the Centers for Medicare and Medicaid Services (CMS), which is mandated if the facilities want to qualify for federal reimbursement for their services, and voluntary accreditation programs serve as additional ways to validate the quality of care that the facilities provide. CMS requires that certain infection control measures are in place, and that a nurse trained in the use of emergency equipment is present during every procedure. If complications develop, the ASC must also have a prior agreement with a nearby hospital for transferring patient for additional care.
Office-based surgery facilities that are licensed are not very different from these accredited surgery centers. But the latter is regulated by an outside accreditation association that conducts routine inspections, which some say tend to motivate facilities to maintain higher quality of care. Ambulatory surgery centers may also have more stringent rules when it comes to which medications are available, or whether or not there is an EKG machine on hand, in case an individual required more monitoring.
How do states determine which procedures can safely be performed in clinics, and which require the stricter oversight of ASCs? Again, the criteria vary widely, but typically, they look at the level of anesthesia involved. In general, procedures that require little or no anesthesia are more likely to be performed in licensed facilities, while those that involve light or moderate sedation tend to be done in ASCs.
As complicated and as piecemeal as the process seems, it emerged out of the need to protect patients while not over-regulating every dermatologist trying to remove a wart. Establishing standards is a well-established way of improving care, especially in an environment where more and more physicians are hanging up shingles to perform simple procedures. “Although there is added cost for the setup and accreditation of such facilities, it protects both physicians as well as patients, and thus creates standards for care and safety. Without strict regulation, oversight, and minimum standards, patients can be at risk for adverse outcomes,” says Dr. Robert Glatter, and emergency medicine physician at Lenox Hill Hospital in New York.
Most reproductive specialists agree, although they admit that there is little evidence to support the idea that ASCs provide higher quality of care over clinics. The American Congress of Obstetricians and Gynecologists (ACOG) released a statement in response to the Texas bill stating:
The bills would require physicians who perform abortions to have admitting privileges at a hospital within 30 miles, allowing abortions only in surgical clinics and setting a higher standard than for other procedures with similar low risk such as colonoscopy. The fact is that abortion is one of the safest medical procedures. The risk of complications from abortion is minimal, with less than 0.5% of abortions involving major complications.
So should other procedures, not just abortions, that are currently performed at clinics (some of which are licensed, and some of which are not), also be regulated in the same way? In some states, the following operations can be performed at facilities that may not be either licensed or accredited:
While relatively safe, the procedure does carry potential risks, including bleeding and unpredictable reactions to anesthetics. The American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgery require that if its member physicians operate in an outpatient or ambulatory surgery facility, that the center be accredited by an established facility accreditation organization or be licensed. Some centers possess a license issued by the state but are not recognized as an ambulatory surgery center. States like Idaho and Hawaii have no accreditation or license requirement.
This procedure often involves taking a small tissue biopsy of the vulva, vagina or cervix, and while it carries a low risk of infection or bleeding it can be considered an invasive operation for an office visit. Still, some states do not require licensing or accreditation of facilities that provide this procedure.
Once done in hospitals with at least an overnight stay, most of these surgeries are now done in an outpatient setting, since surgeons can reposition uncomfortable and bulging tissue in the abdomen using minimal incisions. Again, some states may offer only licensing or a mixture of the licensing and accreditation, but there are a handful that require neither.
If the bill passes, the new law would likely shut down the majority of abortion clinics in Texas since they won’t be able to finance the process of becoming an ASC. But regardless of the outcome of the vote, some medical experts see the debate as an opportunity to improve medical care. “The argument on one side is that people who are demanding licensing and accreditation are anti-abortion. Those who don’t want it, are pro-abortion. I don’t think that’s the issue,” says Dr. Geoffrey Keyes, the president of the American Association for Accreditation of Ambulatory Surgery Facilities. “There is nothing wrong with having standards to adhere to when you are performing procedures on patients.”