Joan Rivers' death puts spotlight on outpatient clinics

(REUTERS)

The tragic death of comedian Joan Rivers a week after slipping into cardiac arrest during a routine throat procedure at an outpatient clinic, has left many wondering: Are these facilities safe?

New York health officials said Thursday that the Yorkville Endoscopy clinic Rivers was visiting when she stopped breathing on Aug. 28 is now under investigation.

“They say it’s a routine investigation based upon the clinic identifying an outcome that went wrong … either as a result of anesthesia, either as a result of something called aspiration – when someone will disgorge the contents of their stomach during a procedure — we don’t know what’s going on, so the Department of Health is looking into it,” Fox News legal analyst, Peter Johnson Jr. told “Fox & Friends” Friday. “There’s another body called the Office of Professional Misconduct, that would also look into a physician’s conduct if it was warranted.”

Advances in medical research and technology have improved surgical safety and recovery times — allowing for many procedures once considered “complex” to be re-categorized as “routine” by today’s standards. But it wasn’t all that long ago that most surgeries — no matter how minor– and diagnostic tests required inpatient hospital stays.

“Almost half now [of all] procedures are done in outpatient ambulatory facilities, but we need to understand in New York and other states across the country … the same regulations do not apply to outpatient ambulatory facilities [as] they do to hospitals,” Johnson said. “Very often, there’s nothing called accreditation… These types of facilities – [Yorkville Endoscopy] opened just in the last couple of years – [are] not subject to the same kind of strictures, so the issue is investigation in terms of discipline.”

The convenience factor

In recent years, the American health care system has seen a surge in the number of outpatient clinics offering a variety of different medical services. Even retailers like CVS and Walgreens are following the trend with their own walk-in clinics that administer vaccines, treat common illnesses, provide check-ups and care for minor injuries which, in the past, may have sent people to the emergency room.

“There are more and more things that typically were done in a hospital that are being done in outpatient settings where they don’t have the infrastructure to deal with an adverse event.”

— Dr. Sreedhar Potarazu

Some experts believe more Americans are opting for outpatient care over the hospital setting out of convenience. However, experts question whether convenience should be a factor in this kind of decision.

“There are more and more things that typically were done in a hospital that are being done in outpatient settings where they don’t have the infrastructure to deal with an adverse event,” Dr. Sreedhar Potarazu, an ophthalmologist and founder of VitalSpring Technologies told FoxNews.com. “In Joan Rivers’ case, it’s not clear whether or not the sedation that was used is what caused her cardiac arrest, but elderly patients can sometimes be more susceptible to the adverse effects of [those] drugs.”

In most cases, perhaps [outpatient surgery] is acceptable, but for elderly patients where you think they’re going to require more sedation, it really has to be handled carefully in terms of whether the clinic thinks there’s the right staffing to support that, he added.

Part of the reason outpatient clinics are so convenient is because they don’t have to adhere to the same regulations as hospitals — which isn’t necessarily a disadvantage. In fact, less regulation can mean quicker turnaround times between patients and better efficiency in handling surgical caseloads. But on the downside, Potarazu warned, it can also mean that important pre-operative procedures are not completed.

“There’s a lot that’s done in pre-op in terms of understanding cardiac issues and otherwise — and sometimes that can be missed,” said Potarazu, who performs many outpatient procedures in his practice. “Often the anesthesiologist doesn’t have the time to view the chart, and they may be looking at it right before the procedure. It’s not uncommon and it starts to set up a pretty slippery slope in terms of things that can go wrong.”

Weighing the risks

But many outpatient clinics are perfectly safe, and their popularity among patients shows no signs of slowing down. According to a 2013 report from Moody’s Investors Service, outpatient clinic procedure revenues have been steadily increasing since 2007, while hospital inpatient surgery cases decline by 0.22 percent annually – something Potarazu said isn’t likely to change because of the bad press around Rivers’ untimely death.

“I think people will still be going [to outpatient clinics] because they still find it more convenient than going to a hospital, but I think that people will be more cautious – and it’s not just outpatient centers -- it could happen in a dentist office,” he said. “You’re getting more clinics that are using anesthesia in settings outside of the hospital.”

Potarazu said Rivers’ death may highlight the need for the government to step up regulations for safety standards in outpatient clinics

“You may find [it’s] something as simple as implementing a checklist to make sure that adequate pre-op is done, that they’ve got the right set up, that they’ve got the right staffing – these are things that have been shown to be effective in preventing adverse events in the hospital setting,” he said. “But I think the consumers themselves – especially elderly patients -- have to be asking questions about how adept a center is, and should there be an adverse event -- what is the training of the people who will be providing support?”

“More people are worried about the complications of the procedure than they are about the anesthesia, but the reality is, they need to be equally concerned about the adverse effects of anesthesia,” he said. “It’s prudent that there’s adequate skill sets that are knowledgeable about the use of these drugs and that consumers become more knowledgeable about the potential for complications.”