For decades, same-day procedures such as joint replacements and colonoscopies have outnumbered inpatient surgeries, yet only recently have consumers had data on the quality and safety of facilities that do them.
Rating organizations have begun to expand to hospital-owned outpatient surgery departments and/or freestanding ambulatory surgery centers, which are typically owned by physicians.
Payers and patients need guidance, partly due to concerns about inappropriate procedures. As a story by Kaiser Health News and IndyStar reported in 2018, outpatient facilities have performed increasingly complex procedures, potentially putting patients at risk.
Current performance measures fall far short of what’s needed, according to experts. There’s “a huge need for more research” into how to assess care outside of traditional settings, said Harvard Medical School surgeon and researcher Thomas Tsai, M.D., M.P.H., in an interview.
When writing about outpatient surgery ratings, experts recommend that reporters pose questions similar to those in an AHCJ tip sheet for hospital ratings. They include:
- What is being measured?
- How were the data gathered and verified?
- What is the purpose? Does the rating organization profit by selling facilities the right to use its logo?
Who’s rating what
So far, at least three organizations are assessing outpatient surgery.
First was The Leapfrog Group, which in 2019 launched a survey of ambulatory surgery centers and added a section about outpatient surgery to its hospital survey. The not-for-profit watchdog focuses on high-risk procedures such as joint replacements and bariatric surgery that are common for patients with private insurance, said Missy Danforth, Leapfrog’s vice president of health care ratings.
Danforth said there’s not enough information for Leapfrog to assign “safety grades” to outpatient facilities as it does for hospitals. Many ambulatory surgery centers lack infrastructure such as electronic health records and staff dedicated to quality and safety. So Leapfrog has focused on basics such as safe surgery checklists, hand hygiene and infection surveillance, she said.
Even so, participation has been low among ambulatory surgery centers, which are not used to answering Leapfrog’s surveys. Danforth said only about 300 centers — a small fraction of the total — are expected to respond this year.
In stark contrast, Newsweek relies mainly on reputational scores for its annual ranking of outpatient surgery centers, which started in 2021. According to its website, Newsweek partners with market research firm Statista to survey “medical experts with knowledge” of the centers about the “top 10 notable [ambulatory surgery centers] in their respective state” and how well those facilities do on four quality “dimensions.”
One third of Newsweek’s score is based on objective government quality measures, but facilities without at least two such measures are rated on reputation alone. Newsweek did not respond to an interview request.
Most recently, U.S. News & World Report added outpatient surgery complication rates to its rankings of best hospitals for two rapidly growing specialties, orthopedics and urology, and announced plans to expand that measure to other specialties.
It calculates complication rates using Medicare claims with software developed by 3M Health Information Systems. The publication has explored adding rankings for ambulatory surgery centers, said Ben Harder, U.S. News managing editor and chief of health analysis.
All of these organizations incorporate data from the Centers for Medicare & Medicaid Services, which runs the Hospital Outpatient Quality Reporting Program and the Ambulatory Surgical Center Quality Reporting Program.
The two programs have different measures, making it tricky to compare hospital-based departments and ambulatory surgical centers that provide the same care. Further, their measures focus on procedures common in Medicare, such as cataract surgery and colonoscopy, limiting usefulness for younger patients.
Facilities must report data to receive full Medicare payments, but CMS does not attach financial incentives or penalties to performance as it does with inpatient care.
“Inpatient care still remains the most expensive and, frankly, the most dangerous, and it’s where the federal government has the most mature public reporting and payment programs,” Danforth said.
Another important source is CMS’s Outpatient and Ambulatory Surgery Consumer Assessment, a tool for collecting patient feedback about factors such as communication with the care team, facility cleanliness and pain management. Starting in 2024, hospitals that receive Medicare payments for outpatient surgery will be required to conduct the survey. The provision starts in 2025 for ambulatory surgery centers.
Some experts want CMS to require outpatient facilities to collect more patient-reported outcomes — asking patients whether they move better a few months after joint surgery, for example. However, the industry has argued this is burdensome.
More scrutiny is coming from other sources as well. The National Committee for Quality Assurance, which accredits health plans, has been considering outpatient surgery measures for its Healthcare Effectiveness Data and Information Set, Tsai said.
For outpatient surgery, Tsai said, factors such as individual clinician quality, patient experience, and the ability to quickly transfer patients to a higher level of care when a complication occurs are particularly important.
Harder noted that some hospitals have shifted much more aggressively into outpatient surgery than others, often in response to capacity and payer issues. The open question of whether the inpatient or outpatient setting is most appropriate for particular procedures would be a “fantastic” angle for journalists to explore, he added.