Joan Rivers and the Future of Ambulatory Surgical Care Centers

Yesterday is history, tomorrow is a mystery, today is God's gift, that's why we call it the present.

Joan Rivers (1933-2014)

When comedy legend Joan Rivers died suddenly and unexpectedly at age 81 of a cardiac arrest at a New York City ambulatory care center specializing inendoscopy, it may have set in motion a series of events that will threaten free-standing physician-owned ambulatory surgery centers.

There are now 5300 of these centers in the U.S., and their numbers have been growing as much as 20% each year. The centers performed 23 million surgical procedures last year, and deaths were less than one in a million. Usually complications occur in obese patients, patients with prior cardiac surgery. those with history of stroke, or in the frail elderly. None of which existed in Joan Rivers who was active until the very end.

The Yorkville endoscopy center, where Joan suffered her cardiac arrest, has been open since February 2013 and had performed 18,000 procedures. It hasreferred only 4 patients to a nearby hospital.n The center said Ms. Rivers was pre-screened by a gastroenterologist, an anesthesiologist, and a nurse. The center had 4 board-certified anesthesiologist on duty and said it was prepared for just such an emergency.

The reasons these centers' numbers are growing are crystal clear: the centers are much more efficient than hospital surgical units, surgeons can create their own teams, use their own tools, schedule their own cases, deliver care more efficiently for themselves and patients, save as much a 50% for the health system, patients, insurers, and self-funded companies, and make more money and get a return on their investment.

Some surgical care centers, like the Oklahoma Surgery Center, have statistics showing they can perform ambulatory surgeries more safely than hospitals, which are prone to be havens for hospital-acquired infections.

The death of Joan Tivers of 81 of a cardiac arrest at a site removed from a hospital, throws the merits of ambulatory surgery centers into doubt. The doubts center on the myth that the endoscopy center was ill-prepared for the arrest and had no resuscitation plan. n the Rivers case, there are also doubts that the surgeon who was to remove a lesion on Ms. Rivers vocal cord was not certified to do so, that she experienced vocal cord spasm, and that she may have received too much of an anesthesia or drug to prepare her for the excision.

No one knows at this point precisely what occurred, but the suspicion exists that this was an unnecessary death.


Certainly this tragic event will play into hospital strategies to label doctor-owned independent ambulatory centers as unsafe, and it may well lead into more extensive and expensive certifications and regulations to avoid future tragedies. It may slow the relentless tide towards decentralization of the health system. And it may cost the health system money, for costs for procedures done in a hospital are inevitably more than those in free-standing units, whose owners do not have to bear the burden of paying for non-profitable services like emergency rooms, burn units, and mental care and psychiatric units.