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Office-based surgery deaths: Who is most at fault? Conclusions ignore procedures performed by other specialties, ASPS spokeswoman says


Dr. Guy
Melbourne, Fla. — Analyses of data on office-based surgery collected by the Florida Board of Medicine have particular meaning to Roxanne Guy, M.D., a practicing plastic surgeon in Melbourne, Fla., and vice president of the American Society of Plastic Surgeons.

Unjustified conclusions She congratulates Brett Coldiron, M.D., for taking a look at the data and believes he has raised some important points. Overall, however, Dr. Guy believes that Dr. Coldiron's conclusions may not be justified, based on the available information. Moreover, she is concerned that his statements are so inflammatory that they will be counterproductive rather than have a positive impact on achieving the goal of improving patient safety.

"Patient safety is a tremendously important issue that needs to be addressed by everyone in medicine, and so I applaud Dr. Coldiron for his interest, as it has helped raise awareness about this topic," Dr. Guy says. "However, I believe the greatest benefits will come through multidisciplinary cooperation and well-designed, rigorous analyses. The involved specialties need to put down their swords and lances and work in collaboration with each other to identify where safety problems exist and the best ways to address them."

Biased interpretations She points out that Dr. Coldiron's unblinded analyses are open to biased interpretations and that there are several flaws in the Florida medical board's data. First, she says, the reporting system was imperfect, at best, and it created loopholes for surgeons to hide complications. In addition, changes were made since reporting was first required in 2000 with regard to allowed surgeries and the types of events that must be reported.

Strikingly, Dr. Coldiron's conclusions as to who is responsible for patient deaths and serious complications ignore the total number of procedures performed by each specialty, Dr. Guy says. While data collected on office surgery deaths began in January 2000, reporting of all office-based procedures was required only between June 2002 and Jan. 31, 2004. The latter information is needed to analyze mortality rates that allow for more valid comparisons across physician specialties.

"Incidence analyses show that the death rate for procedures done in the office setting by specialists other than board-certified plastic surgeons was more than three times greater than the mortality rate for procedures done by board-certified plastic surgeons during the same period: 0.0092 percent vs. 0.0027 percent, respectively," Dr. Guy says.

Apples to oranges She also says that Dr. Coldiron is unfairly comparing apples to oranges in contrasting the safety records of dermatologists and plastic surgeons.

"Comparing the risk of complications occurring in patients undergoing skin cancer excision against those undergoing a larger procedure such as liposuction with abdominoplasty makes it difficult to study the issue of patient safety in a valid manner," she says.

Furthermore, it is important to recognize that the Florida medical board did not require physicians to keep logs of Level I procedures, which are those done under local anesthesia and include tumescent anesthesia liposuction, she says.

"For that reason, it is no wonder that there was a paucity of reported problems with those types of surgeries," Dr. Guy says.

Positive initiatives The ASPS has been very active in undertaking projects and initiating programs and policies to enhance patient safety. It requires all members who do office-based surgery under anesthesia other than minor local anesthesia to perform the procedures in a facility accredited by one of three nationally recognized accreditation organizations.

"We believe accreditation has value for creating a safer environment because it ensures that a facility meets basic standards for performing office-based surgery across a spectrum of areas that have the potential to affect patient safety," Dr. Guy says.

In addition, the ASPS is partnering with other specialty organizations to address safety issues and has established a Patient Safety Task Force. That multidisciplinary committee is addressing patient safety in office surgery. It has already studied liposuction, pain management, postoperative nausea and deep vein thrombosis prophylaxis, and, based on its investigations, has issued advisories to guard against problems in those areas.


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