A n estimated 25% of all surgical procedures and 50% of all cosmetic procedures are performed in physicians’ offices.1 Patient and physician convenience, ease of scheduling, cost savings and avoidance of nosocomial infections are all benefits of office-based surgery.
But is surgery in the office setting safe? Some physicians and lawmakers don’t seem to think so and are pushing for regulation of office-based surgery.

Many studies support the safety of office surgery, including several large retrospective cohort studies.2-5 Despite the strong evidence of safety, legislation is moving ahead, propelled by the impact of rare, but well publicized, severe adverse events.

Several states require offices that perform outpatient surgery to register. Four states will deliberate office-based surgical regulations in 2004.6 In Massachusetts, a bill proposes requiring all medical offices providing ambulatory surgery to register and obtain a certificate of need in order to continue to perform surgical procedures. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently established a standard that will require physicians to perform a minimum number of procedures in the hospital each year in order to retain privileges, even for procedures that are typically performed in an outpatient setting.7 This requirement would impede dermatologists from receiving and retaining hospital privileges and credentials.

Fortunately, more well-reasoned guidelines are being proposed. The American Academy of Dermatology Association (AADA) has published a position statement on office-based surgery.8 First, it supports comprehensive, mandatory reporting of adverse events. Second, it supports reasonable anesthesia guidelines, specifically state regulations that would restrict or ban general anesthesia except in accredited medical facilities. Third, it encourages reasonable physician credentialing (including review by peers in the physicians own specialty). Such guidelines may help promote patient safety. Such guidelines are clearly better founded than suggestions that physicians be required to have hospital privileges, as the Florida data show that having hospital privileges does not reduce the rate of office surgery adverse events.9

The regulation of office surgery is as important as any recent issue to arise in dermatology. Office-based surgery should only be performed by properly trained physicians working within their scope of practice. Physicians recognize this, and the vast majority practice in this manner. Further regulation will adversely affect all these physicians and their patients, while doing little if anything to prevent abuses. Uniform reporting of adverse events and mortality related to office surgery is important. Identifying specific areas of patient safety lapses is paramount. The available data demonstrate the safety, effectiveness and value of office-based surgery. This message needs to be heard by legislatures, medical boards, physicians and the public — and soon.

Drs. Williford and Hancox are with the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.