Wendy Salo was alarmed when she learned where her doctor had scheduled her gynecologic operation: at an outpatient surgery center. "My first thought was 'Am I not important enough to go to a real hospital?' " recalled Salo, 48, a supermarket department manager.

Before having her ovaries removed this fall, Salo drove 20 miles from her home in Germantown, Md., to tour the Massachusetts Avenue Surgery Center in Bethesda, Md. Her fears were allayed, she said, by the facility's cleanliness and its empathic staff. Salo said the main difference between the multi-specialty center and Shady Grove Adventist Hospital — where she underwent breast cancer surgery last year — was that the former had "better parking."

Salo's initial concerns mirror questions about the safety of outpatient surgery centers that have mushroomed since the highly publicized death of Joan Rivers. The 81-year-old comedian died Sept. 4 after suffering brain damage while undergoing routine throat procedures at Yorkville Endoscopy, a year-old free-standing center in Manhattan.

Federal officials who investigated Rivers' death found numerous violations at the accredited clinic, which remains open but faces termination from the Medicare program. It must correct deficiencies and pass an unannounced inspection. Yorkville officials have said they have corrected the deficiencies and are cooperating with the investigation.

"Any time there is a major or minor accident, people begin to question the safety record," said anesthesiologist David Shapiro, past president of the Ambulatory Surgery Center Association, a national trade group and member of the board of an organization that accredits surgery centers. Rivers' death, Shapiro said, is an aberration. "We have an exceptional, exceptional success rate," he said, adding that his industry is "very, very tightly regulated."

A 2013 study by University of Michigan researchers who analyzed 244,000 outpatient surgeries from 2005 to 2010 found seven risk factors associated with serious complications or death within 72 hours of surgery. Among them: overweight, obstructive lung disease and hypertension. The overall rate of complications and deaths was 0.1 percent — about 1 in 1,000 patients — and involved 232 serious complications, such as kidney failure, including 21 deaths. Comparable statistics could not be obtained for hospitalized patients because most studies involve specific procedures.

Another study found that about 1 in 1,000 surgery center patients develops a complication serious enough to require transfer to a hospital during or immediately after a procedure.

Lisa McGiffert, director of Consumers Union's Safe Patient Project, has a significantly less rosy view than Shapiro. Surgery centers, she said, largely operate under a patchwork of state laws of varying strictness. Detailed information about outcomes and quality measures is lacking, she said, and the Rivers case raises questions about "the relaxed attitude that might have prevailed."

The number of ambulatory surgery centers — which perform procedures such as colonoscopies, cataract removal, joint repairs and spinal injections on patients who don't require an overnight stay in a hospital — has increased dramatically in the past decade, for reasons both clinical and financial. More than two-thirds of operations performed in the United States now occur in outpatient centers, some of which are owned by hospitals.

Advances in surgical technique and improved anesthesia drugs have allowed many procedures to migrate out of full-service hospitals to free-standing centers, which offer doctors greater autonomy and increased income. Patients say the centers are cheaper, require less waiting and offer more personalized care. Nearly all ambulatory surgery centers are owned wholly or in part by doctors who refer patients to them. These doctors earn money by performing procedures and receive a share of the fee charged by the facility.

Baltimore internist Matthew DeCamp, an assistant professor of bioethics and internal medicine at Johns Hopkins, said that as a result of Rivers' death, patients have asked him whether they should avoid surgery centers.

"I don't think there's necessarily one answer for all patients," said DeCamp. But he has advised prospective patients to ask about safety equipment.