In this segment of the ‘Open Heart Surgery Series’ I would like to focus our attention on the importance of choosing your heart surgeon and hospital as it is probably one of the biggest decisions that you will be making. Moreover, as you consider your options it is equally important to weigh in the risks and benefits of the recommended surgical procedures. In our experience, choosing your surgeon is a multi-faceted decision that requires much consideration on many different levels. For example, one patient may have time to gather second opinions while another is rushed into the emergency room for a life saving procedure. As Dr. Kathleen Blake shares in her Foreword to The Open Heart Companion: Preparation and Guidance for Open Heart Surgery Recovery, ‘Every cardiac patient comes to this experience with their own unique life history behind them and with their own strengths and challenges, hopes, and fears’.
For many heart patients and their caregivers the ability to seek a second or even third opinion is vital. In Michelle’s words: “Second opinions are also valuable if time allows to ensure that you and your loved ones feel comfortable and at ease with the doctor who will be performing your surgery. Will they listen to your concerns and questions, etc? It was very important to me for my surgeon to attempt to repair my valve rather than replacing it. The first surgeon that was recommended to me was very “cocky” and brushed off our questions and told us that because of the severity of my valve and leaflets that there would be no way to repair it and he wouldn’t even attempt to. The second surgeon was very patient with us, answered all of our questions and ran more tests to make sure he had all of the information to determine if a repair was possible. He knew a repair was important to me and said he would attempt it before just giving up and replacing the valve. He did walk us through the differences between an artificial valve and a tissue valve. He made sure to answer all of our questions no matter how many times we asked. Thankfully he was able to repair the valve after all”.
In Michelle’s case and many others knowing that your surgeon will answer all of your questions to your satisfaction and attempt a challenging procedure is extremely important. After all, your life is in their hands! My husband Steve also had a very complicated case and we wanted to ask as many questions as possible in order to understand the complexities of the surgery but also to have the assurance that the surgeon was going to do his very best to attempt a mitral valve repair vs an automatic mitral valve replacement.
As you obtain your second or third opinions it is also important to gather information regarding the surgeon’s and hospital’s rates specificially: rates of readmissions after certain cardiac procedures, number of procedures per year, success rates, post surgical infections, stroke, re-operations, failure rates, and mortality rates. While this data is crucial, it is alarming that it is not always readily available to the consumer as documented by Naftali Zvi Frankel in JAMA Internal Medicine. After I reviewed Frankel’s results, I was immediately intrigued by its implications on a patient’s ability to make an informed decision. I took the initiative and reached out to Naftali Zvi Frankel in hopes of discussing his work. I was pleasantly surprised when he responded and granted me an interview. We had a very pleasant conversation regarding his thoughts, his motivation behind the publication, and his hopes that data become readily available to the consumer. For a detailed report, I encourage you to take a moment and read Frankel’s research findings in JAMA Internal Medicine. The following are key highlights of our conversation regarding his publication as well as other considerations.
What was Frankel’s work about?
Frankel’s grandfather who had been diagnosed with aortic stenosis needed to find the best heart surgeon in New York and choose the most appropriate treatment. His grandfather was given the choice to enroll in a trial for a transcatheter aortic valve replacement (TAVR) or choose open heart surgery to undergo an aortic valve replacement (SAVR). As a result, Frankel set out to understand the risks and benefits of the surgical options his grandfather was given.
How did Frankel find this information?
He poured over medical journals, corresponded with different medical professionals, and contacted the Department of Health in New York. He also filed a FOIL (Freedom of Information Act) to obtain certain statistics.
What did Frankel find?
Frankel realized that not enough data was readily available to the consumer to review for certain cardiac procedures. Then he found that TAVR which was being presented as a viable option for his grandfather had significant risks.
What did his grandfather choose?
His grandfather chose to undergo traditional open heart surgery for an aortic valve replacement based on Frankel’s findings. I asked Frankel about his grandfather and he was happy to report that the surgery was successful and that his grandfather was doing well.
What are the ramifications of this study?
Since data is currently not readily available to the consumer Frankel is passionate about empowering both consumer and surgeon with data that will serve both patient and hospital alike. With that said, he clarifies the importance that heart surgery centers have transparency when it comes to their data reporting. He however stresses that it is extremely important that transparency is in conjunction with risk adjustment in order to prevent that surgeons who are taking challenging cases are not cast in a negative light if their data outcomes are not as expected.
Are hospitals required to submit their cardiac data to the state?
Yes, ‘according to the National Association of Health Data Organizations (NAHDO), 37 states have mandates that require the collection of health care data’. These states are in varying stages of developing and implementing their reporting practices.
Which states are publicly reporting their cardiac outcomes data at the present?
At the present these are the states which have public cardiac outcomes reporting to varying degrees with New York and Pennsylvania leading the way. New York is detailed in their reporting to include the mortality and stroke outcomes for individual physicians as Frankel points out.
Other states are beginning to realize the importance of having such data available to the consumer and are taking action in their reporting practices. In Washington for example, they are providing some surgeon data through the Clinical Outcomes Assessment Program. In addition, efforts continue through the California Society of Thoracic Surgeons and the University of California, Irvine to provide more information to the consumer.
While the need for information to be readily available to the consumer is becoming more apparent the reality is that the vast majority of states do not have a cardiac outcomes public reporting system in place. This is a complex issue on many different levels and Frankel and I are in agreement that there is an urgent need for data to be submitted, collected, and available to the consumer for review on a much larger scale.
What if I cannot find cardiac data for my state?
If the information is not readily available for your state you may consider these resources. For example, you may start with researching the surgeon through Society of Thoracic Surgeons, Consumer Reports, surgery center, or other trusted source such as Healthgrades. To learn more about specific risks and benefits from certain cardiac procedures you may need to research medical journals or ask your health care team for guidance.
In addition, you should always feel free to ask your surgeon directly what his/her success rates are for that specific surgery, how many surgeries does he/she perform per year, days of hospitalization, mortality rate, stroke, and rate of re-hospitalizations due to complications along with other risks associated with the procedure.
What if my hospital is not on the list from Consumer Reports?
If the hospital is not listed it might mean that the hospital either did not submit the data or that the data is not available. However, it should not dissuade the consumer from independently seeking the outcomes data by contacting the facility directly.
How will the Affordable Care Act affect my ability to choose a surgeon?
There is definitely much debate when it comes to the Affordable Care Act and its implications on long term health care as well as a patient’s ability to choose his/her medical team. I wanted to address this very real concern as it warrants consideration especially if the consumer wishes to see a surgeon outside his/her network.
Being a California resident, I have learned that if someone enrolls through CoveredCA, the individual must choose a health care provider that will accept their subsidized coverage. This in turn translates into being accepted into a very narrow community of medical providers within a very specific network. There might be differences from state to state but as far as I know California’s implementation of the new legislation has had a tremendous impact. However for those with health insurance through a place of employment or Medicare the options may differ. In either case, if you are considering a specific heart surgery center or surgeon it warrants a call to member services to verify that your surgeon and hospital will accept your coverage or if there are allowances to see a surgeon outside your network under special circumstances. However, if you feel very strongly about choosing a surgeon outside your network there might be out of pocket costs to consider.
What does this mean for you and your loved one?
My hope is that you will use this article as a resource to aid in your efforts to find the best heart surgeon and hospital. In addition, I hope it helps you realize that although a procedure might be presented as an option you as the consumer have the right to understand its potential risks and benefits. I wish there was a way to find such information in a streamlined fashion but until more data is readily available it will take time and perseverance to find the answers that you need. And in my humble opinion it will be worth it.
Thank you for visiting Heart Care Matters today. I would like to send a warm thanks to Michelle for sharing her comments and to Frankel whose publication sheds light and insight for all consumers in need of real answers when it matters the most. My hope is that Frankel’s publication will stir the medical community and those at the state level to continue in their efforts to publicly provide cardiac reporting outcomes for everyone’s benefit.
California Cardiac Surgery Intervention Project. http://www.californiacardiacsurgery.com/CCSIP-2012/index.html
Clinical Outcomes Assessment Program. http://www.coap.org/overview
Frankel N. Surgical Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement: A Consumer’s Perspective Regarding Data Education and Transparency of Hospitals. JAMA Intern Med. 2014;174(4):495-496. doi:10.1001/jamainternmed.2013.12829.
Licentenberg, M. (2006) The Open Heart Companion: Preparation and Guidance for Open Heart Surgery Recovery. New Mexico: Open Heart Publishing.
Mass-Dac Data Analysis Center. http://www.massdac.org/
New Jersey Department of Health. http://www.state.nj.us/health/healthcarequality/cardiacsurgery.shtml#CSR
New York State Department of Health. https://www.health.ny.gov/statistics/diseases/cardiovascular/
Pennsylvania Health Care Cost Containment Council. http://www.phc4.org/reports/cabg/
Pennsylvania Health Care Cost Containment Council. http://www.phc4.org/reports/fyi/fyi17.htm
Ritley D. and Romano P. The State of Cardiac Revascularization Outcomes Reporting. Davis, CA: University of California, Davis, Center for Healthcare Policy and Research, 2011. Accessed October 1, 2014.
Rosengart, Todd K MD. Understanding New York State’s Reporting of Heart Surgery Outcome Data-When a List is Not a List. April 3, 2012. http://medicine.stonybrookmedicine.edu/surgery/blog/understanding-new-york-states-reporting-of-heart-surgery-outcome-data. Accessed November 22, 2014.
Stanford School of Medicine. Surgical Outcome Reports. http://ctsurgery.stanford.edu/patient_care/outcomes.html Accessed November 22, 2014.