Many patients often wonder how they can prepare for their heart surgeries and that is a very personal choice depending on many factors from current health status to the type of procedure being performed. Also, a surgeon’s reputation along with hospital recognition may also play a major role in how a patient chooses his or her surgeon. These are all very important considerations.
Over the last year I have been following an important consideration that is rarely brought up in any type of discussion with either peers or medical professionals….public reporting of heart surgery data outcomes. Recently, ProPublica published a revealing article entited, ‘Making the Cut: Why choosing the right surgeon matters even more than you know’ about surgeon’s performance in eight elective procedures. Granted cardiac outcomes were not the focus of the article but it nevertheless has brought about a tremendous debate when it comes to publicly reporting surgeon’s outcomes and the consumer’s ability to make an informed decision based on the surgeon’s performance. It is a highly debatable topic and opponents are firm in their belief that consumers do not seek this data or benefit from it. However, in the case of Naftali Zvi Frankel seeking to help his grandfather choose between SAVR and TAVR we see a different story regarding public reporting. I invite you to read Frankel’s quest for data to learn more about his determination to seek the information he needed to help his grandfather choose between SAVR and TAVR.
‘Many believe that greater transparency around patient outcomes, including public transparency, is a critical step toward achieving these goals. Such reports already exist for some cardiac procedures performed in New York and Massachusetts. In the United Kingdom, public reporting of surgeon-specific outcomes for certain procedures is now required by the National Health Service’ US News and World Report.
In California since hospitals started reporting CABG outcomes in 2003 mortality rates have decreased significantly. However, what most people do not realize is that PCI (or angioplasty) and heart valve surgeries such as mitral valve repair or replacement outcome data is not available to the consumer in a report surgeon-specific format.
So what does this mean?
It means that a public report on mitral valve surgery or PCI outcomes is not currently available because OSHPD is not mandated by the legislature to collect and analyze the cardiac outcome data. Dr. MacMillan in his letter in support of SB-830 notes, ‘OSHPD is only authorized to collect and report detailed clinical data for CAB at this time and would only need legislative authorization to expand its mission to PCI. Its data analysis systems are equipped to handle the additional procedures’ (Letter of Support, MacMillan) .
If such a report existed, would it be possible then to see a positive effect for heart valve surgery and PCI outcomes as in CABG outcomes? Granted, this is perhaps an over simplified assumption but one that warrants consideration. It is a highly debatable topic and there are strong views that support more pubic reporting while others caution against it. Still others support more public reporting with the correct infrastructure in place to provide for better patient outcomes (US News and World Report).
Last year I had the privilege of meeting Dr. Joseph Carey interim Executive Director from CASTS and he shared his thoughts about the current status of California’s cardiac public reporting system. You can read my findings impacting California patients here.
In addition, the following represent current concerns affecting California patients and those that were presented to Senator Galgiani in a letter dated April 16, 2014 by Dr. MacMillian in support of SB-830.
- In California there is an increase in heart valve surgeries due to population growth and older patients.
- PCI procedures or also known as angioplasty is not reported publicly at this time and yet PCI accounts for more deaths and complications than cardiac surgery. Dr. MacMillian’s letter states, that ‘recent results show that PCI mortality rates exceed CAB rates by a significant amount (2.41% vs 1.63%).
- Newer technology such as transcatheter procedures need to be evaluated over the long term as more high risk patients are opting for these less invasive procedures.
In order to further understand this matter I took the liberty to reach out to California heart surgery centers and the responses confirmed my understanding that heart valve outcomes are not publicly reported to the state at this time. Yet, I need to be clear that the STS does have data regarding aortic valve surgeries but not mitral valve procedures.
- One hospital representative stressed the importance of knowing the surgeon’s success rates versus knowing ‘data outcomes’.
- Another representative acknowledged the importance of having more cardiac data available but also shared openly that our state is in a financial crisis.
Furthermore, Lisa Nichols, RN, Director of Cardiac Services from the San Ramon Regional Medical Center shared her responses to these questions via email:
Aida: Is a patient able to find ratings for valve procedures through your hospital? Who can he or she ask?
Lisa: STS ratings are available. For aortic valve replacement surgery we are a two star center on a 1-3 scale. Very few hospitals are a one star and very few are a three star, so that is minimally helpful. They can ask me.
Aida: Is a patient directed where he or she might find useful statistics on any of the literature he or she is given?
Lisa: Most patients ask their surgeon that information.
Aida: Where do you recommend a patient search for cardiac outcomes for valve surgery outcomes?
Lisa: Some of the regional centers and teaching hospitals have fancy brochures with the outcomes listed.
Aida: What are your thoughts on SB 830, the legislation in our state that would require OSHPD to report on heart valve surgery outcomes if passed?
Lisa: People do not realize how complex the process is to keep the outcomes data valid and reliable. As we have seen with the decision to not fund the PCI data there would need to be additional funding to increase the amount of cardiac data reported. However, this is a possible trend for the future.
What can the patient or family member do?
It is my personal conviction that each patient must proceed with the best information presented to him or her, including a surgeon’s data on a given type of surgery. I also wish to be clear that data is only part of the equation though a weighty consideration. I appreciate Dr. Adams from Mount Sinai thoughts as he believes in patient education and preparation.
Dr. Adams shares that it is extremely important for a patient to understand his or her indication for surgery as some patients do not experience any symptoms. He also adds the following:
- Understand the condition of your heart valves or your heart condition.
- Research your surgeon’s volume and experience with surgery needed along with success rates. In California you are able to review hospital volume for valve procedures here. This data will show the volume of valve surgeries per hospital.
- Educate yourself on the short term effects and long term effects of your cardiac procedure.
In summary, Dr. Adams makes it clear that a patient should understand their condition, the short term and long term effects of the procedure as well as researching a surgeon’s volume and experience. With an expansion of cardiac reporting in California a patient will have more access to this type of information that is essential in making an informed decision.
Preparing for surgery and choosing the right surgeon takes time and much patience especially under stressful conditions. I also believe it takes a commitment from our providers and legislators to be transparent and willing to progress the expansion of cardiac public reporting in our state as consumers and providers will both benefit.
Important Update on SB-830
‘While legislation was introduced in the California Senate (SB 830) which was going to allow OSHPD the reporting of outcomes after percutaneous coronary intervention (PCI) and valve procedures as well as CABG, the California Senate did not appropriate funds. Until such legislation is successful, CCSIP reports might give hospitals a heads-up on their relative performance status for interventional cardiovascular care in advance of public reporting’ (CCSIP).
Although SB-830 was not approved I am hopeful that with increased patient awareness and the California Society of Thoracic Surgeons continuing to advocate for an expansion of public reporting it is a step in the right direction for consumers and providers.
In closing if this article has sparked in interest in public reporting of cardiac outcomes expanding to include PCI and valve surgeries in the state of California, please take a moment and submit your comments to CASTS’s blog on public reporting. I would also love to hear from you and how this has helped you with your situation.
Thank you for visiting today. I wish you the very best as you continue to make your preparations for the journey ahead.
Each day is a gift,
California Society of Thoracic Surgeons. CASTS Update on Public Reporting: Comments Requested. Accessed May 1, 2015.
California Society of Thoracic Surgeons. Public Reporting of PCI and Valves Moves along SB-830. SB 830 Committee Letter. MacMillan. Accessed March 19, 2015.
Consumer Reports Health. A grandson’s quest for the best care. Accessed July 31, 2015.
HeartValveSurgery. Surgeon Spotlight: Dr. David Adams, Mitral Valve Expert, Harness Education to Improve Patient Outcomes. Accessed July 31, 2015
Making the Cut: Why choosing the right surgeon matters even more than you you know. Accessed July 31, 2015
US News and World Report. Public Reporting is a Judgment Call. Accessed July 31, 2015