Julie A Swain MD

Cardiothoracic Surgeon Professor of Surgery Gill Heart Institute at the University of Kentucky College of Medicine

Lexington, Kentucky

The prospect of undergoing heart surgery terrifies most patients and their family members. Moreover, many cardiac surgery operations, especially coronary bypass procedures, must be done urgently. If it is possible to schedule the operation for a future date, patients will have a greater opportunity to ask questions to guide them in the choice of a surgeon and a hospital. However, if an immediate operation is needed, it should not be delayed.

When Surgery Is Recommended

Almost always, a cardiologist will diagnose a condition and, if warranted, will recommend surgery. The cardiologist may then recommend a surgeon or ask the family physician to recommend a surgeon. A persona! recommendation by a cardiologist or primary care physician is the most common way a surgeon is chosen. This remains one of the best methods of choosing a surgeon. It is appropriate,

however, to ask questions about the surgeon.

A cardiologist has an obligation to know the "track records" of the surgeons to whom he or she refers. The majority of the referring doctors send patients to the surgeon whom they think will deliver the best care. However, in this era of managed care and other economic factors, referrals might be influenced by other considerations.

How to Judge Surgical Quality

The track records of cardiac surgeons have been subjected to closer scrutiny than those of any other physicians. This is because cardiac surgery is high profile and high cost, and the results are relatively easy to measure and compare. The most common indicator used to judge the quality of a surgeon is the death rate after cardiac surgery.

The average death rate after coronary bypass surgery is three out of every one hundred patients operated upon (3 percent). A patient who is older or has other diseases has a higher risk, whereas younger patients without serious medical conditions are at a lower risk of dying after surgery. To judge the quality of a surgeon or surgery program, one has to know how "sick" their patient population is. Much effort has been made to develop a "risk-adjustment" scale to level the playing field.

What You Should Know about

Cardiac Surgery Databases

The Society of Thoracic Surgeons, the main professional organization for cardiac surgeons, has spent years developing a database for risk adjustment. Although individual surgeon data and hospital data are not available, the national average data can be accessed by the public on the Internet at www.sts.org. Most of the cardiac surgeons in the country use this database to track their results and to compare themselves with other surgeons.

Other databases exist for regions (such as Northern New England and Cleveland) and for the Veterans Affairs hospitals. New York and Pennsylvania have databases that are available to the public and rate both individual surgeons and hospitals. Surgeons themselves should be enrolled in a database to be able to assess their results. Although many of these databases only rate the quality of results for coronary bypass operations, other operations usually parallel these results.

Still another database at www.healthgrades.com contains Medicare data for all heart surgery programs in the United States.

A surgeon may have a very low death rate because he or she is an excellent surgeon. Alternatively, the surgeon may be average or worse and have a low death rate because he or she only operates on the lowest risk patients. Likewise, an excellent surgeon can have a high death rate because he or she operates on the sickest of patients. The databases were developed to help physicians and hospitals sort out these results. For example, a surgeon who operates on very complicated cases may have a death rate of 4 percent (four out of every one hundred patients). If the predicted death rate from the database is 8 percent, then this death rate of 4 percent shows he or she is an excellent surgeon. Conversely, if the predicted death rate is only 2 percent and the actual death rate is 4 percent, the results indicate a worse-than-av-erage track record.

Referring physicians should know the track records of the surgeons to whom they refer and be able to explain these relatively complicated scales to their patients. Likewise, every surgeon should know their results and share them with their referring doctors and prospective patients.

Is Bigger Necessarily Better?

There is much controversy about whether the quality of surgery is better at a big hospital where a large number of operations are performed versus at a smaller hospital. Excellent results are obtained by some small programs, whereas lower-quality results may be obtained by some

Information on cardiac surgeons can be found on the Internet. The Society of Thoracic Surgeons website, left, posts a database at www.sts.org. Medicare statistics can be found at www.healthgrades.com, below.

large programs. There seems to be a certain minimum number of operations needed to keep an open heart team trained. This number is about two hundred operations per year.

Almost every state and most large cities have at least one high-quality surgery program. It is advantageous to have medical care close to home for many reasons, including ready access to follow-up care, proximity to family and social support structures, and the ability to be cared for by your own physician.

Surgeons Perform Operations, Not Hospitals

It may seem obvious, but surgeons perform operations, not hospitals. There may be a wide range between the abilities of different surgeons at the same hospital. However, the quality of a hospital can affect the results of all surgeons.

Surgeons should appreciate the opportunity to have an informed patient and be willing to answer all questions. The rapport patients develop with their surgeon will be important in the postoperative period, and it is important that patients are comfortable talking with the surgeon.

The following questions are suggested to help evaluate the quality of care. Patients may want to give this list to the surgeon to guide the discussion. After talk

ing with their surgeon, patients may also want to discuss the answers with their cardiologist or primary care physician.

The Top Ten Things You Need to Ask before Cardiac Surgery

1. How many of these operations has the surgeon personally performed in the past three years? (A prevailing opinion is that a surgeon should perform at least seventy-five open heart surgery operations per year, although more experienced surgeons can obtain excellent results even though they may do fewer operations per year.)

2. What percentage of the surgeon's patients over the last three years have died in the hospital after coronary bypass operations?

3. Does the surgeon use a nationally recognized database to compare his/her results to those of other surgeons? How do the results compare? If a state database exists in your area, how does this surgeon rate?

4. Is the surgeon board certified by the American Board of Thoracic Surgery? (This is the only certifying organization for United States-trained surgeons and requires a rigorous examination process and documented training in a residency approved by the Board.)

5. Is the surgeon a fellow of the American College of Surgeons? (Don't be confused by names such as the "International College of Surgeons." The American College of Surgeons requires a peer evaluation of surgical practice and is the largest professional organization of board-certified American surgeons.)

6. Why did your doctor choose this hospital over any others in which the surgeon operates?

7. How many open heart operations are done per year at this hospital? How long has the hospital had an open heart surgery program?

8. Does the operating room have staff in the hospital twenty-four hours a day for emergencies? (Open heart surgery patients sometimes have to return to the operating room quickly.)

9. Who will assist the surgeon with the operation? (Some states require a second surgeon to be present in the operating room.)

10. Will there be a physician or physician's assistant in the hospital overnight to take care of you if an emergency arises? Are these people trained in cardiac surgical care?

These questions about case volume and quality assessment can also apply to a choice of cardiologist for an angioplasty procedure.

It must be emphasized that the personal recommendation of a trusted physician who is knowledgeable about cardiac surgery is very important and should be used in combination with these guidelines.

Drs. Alfred Blalock (left) and Helen Taussig (right).

The famous "blue baby operation," or Blalock-Taussig shunt, was the first surgical procedure developed to treat a congenital heart defect.

In this operation, an artery from the arm is connected to the pulmonary artery to help supplement blood flow to the lungs and thus provide more oxygenated blood to the body.

Right Subclavian Artery Innominate Artery

Right Subclavian Artery Innominate Artery

Left Carotid Artery

Shunt (Left Subclavian Artery)

Pulmonary Artery

CHAPTER SEVEN

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