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Choosing a heart surgeon

NOV 2012

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The way public data are presented may influence your choice.

If you're shopping for a car, it's easy to find information on gas mileage, repair rate, and other factors of interest to consumers. Moreover, it's possible to compare models in order to find which one is most likely to meet your needs. Can you do the same with heart surgeons?

Yes, you can, but it's not easy. Although some of the information consumers want is available on government, insurance company, and commercial websites, a Harvard study found that the data are not always presented in ways that are easy to understand and interpret correctly.

How public surveys fall short

"Several public agencies have tried to respond to consumer demand for information about which doctors and hospitals are better than others, but it has turned out to be more complex than it appears," says Dr. Karen Donelan, the senior survey scientist from the Mongan Institute of Health Policy at Harvard-associated Massachusetts General Hospital and lead author of the study.

The study was initiated when Massachusetts decided to make information on complications and death rates from coronary artery bypass grafting (CABG) procedures available to the public. Dr. Lawrence H. Cohn, a distinguished heart surgeon at Brigham and Women's Hospital and a professor of surgery at Harvard Medical School, was invited to help determine what information should be presented and how.

"The public should have the opportunity to know who's the best. Our state is one of a handful that documents every morbidity [complication] and mortality [death] associated with every CABG. The issue was how to make this accessible to the consumer," Dr. Cohn says.

Perceptions make a difference

For data to be useful, they must be presented in a way that can be understood and easily interpreted. Dr. Donelan and a team from Partners Healthcare created a survey with data presented in four different formats, including the one used in Massachusetts. Each format contained information on three to five fictitious surgeons and included the number of CABGs performed, patient operative deaths, observed patient mortality, expected patient mortality, and risk-adjusted mortality.

The researchers discovered that the ability to correctly interpret which surgeon was best varied between 16% and 66%, depending on the format.

"Some displays were more understandable than others, but the ones the respondents said they preferred were not necessarily the ones they interpreted accurately," says Dr. Donelan. "Some people liked numbers in a table. Some liked graphs with colors and bars. Others were better with proportions, rates, and measurements," she says.

In addition, the survey revealed that most people desire information on others' experiences with care, including their perception of their surgeon's interpersonal skills, in addition to objective measurements.

Issues with terminology

It was also apparent that most people did not understand the terminology used in the graphs, particularly the important concept of "risk-adjusted mortality." Instead, they focused on number of deaths. Because the concept of risk adjustment is so critical to distinguishing the role of major medical centers, this greatly concerned the Harvard researchers.

"Tertiary care hospitals care for very sick people who are referred because they may be too complicated for a community hospital to handle. Sicker patients are at higher risk for poor surgical outcomes. If you only look at mortality rates that do not adjust for these risks, you may miss this fact," says Dr. Donelan.

Dr. Andrew Eisenhauer, a cardiologist at Harvard-affiliated Brigham and Women's Hospital and co-author of the survey study, says the impact of this misunderstanding has backfired.

"It is said that public reporting saves lives, because the overall death rate following heart surgery has decreased over time. But the hospitals where deaths occur are treating the sickest patients. These people have a greater chance of being helped, but because they are so ill, a higher percentage of them may die. Even when this risk is accounted for, some skilled surgeons have developed an aversion to operating on the sickest patients due to concerns about public reporting. Therefore, desperately ill patients may be left out."

No simple answer

Because people want to make informed choices, the American Society of Thoracic Surgeons has made its members' statistics available. You can find them at www.health.harvard.edu/CABG. States that gather such data are working on the best ways to present it.

"Public reporting is good in theory, but difficult in concept. It's like saying, ‘What's the best car?' There are many opinions and many factors to consider when deciding what's best for you," says Dr. Eisenhauer.

How valuable is board certification?

Most professionals consider board certification a measure of competence, yet there are heart surgeons who are not board-certified practicing in top U.S. hospitals. Most were foreign-trained or admitted to the hospital's staff before board certification was required. Certification by the American Board of Thoracic Surgery merely indicates the surgeon is qualified to perform chest and lung surgery, as well as cardiac surgery.

Harvard experts recommend how to proceed

Since using public data may not be the easiest way to choose a heart surgeon, Harvard heart surgeon Dr. Lawrence H. Cohn, cardiologist Dr. Andrew Eisenhauer, and survey scientist Dr. Karen Donelan offer the following advice:

Dr. Lawrence H. Cohn

Dr. Lawrence H. Cohn,
Cardiac surgeon
Brigham and Women's Hospital

Ask about your personal risk

Dr. Cohn: Ask your cardiologist about your individual risk of death or complications from the surgery. It will be based on many factors, including your age, the urgency of the situation, how well your heart functions, the quality of your vessels, and any other serious medical issues you may have. If you are at increased risk, you need the type of sophisticated, comprehensive medical care available at big medical centers. The hospital you choose should provide care for multiple organ failure and have critical care intensivists in the hospital around the clock. You want full support services, since you could develop kidney failure and need dialysis, which a community hospital may not have.

Dr. Eisenhauer: If you are at higher-than-average risk, find a surgeon with significant experience. You want someone who does a good job because he or she does it often enough to do it well.

Trust your cardiologist

Dr. Eisenhauer: Assume your cardiologist is acting in your best interest. We want patients to come back and say, "Thank you. I had a good experience."

Dr. Cohn: Cardiologists establish rapport with surgeons who have good records. Your cardiologist will not send you to someone who does a terrible job. That being said, it's okay to ask your cardiologist, "If I were your relative, to whom would you send me and why?"

Dr. Donelan: In case the surgeon to whom you are referred is not available, ask for two or three names.

Dr. Karen Donelan

Dr. Karen Donelan
Senior survey scientist
Massachusetts General Hospital

Do your homework

Dr. Donelan: Use multiple sources of information in your search. Call your health plan. Check your state's website. Ask your primary care physician and other doctors and nurses you know for a recommendation. Often, the best surgeons' names will come up again and again.

Know what makes a surgeon good

Dr. Cohn: Use of the internal mammary artery (IMA) in CABG is standard-of-care and should be used in 99% of cases. Quality standards include completeness of revascularization—all blocked arteries should be bypassed in the same procedure. The surgeon should have low readmission rates for complications such as fluid around lungs or shortness of breath, and length-of-stay after surgery should be short, indicating lack of complications. Also, make sure the surgeon is doing a large number of procedures: the average surgeon performs around 150 CABGs a year.

Dr. Eisenhauer: Lack of outcomes such as infection or stroke is closely related to competence and skill. The in-hospital death rate is also important, but so is overall well-being and the death rate at six months, one year, five years, and longer. You should discuss long-term outcomes with your surgical team.

Dr. Andrew Elsenhauer

Dr. Andrew Eisenhauer
Cardiologist
Brigham and Women's Hospital

Consult with the surgeon

Dr. Eisenhauer: Make sure you are comfortable with the surgeon's personality. Some people believe a surgeon should be aloof and demanding. Others feel more comfortable with a warmer style. You need to be on the same wavelength. Bring someone with you who can listen and be as objective as possible.

Also, it's okay to ask the surgeon, "If you weren't going to do my surgery, who would you send me to?" Don't be confrontational: you are only asking for a fact.

Dr. Cohn: It's perfectly reasonable to ask about the surgeon's mortality rate for the procedure you are going to have done. After all, it's your life.