Aortic heart valve replacement Best answer on the web
point in the next few years. My understanding is that the best results
are obtained when surgeons who have the most exerience with the
procedure perform the work.
I am from Missoula, Montana where the International heart institue of
Montana is located however at present I am living In Seattle while
attending graduate school. My preference is to have the procedure done
in either the seattle area or in Montana.
I would like to know how the surgeons in Montana stack up to the other
surgeons around the country in aortic valve replacement procedures. I
would like this evaluation in terms of the number of procedures
performed and in terms of the success rate. I would like to have the
names of the surgeons who have the most experience with the procedure
and highest success rate. I would like to have the same information
for the Seattle area. Many Thanks. Tom
As you know, the number of procedures performed has been shown to correlate with outcomes. I agree with the commenter (msgirl38111-ga) who stated that the mortality statistic is the most important statistic. Determining how applicable the Medicare data is to your specific situation is a little tricky, since most young people are not on Medicare. The data therefore describes a somewhat different, older population. I do think, however, that there is some correlation with this data and how good each hospital is in terms of outcomes. I've tried to give you some additional information based on the overall populations in each location.
Here is a recent article discussing the issue of numbers of procedures versus outcomes, from MedicineNet:
http://www.medicinenet.com/script/main/art.asp?articlekey=46862
Here's a reference to the original article cited by the above report:
Schelbert EB, Vaughan-Sarrazin MS, Welke KF, Rosenthal GE. Hospital volume and selection of valve type in older patients undergoing aortic valve replacement surgery in the United States. Circulation. 2005 May 3;111(17):2178-82. Epub 2005 Apr 25.
http://www.ncbi.nlm.nih.gov.ezproxy.umassmed.edu/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15851595&dopt=Abstract
Although this article is not freely available online, you can request a free reprint from Dr. Schelbert at this address: erik-schelbert@uiowa.edu
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So, knowing that, who has performed the most procedures in the locations you describe?
I couldn't find a reference for the Medicare data cited, so I wanted to corroborate this information in some way. There's a useful online tool provided by the Department of Health and Human Services called H-CUP. This database catalogues data from hospitals around the country.
http://hcup.ahrq.gov/HCUPnet.asp
I'll first present the results, then tell you how to do your own searches.
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Washington
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For Washington state, the most recent data available is for 2003. The data is tabulated for all valve repairs taken together. There were a total of 1,814 heart valve procedures performed, 96.2% of which were in metropolitan hospitals. The data broken down another way shows that 64.8% of procedures were performed in teaching hospitals (i.e., associated with the University of Washington), 74.5% were in "large" hospitals compared to 22.3% in medium and 3.2% in small hospitals. 88% were done in private not-for-profit hospitals.
The mean length of stay for the metropolitan hospitals was 7.3 days, which was the same as the mean for the whole state. The median length of stay was 6 days for metropolitan hospitals, also the same as the state as a whole, likely because of the large number of procedures performed in metropolitan hospitals.
For all patients in all risk categories, there was a 4.9% in-hospital death rate for the metropolitan hospitals. The highest death rate was in non-teaching hospitals (grouping them all together), which was 7.1%. The state-wide death rate was 5%.
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Some cardiothoracic surgeons at the University of Washington:
Dr. Gabriel S. Aldea
http://depts.washington.edu/surgery/faculty/aldea.html
aldea@u.washington.edu
Chief of cardiac surgery at UW. One of his specialties is valve repair and replacement. He is also an expert on aortic root pathology.
______
Dr. Edward D. Verrier
http://depts.washington.edu/surgery/faculty/verrier.html
edver@u.washington.edu
Vice-chairman, Chief of Cardiothoracic Surgery
He is an expert on thoracic aortic surgery and valvular repair and replacement.
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Montana
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The population of Missoula was estimated to be about 61,790 in July, 2004 according to this source: http://www.city-data.com/city/Missoula-Montana.html
I've never been there, but it looks like a beautiful city! There are two medical centers: COMMUNITY MEDICAL CENTER INC (2827 FT MISSOULA RD)
ST PATRICK HOSPITAL CORP (500 W BROADWAY BOX 4587)
As you may know, the International Heart Institute is affiliated with St. Patrick Hospital.
Unfortunately, the H-CUP database does not have information on Montana - a bad sign in terms of the likely number of procedures performed. The closest we can get is by region, which includes everything in the west, which isn't useful. If it weren't for the IHI, I would say that the data from the H-CUP for the non-metropolitan portion of Washington state would be a good estimate. This would give about 69 procedures for 2003. A better estimate is to look at research done by the IHIMF to see how many patients they discuss.
The following reference, although somewhat dated, gives us a better picture:
"Objectives: The presence of moderate aortic valve (AV) lesions associated with other pathologies that require surgery presents a problem since ignoring or replacing the valve seems unsatisfactory. AV repair can be an attractive alternative if shown to perform satisfactory. Methods: To evaluate this possibility, all consecutive AV patients who underwent operation between July 1988 and July 1999 were reviewed. Out of 1764 AV patients, 239 (14%) underwent repair and 86 (study group) had moderate lesions associated with mitral (73), tricuspid (33), coronary disease (5) and others (8). Mean age was 28 years (range 2?66); 78% were rheumatic, 71% were in sinus rhythm and 71% in NYHA class III?IV. Results: There were seven hospital deaths (8%) and three patients were lost to follow-up (95% complete). Late mortality was 8% and 10-year actuarial survival was 86±4.5% (excluding hospital mortality). There were four (5%) embolic events (actuarial freedom 94±3.5%). Twenty-one patients required reoperation with two mortalities. The AV was not touched in five patients. In the remaining 16, the AV was replaced. Only one patient had isolated AV replacement while in all others, additionally, the mitral, tricuspid, or both required surgery. All reoperated patients had rheumatic etiology. Actuarial freedom from AV dysfunction at 8 years was 68±7.5%. Conclusions: Repair of associated moderate AV lesion is worth considering even in a predominantly young rheumatic population."
So, the IHIMF has been doing roughly 160 aortic valve repairs per year. Their mortality rate was 8% (with a mean patient age of 28 - these were not all old high risk patients), which is higher than the current data for metropolitan Washington state, but similar to the non-teaching Washington state data (7.1%). Again this is only an estimate in terms of the number of cases, but the bottom line is the mortality rate. The posted Medicare data may be more accurate, but I cannot verify that.
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Here are the primary surgeons at the IHI:
Dr. Carlow M. G. Duran
http://www.ihimontana.org/ihi/duran.html
Dr. Carlos M. G. Duran is a well known leader in the field of valve repair and is the driving force behind the founding of the IHIMF. You can read more about him in a recent newsletter from the IHIMF:
http://www.ihimontanafoundation.org/newsletters/IHIMFNewsletter_Vol1Iss.pdf
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Dr. Matt Maxwell
http://www.ihimontana.org/ihi/maxwell.html
Dr. Maxwell is the former head of cardiothoracic surgery at the Naval Medical Center in San Diego.
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To do searches of this type:
Visit H-CUP:
http://hcup.ahrq.gov/HCUPnet.asp
Select State Statistics from the SID
Select Researcher, medical professional
Select Statistics on specific diagnoses or procedures
Select the State/Year you're interested in
Select Diagnoses grouped by Clinical Classifications Software (CCS)?
Select Principle Diagnosis
Type "heart valve," click search, and select heart valve
Click the boxes for the information you're interested in, e.g. %died, number of discharges, length of stay, etc.
Select how you would like the data broken down (e.g. metropolitan vs. non-metropolitan, large vs. small)
Next, select how you would like the data displayed. One-way tables are more straight-forward, but two-way tables give a more detailed cross reference of the data.
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Based solely on the 8% vs. 4.9% mortality rates, I would lean toward having the procedure done at the University of Washington in Seattle. I also don't think you would do badly at the International Heart Institute, but I'm just going by the numbers that I can verify and that I think cover a broader demographic than the Medicare data. There's no way to know from the data what proportion of people in each sample was higher risk. If the IHIMF sees more high risk patients, then we would expect them to have a higher mortality rate. I tend to think that their patient populations are similar if only because the mortality rate for IHIMF is similar to that for the non-teaching hospitals in Washington State, which is similar in demographics (outside Seattle) to Montana.
I hope this information is helpful. I wish you the best in getting through your surgery and recovery. Please request any clarification prior to rating.
Best,
-welte-ga
Can you provide data on Florida facilities?
Can you share your checklist?
I have an uncle facing this surgery who is trying to locate a facility and surgeon in his area.
Thank you.
ctanelli@hotmail.com
Here are three sets of info: ten hospitals doing most valve replacements, the Seattle hospitals, and Montana hospitals (with procedure #'s and mortality rates reported to Medicare)
Most Valve Replacements Ranked by Mortality # of Valve Replacements Mortality
Brigham Young Boston 277 2.65%
Cleveland ClinicCleveland OH 1043 2.78%
St Francis Roslyn NY 429 3.52%
St. Luke's Milwaukee 372 4.10%
New York University NYC 490 4.68%
St. Mary's Rochester MN 594 5.65%
St Thomas Nashville 308 6.28%
Riverside Hosp Columbus Ohio 280 6.75%
Florida Hospital Orlando 344 9.21%
Montana Hospitals Performing Valve
Deaconness Billings 47 2.10%
St Patricks Missoula 87 2.69%
Benefis Great Falls 40 2.80%
St Vincent's Billings 58 9.28%
Kalispell Kalispell 15 9.81%
Seattle Area Hospitals Performing Valve
Virginia Mason Seattle 56 3.13%
Swedish Medical Seattle 85 3.33%
Providence St Peter Olympia 71 3.80%
Swedish/Providence Seattle 51 4.38%
Sacred Heart Spokane 258 6.06%
Providence Everett Everett 45 6.73%
Deaconness Spokane 95 6.93%
Univ of Washington Seattle 64 7.47%
Overlake Bellevue 59 9.72%
Yakima Regional Yakima 48 12.33%
St Joseph Tacoma 78 14.14%
There are definitely some hospitals you should rule out from the data.
I would be happy to share with you process differences between the hospitals with low mortality and high mortality on heart bypass. A friend of mine went to Mayo's Clinic and used my checklist of questions to ask the surgeon and the hospital and was very pleased with the result.
I will keep checking back to see if you have posted a comment or a question for me.
You ARE doing the right thing to base your decision on the statistics.
I would appreciate being able to use your checklist of questions for the Surgeon if you would want to share it with me. If so, is it something you could send electronically? Thanks again. Tom
Very interesting data you presented.
Is the source of your statistics available online? Or only through a restricted-access database?
If you could tell me a bit more about the data source, I'd like to explore it myself.
Thanks.
pafalafa-ga
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