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Q: Aortic heart valve replacement ( Answered,   5 Comments )
Question  
Subject: Aortic heart valve replacement
Category: Health > Conditions and Diseases
Asked by: ouzel-ga
List Price: $70.00
Posted: 08 Nov 2005 11:38 PST
Expires: 08 Dec 2005 11:38 PST
Question ID: 590619
I will need to have my aortic heart valve repaired or replaced at some
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
Answer  
Subject: Re: Aortic heart valve replacement
Answered By: welte-ga on 26 Nov 2005 18:54 PST
 
Hi Tom, and thanks for your question.

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

__________________

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.

=========
Washington
=========

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%.

______

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.



=======
Montana
=======

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 864.5% (excluding
hospital mortality). There were four (5%) embolic events (actuarial
freedom 943.5%). 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 687.5%.
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.

______


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

______

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.


================================

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.


================================

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
Comments  
Subject: Re: Aortic heart valve replacement
From: msgirl38111-ga on 19 Nov 2005 20:43 PST
 
ouzel-ga, I am not a registered Researcher but I saw your question and
thought I could help you. For the past 15 years I have worked with
hands-on doctors and nurses to visit and observe best performing
hospitals and poorest performing hospitals on any given specific
measure. They flowchart and make notes of the steps they see,
re-convene and rigorously compare and contrast the observed processes
in the best versus the worst to isolate the process differences that
underlie the performance. Knowing what I know now, I would first
choose at hospital. Then, find out about the surgeons. You are right
to look at the statistics. I work with the Medicare data on heart
bypass and valve replacement. The mortality statistic is the most
valuable, in my opinion.
 
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%
Subject: Re: Aortic heart valve replacement
From: msgirl38111-ga on 19 Nov 2005 20:56 PST
 
This is 2003 Medicare data. I can do a bit more analysis to determine
an average mortality rate.. . looks to be in the 6.0%.  This data is
severity adjusted meaning statisticians adjusted the data to equalize
for sicker patients. SO, no hospital can excuse a poor mortality rate
by saying "our patients are sicker."

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.
Subject: Re: Aortic heart valve replacement
From: ouzel-ga on 19 Nov 2005 22:19 PST
 
Thank you msgirl3811ga for your helpful info. I was happy to see that
St, Patricks Hospital in Missoula, Montana rates well. That is where I
would like to have the procedure done. I was surprised to see that
some of the Montana hospitals have a lower mortality rate than the
Seattle hospitals.

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
Subject: Re: Aortic heart valve replacement
From: pafalafa-ga on 20 Nov 2005 08:56 PST
 
msgirl38111-ga,

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
Subject: Re: Aortic heart valve replacement - for msgirl38111-ga
From: cathymt-ga on 05 Jan 2006 14:10 PST
 
Thank you for your detailed information.

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

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