If you've wondered about the value of experience, here is something lifted from the interesting TCTMD website ( http://www.tctmd.com/journal-synopses/one.html?synopsis_id=4084 [registry on the site is free, if you're interested, and the site states they won't sell your information]).
It verifies a concept that many of us have long embraced and endorsed in this forum.
Note that I had to reformat some of the tables due to spacing issues, so their appearance (not content) is changed somewhat from the original. I must ask Ross about transferring table spacing and tabs to active posts.
I believe that for a generally healthy individual, the mortality numbers for AVR are much better than this. These numbers may reflect the growing number of procedures being performed on very elderly and marginal patients who would not have been attempted in the past (such as an 82-year-old Rodney Dangerfield). The AVR mortality rate is a sliding scale that is largely based on age and general health, so the numbers I choose to live in are more fixed to situations similar to my own, and decidedly more comforting:
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Surgeon Volume and Operative Mortality in the United States
NEJM 2003; 349:2117-2127
Authors:
J. Birkmeyer
TA Stukel, AE Siewers, PP Goodney, DE Wennberg, FL Lucas
John D. Birkmeyer The authors undertook a comprehensive evaluation of the operative risk associated with eight different cardiovascular procedures and cancer resections using data from the national population of Medicare recipients. The authors had two primary aims: to assess the association between surgeon volume and operative mortality for various procedures and to achieve a better understanding of the extent to which the observed effects of hospital volume can be explained by the experience of the operating surgeon.
The authors obtained 100 percent of the national analytic files from the Center for Medicare and Medicaid Services for 1998 and 1999. The authors presented four cardiovascular procedures and four cancer resections including coronary-artery bypass grafting, carotid endarterectomy, aortic-valve replacement, and elective repair of an abdominal aortic aneurysm. Patients who underwent repair of an abdominal aortic aneurysm were excluded if they had diagnosis or procedure codes suggesting the rupture of an aneurysm, the presence of a thoracoabdominal aneurysm, or both. Patients who had simultaneous coronary-artery bypass grafting and valve replacement were also excluded. A total of 474,108 Medicare patients underwent one of the eight cardiac procedures or cancer resections during 1998 or 1999.
Operative mortality was defined as the rate of death before hospital discharge or within 30 days after the index procedure. Surgeon volume was determined on the basis of the total number of procedures performed in both Medicare and non-Medicare patients.
There were negligible differences in age, sex, and coexisting conditions between low-volume surgeons and high-volume surgeons. Patients receiving care from low-volume surgeons were more likely to be black and to be admitted to the hospital nonelectively.
When surgeon volume was assessed as a continuous variable, it was inversely related to operative mortality for all four cardiovascular procedures (p<0.001 for all four procedures). Adjusting for hospital volume attenuated the strength of the associations between surgeon volume and outcome, but the effect of surgeon volume remained statistically significant.
When hospital volume was assessed as a continuous variable, it was inversely related to operative mortality for three of the four procedures (p=0.20 for carotid endarterectomy, p<0.001 for the other procedures). After adjustment for surgeon volume, however, higher hospital volume remained a significant predictor of decreased mortality for only repair of an abdominal aortic aneurysm. In fact, after adjustment for surgeon volume, high hospital volume was associated with increased mortality among patients undergoing carotid endarterectomy. For many procedures, surgeon volume accounted for a large proportion of the apparent differences in operative mortality between high-volume hospitals and low-volume hospitals. Among patients undergoing elective repair of an abdominal aortic aneurysm, for example, surgeon volume accounted for 57 percent of the apparent difference in mortality between low-volume and high-volume hospitals. The proportion of the apparent effect of hospital volume that was actually attributable to surgeon volume varied according to the procedure: it was 100 percent for aortic-valve replacement and 49 percent for coronary-artery bypass grafting.
For carotid endarterectomy and aortic-valve replacement, the mortality rates decreased with increasing surgeon volume; but it did not change substantially with increasing hospital volume. For bypass surgery and abdominal aortic aneurysm repair, operative mortality decreased to relatively similar degrees with increasing hospital volume and increasing surgeon volume. Even high volume hospital, patients who received their care from low-volume surgeons had considerably higher mortality rates than patients who received care from high-volume surgeons.
Operative Mortality from Carotid Endarterctomy
Annual Hospital Volume (procedures)........<63.5......63.5-134.5.....>134.5
Surgeon volume......<18.0 procedures..........1.7%..........1.9%...........2.0%
Surgeon volume........18.0-40.0 procedures...1.3%..........1.2%...........1.4%
Surgeon volume.......>40.0 procedures..........1.0%..........1.2%...........1.1%
Operative Mortality from Aortic Valve Replacement
Annual Hospital Volume (procedures)........<68.0......68.0-163/0....>163.0
Surgeon volume..<22.0 procedures..............8.7%........9.5%..........10.2%
Surgeon volume....22.0-42.0 procedures.......7.7%........7.9%...........7.7%
Surgeon volume..>42.0 procedures...............6.6%........7.3%...........6.1%
Operative Mortality from Coronary Artery Bypass Surgery
Annual Hospital Volume (procedures)..........<14.0.....314.0-628.0....>628.0
Surgeon volume..<101.0 procedures..............5.4%..........5.3%...........5.5%
Surgeon volume....101.0-162.0 procedures.....4.4%..........4.4%...........3.8%
Surgeon volume...>162.0 procedures..............4.6%..........4.3%...........5%
Operative Mortality from Elective Abdominal Aortic Aneurysm Repair
Annual Hospital Volume (procedures).............>27.5......27.5-60.5.....>60.5
Surgeon volume....<8.0 procedures..................6.4%.........6.1%.........6.0%
Surgeon volume......8.0-17.5 procedures...........5.0%.........4.3%........4.3%
Surgeon volume...>17.5 procedures..................5.2%.........3.9%........3.6%
The authors conclude: "For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently."
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So, as many here have said, there may be value to going to the surgeon who has the experience, rather than the young buck who has just learned the latest technique and is itching to try it out on you. Also, picking the high-volume hospital alone does not appear to be enough to significantly change your odds.
Best wishes,
It verifies a concept that many of us have long embraced and endorsed in this forum.
Note that I had to reformat some of the tables due to spacing issues, so their appearance (not content) is changed somewhat from the original. I must ask Ross about transferring table spacing and tabs to active posts.
I believe that for a generally healthy individual, the mortality numbers for AVR are much better than this. These numbers may reflect the growing number of procedures being performed on very elderly and marginal patients who would not have been attempted in the past (such as an 82-year-old Rodney Dangerfield). The AVR mortality rate is a sliding scale that is largely based on age and general health, so the numbers I choose to live in are more fixed to situations similar to my own, and decidedly more comforting:
---
Surgeon Volume and Operative Mortality in the United States
NEJM 2003; 349:2117-2127
Authors:
J. Birkmeyer
TA Stukel, AE Siewers, PP Goodney, DE Wennberg, FL Lucas
John D. Birkmeyer The authors undertook a comprehensive evaluation of the operative risk associated with eight different cardiovascular procedures and cancer resections using data from the national population of Medicare recipients. The authors had two primary aims: to assess the association between surgeon volume and operative mortality for various procedures and to achieve a better understanding of the extent to which the observed effects of hospital volume can be explained by the experience of the operating surgeon.
The authors obtained 100 percent of the national analytic files from the Center for Medicare and Medicaid Services for 1998 and 1999. The authors presented four cardiovascular procedures and four cancer resections including coronary-artery bypass grafting, carotid endarterectomy, aortic-valve replacement, and elective repair of an abdominal aortic aneurysm. Patients who underwent repair of an abdominal aortic aneurysm were excluded if they had diagnosis or procedure codes suggesting the rupture of an aneurysm, the presence of a thoracoabdominal aneurysm, or both. Patients who had simultaneous coronary-artery bypass grafting and valve replacement were also excluded. A total of 474,108 Medicare patients underwent one of the eight cardiac procedures or cancer resections during 1998 or 1999.
Operative mortality was defined as the rate of death before hospital discharge or within 30 days after the index procedure. Surgeon volume was determined on the basis of the total number of procedures performed in both Medicare and non-Medicare patients.
There were negligible differences in age, sex, and coexisting conditions between low-volume surgeons and high-volume surgeons. Patients receiving care from low-volume surgeons were more likely to be black and to be admitted to the hospital nonelectively.
When surgeon volume was assessed as a continuous variable, it was inversely related to operative mortality for all four cardiovascular procedures (p<0.001 for all four procedures). Adjusting for hospital volume attenuated the strength of the associations between surgeon volume and outcome, but the effect of surgeon volume remained statistically significant.
When hospital volume was assessed as a continuous variable, it was inversely related to operative mortality for three of the four procedures (p=0.20 for carotid endarterectomy, p<0.001 for the other procedures). After adjustment for surgeon volume, however, higher hospital volume remained a significant predictor of decreased mortality for only repair of an abdominal aortic aneurysm. In fact, after adjustment for surgeon volume, high hospital volume was associated with increased mortality among patients undergoing carotid endarterectomy. For many procedures, surgeon volume accounted for a large proportion of the apparent differences in operative mortality between high-volume hospitals and low-volume hospitals. Among patients undergoing elective repair of an abdominal aortic aneurysm, for example, surgeon volume accounted for 57 percent of the apparent difference in mortality between low-volume and high-volume hospitals. The proportion of the apparent effect of hospital volume that was actually attributable to surgeon volume varied according to the procedure: it was 100 percent for aortic-valve replacement and 49 percent for coronary-artery bypass grafting.
For carotid endarterectomy and aortic-valve replacement, the mortality rates decreased with increasing surgeon volume; but it did not change substantially with increasing hospital volume. For bypass surgery and abdominal aortic aneurysm repair, operative mortality decreased to relatively similar degrees with increasing hospital volume and increasing surgeon volume. Even high volume hospital, patients who received their care from low-volume surgeons had considerably higher mortality rates than patients who received care from high-volume surgeons.
Operative Mortality from Carotid Endarterctomy
Annual Hospital Volume (procedures)........<63.5......63.5-134.5.....>134.5
Surgeon volume......<18.0 procedures..........1.7%..........1.9%...........2.0%
Surgeon volume........18.0-40.0 procedures...1.3%..........1.2%...........1.4%
Surgeon volume.......>40.0 procedures..........1.0%..........1.2%...........1.1%
Operative Mortality from Aortic Valve Replacement
Annual Hospital Volume (procedures)........<68.0......68.0-163/0....>163.0
Surgeon volume..<22.0 procedures..............8.7%........9.5%..........10.2%
Surgeon volume....22.0-42.0 procedures.......7.7%........7.9%...........7.7%
Surgeon volume..>42.0 procedures...............6.6%........7.3%...........6.1%
Operative Mortality from Coronary Artery Bypass Surgery
Annual Hospital Volume (procedures)..........<14.0.....314.0-628.0....>628.0
Surgeon volume..<101.0 procedures..............5.4%..........5.3%...........5.5%
Surgeon volume....101.0-162.0 procedures.....4.4%..........4.4%...........3.8%
Surgeon volume...>162.0 procedures..............4.6%..........4.3%...........5%
Operative Mortality from Elective Abdominal Aortic Aneurysm Repair
Annual Hospital Volume (procedures).............>27.5......27.5-60.5.....>60.5
Surgeon volume....<8.0 procedures..................6.4%.........6.1%.........6.0%
Surgeon volume......8.0-17.5 procedures...........5.0%.........4.3%........4.3%
Surgeon volume...>17.5 procedures..................5.2%.........3.9%........3.6%
The authors conclude: "For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently."
---
So, as many here have said, there may be value to going to the surgeon who has the experience, rather than the young buck who has just learned the latest technique and is itching to try it out on you. Also, picking the high-volume hospital alone does not appear to be enough to significantly change your odds.
Best wishes,
