Weighing hospital outcomes against local convenience

[pem]

How does one choose between hospitals? I'm trying to decide between a hospital several states away (Cleveland Clinic), which does about 1600 isolated AVR per year with a mortality rate of 0.9%, and my local hospital, which does about 75 isolated AVR per year and had 2 losses in 2008, 2 in 2009, and 0 in 2010. Also the local place only began performing a partial sternotomy in 2010 and does almost exclusively tissue valves (I have chosen to get a mechanical valve). The local hospital is a 10 minute drive from my house. I've been led to believe the local surgeon is technically outstanding, but I understand that outcomes depend upon more than just the surgeon.

I understand there are lots of reasons to choose one hospital over another, but I wonder if anyone could weigh in on what choice they made, how they made it, and lessons learned.

(Not sure if there's a more suitable forum than "valve selection" for this, but I couldn't find one.)

Thanks a lot,
pem

 

[Just ASK]

Part of your decision process is missing....where would you prefer to be if there is more to be done than simply an isolated AVR? For me the trip from Pensacola Florida to the Cleveand Clinic was tough before surgery, but absolutely the right decision after the fact as I had multiple complications. I have said many times that I'm glad that geography didn't keep me away from CCF and their deep bench of docs that handle complications on a daily basis. It is an important decision, but keep in mind that we aren't talking about getting a tooth pulled...we are talking Open Heart Surgery. Just my $.02...

 

[epstns]

pem - It looks to me like you have the two opposing ends of the spectrum covered. You have the #1 facility in the country and a local/regional facility, each with their own plusses and minuses. Have you explored other options that perhaps aren't as far away as Cleveland? I would bet that there are several in the DC area, given all the government population there.

In my case, living in Chicago, I had similar choices. I could have flown to Cleveland or gone to my local suburban hospital. Instead I chose to go 30 minutes away to Northwestern Memorial Hospital in downtown Chicago. It is top-ranked in Illinois and is a world class institution having world class staff. Maybe you have similar choices closer to home, where they do more than 1 or 2 valves a week.

 

[DeuxofUs]

For me, I am looking more at the surgeon than the hospital (maybe this isn't a good idea) but I am flying literally from the west coast to the east coast. Best doc.. very good hospital. There is also one about 2 hours away that would be a runner up but I figure, (like someone said already) this is OHS... not a tooth being pulled.

Go with your gut and don't let geography be a factor. This is your life and a plane ride is nothing in comparison.

 

[ken taylor]

I have had two OHS surgerys . Boath at St. Lukes in Houston, There is no other place to go for me , And my surgeon Igor Gregoric is world famous and a kind caring man, If I have a third it will be him. With that said I would stick with one of the top four in the nation, But not just any surgeon, Then I would want one of the top two surgeons at that hospital. Valve surgery in the right hands can be easy, Im threee weeks out and walking two miles a day, with no proublems. If some one is going to bat for me I want it to be Josh Hamilton an MVP, stick to the best do not take chances. Thats my two cents worth.

 

[kfay]

I've had 2 OHS and traveled for both. My first was at Duke when I lived in Tenn. At the time, it was the only hospital in the country doing that type of surgery, so not much choice there. For my second one, three years ago, I chose to travel to the Mayo clinic from NC. That choice was made based on the fact that what I needed done is not done very much and I'd rather have a surgeon that does 25 a year vs. a surgeon who MAY do 1 every year or two. I didn't really look into the specifics of the hospital itself, I was just surgeon shopping and hoped that everything else would fall into place. I don't have anything but wonderful things to say about my care there.

As far as convenience goes, I really didn't find it that inconvenient to travel for my surgery. I found someone to stay at my house with my kids, and off my husband and I went. He would probably tell you it was more of an inconvenience than I felt it was.

 

[Jkm7]

I had two OHS at Mass General which is under an hour from our home. It is only hypothetical but had Mass General been a flight away from my home, I think I probably would have traveled there rather than depend upon a community hospital with limited experience. Given the choice, why not be in the best facillity that you can?

IMO it is very important to consider the support staff, nursing staff, total care you will get aside from the technical skill of the surgeon. It is the nurses who are with you most of the time and their competence and training and experience is of great importance. The NP and Physician Assistants and cardios all should be considered.

Pem......As to your local hospital doing mostly tissue valves, you may wish to check but it seems to me I have read here that Cleveland Clinic does a large majority tissue valves also. Yes, they do mechanicals but they seem to recommend tissue for many cases.

All best wishes. These are such hard decisions we have to make.

 

[epstns]

I had also heard that Cleveland Clinic does a high percentage of tissue valves. IIRC, their tissue valves make up something like 85% of their valve implants. My surgeon, Dr. McCarthy came to Northwestern from Cleveland Clinic, and he told me that he, too, is doing mostly tissue valves of late. The common opinion is that the newest ("third generation") tissue valves will last much longer than previous generations, so they can be used for patients younger than in the past. The "dividing line" age for recommending tissue over mechanical valves used to be 65, now it is about 60.

Then there's that "long shot" possibility that when recipients of current generation tissue valves need their next valves, the percutaneous (via catheter) valves may be a mainstream procedure.

 

[Lionheart]

PEM,

I figured that the surgeon and the hospital staff combined would have an affect on the outcome. Granted you will be in the operating room for a few hours under expert care, but then you will be several days in the ICU and step down unit recovering. In addition to an expert surgeon, I wanted a group of experts in heart surgery care that knew what do do if there were unexpected issues, so even with several exceptional hospitals closer to home, I chose to travel farther away. My Cardio was at first a little upset and said I was going to a "valve factory". I thought, "What better place to get a new valve but from the factory?"

A lot of people choose to stay closer to home for insurance reasons or to be close to friends and family, but those visitors will have little influence on a positive outcome.

Best,
John (also a scientist)

 

[Grey]

Just ASK...I tried to post this yesterday, but it doesn't look like it went though. Another question for you (and I think it'll help PEM as well), is what was it like to travel back to Pensacola after your surgery at CCF? How soon did they let you fly, and was the flight a problem for you? For anyone thinking about surgery away from home this has to be at least a passing concern.

Thanks,

Grey

 

[Duffey]

I believe several members have had good outcomes following replacement at INOVA. However, 75 isolated avr's per year would not meet my selection critieria.

 

[Just ASK]

Just ASK...I tried to post this yesterday, but it doesn't look like it went though. Another question for you (and I think it'll help PEM as well), is what was it like to travel back to Pensacola after your surgery at CCF? How soon did they let you fly, and was the flight a problem for you? For anyone thinking about surgery away from home this has to be at least a passing concern.

That was the largest mental hurdle I had about Cleveland vs somewhere closer. I had a bumpy initial recovery that required me to be at CCF for 15 days before I was able to head home. Sans complications, I could have flown at 10 days out. I flew US Air, which required two hops with a 2 hour layover in between. I'm not real excited about the whole airline flight experience in general even prior to OHS and I was mentally prepared for a long, uncomfortable, miserable day of flying. Truth is that it was a breeze. The most important aspect was to get the airline to transport you by cart or wheelchair while you are at the airport. Even at 2 weeks out, there was no way I would have been able to traverse the distance we had to cover from the curb to the gate without wheeled transport. The TSA checkpoints are extremely quick when you say "Open Heart Surgery" while seated in a wheeled "chariot". We even got our seat assignments changed to be at the front of the plane on both flights.
Before the flights, I was worried and apprehensive as to whether I had made a mistake in travelling all the way to Cleveland. After it was all over, I realized that I made the absolute correct decision....and I would do it the same way if the need arose again. Don't sweat the plane ride....make your decision based upon the facility.

Scott

 

[RobThatsMe]

pem,

My surgery was complex. The local hospital was rated very highly in the national survey. CCF was rated # 1. At first I was considering the local hospital so that it would be easy for the wife, family and friends to visit me. Then a friend said to me, " Ther is only one you, and if you can choose between the # 1 heart hospital, and the number 26, why would you not pick # 1. Let your family and friends visit you after you are fixed".

Three weeks after my surgery, I was released to come home, and after being home for less than 24 hrs, I had some complications, and had to check into the local Nashville hospital for yet another week. I had fluid buildup in my chest cavity. During my stay, the head cardiologist came in with his interns, as it was a teaching hospital. Once the visit was made, he lead them out of my room and returned. At this point he came over to me and said; " I just wanted to let you know that you made the right decision. There is no one in Nashville that could have done what they did for you in Cleveland". That really made my day!

Rob

 

[LeakyUK]

In the UK surgery is concentrated at relatively few hospitals. My AVR was at a centre covering 1.5m population, and employs 6 surgeons, who between them do about 90 isolated AVR procedures a year. There appear to be a similar number of combined AVR and CABG. Total heart surgeries are about 1000 a year. I was looked after very well, but did not have the choices available in the US with good insurance. There have been reports in the UK relating to a clinic in Bangalore which performs the worlds largest number of valve surgeries at a cost of $1800 (UK operations were said to cost $18000). And while I have not answered your question I would have jumped at the chance to use the Cleveland Clinic.

 

[Grey]

Before the flights, I was worried and apprehensive as to whether I had made a mistake in travelling all the way to Cleveland. After it was all over, I realized that I made the absolute correct decision....and I would do it the same way if the need arose again. Don't sweat the plane ride....make your decision based upon the facility.

Thanks, Scott...sometimes those logistical arrangements become a real mental challenge for people looking at surgery away from home. I'm glad is worked out so well for you....and others here, from the sounds of it.

Thanks again, Grey

 

[pem]

Part of your decision process is missing....where would you prefer to be if there is more to be done than simply an isolated AVR?

I guess one never expects complications, though I may be more wary than some given my experience with the heart catheterization.

In terms of surprises, at most, I would expect to have work done on my aortic root, since it is "high normal".

On the other hand, if one has complications which require successive follow-ups, wouldn't it be easier close to home? But I suppose a "valve factory" would be best equipped for this.

Not an easy choice for me...

Thanks,
pem

 

[pem]

Have you explored other options that perhaps aren't as far away as Cleveland? I would bet that there are several in the DC area, given all the government population there.

Steve - that's a great point, thanks. I have not explored other local options because the surgeon I'm considering locally is top-rated by local cardiologists and, for what it's worth, seems to be the go-to surgeon for congress-folks. Though he may only perform 75 or so isolated AVRs/year, I think he performs about 200 surgeries/year and seems to be technically outstanding. I've read another post on the forum stating that he saved someone who had an aortic aneurysm. So I guess my concern is more institutional.

 

[pem]

Go with your gut and don't let geography be a factor.

For someone who lives in his head (me), going with my gut may be my greatest challenge

 

[pem]

Valve surgery in the right hands can be easy, Im threee weeks out and walking two miles a day, with no proublems.

Thanks - sounds like you had a great outcome!
pem

 

[pem]

I really didn't find it that inconvenient to travel for my surgery.

Thanks - that's good to know. With us, I think kids would have to come along, but we could also bring extended family to keep an eye on them.