Weighing hospital outcomes against local convenience

[pem]

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.

Thanks - lots of useful feedback here. What makes the choice so difficult for me is that the local facility is relatively strong. Also, there aren't enough local outcomes to make good statistical comparisons. I think the local surgeon is Cleveland Clinic caliber, but perhaps with less of a research bent. Is this advantageous? At least locally I know he would be the one actually performing the procedure. U.S. News rates the local facility 1 out of 5 in terms of patient safety. Cleveland Clinic gets 3 out of 5. Not sure how much stock, if any, to put into that. It probably applies to the entire hospital, and since they have a separate ICU and step down locally, those facilities may be more attentive than the hospital at large. I realize some of it is procedural. I think there's a hospital equivalent of ISO9000 (The LeapFrog Group - http://www.leapfroggroup.org/cp seems to related to organizational maturity for patient safety, but my local hospital doesn't respond to their survey).

Anyway, I take a similar perspective on short-term outcomes depending substantially on the post-op support. That's partly what motivates my question.

In terms of tissue vs. mechanical, is there really a technical difference in terms of implanting them? If they are both stented, isn't it "just" a matter of excising the diseased leaflets, preparing the space, and sewing in the ring, regardless of whether it is a tissue valve or mechanical valve?

Here's a related question: if I were to have the surgery done elsewhere, would my local support for any ensuing complications or issues suffer for that?

Thanks again,
pem

 

[pem]

IIRC, their tissue valves make up something like 85% of their valve implants.

Thanks - that's good to know!
pem

 

[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?"

LionHeart (where did you get your lion valve - that sounds pretty powerful) - this is all well-taken and similar to my own thinking. The local facility has recently established an independent but attached structure for CTS and vascular stuff. I think they are working very hard to raise their organizational maturity - they have an independent ICU and step-down unit. I don't know process-wise, where they are though. Part of what makes the decision so difficult is that I think this is considered the best surgeon and best facility in the DC area to get AVR. Are the benefits of a "valve factory" sufficient to compel me in that direction?

For my decision process, I'm trying hard to pretend that both facilities are local and then ask the question which would I choose. In terms of technical competency for AVR, I would consider both surgeons equal. Once you get to their elite level, small differences may not matter for straightforward AVR. The local surgeon has experience with the valve I want, but the CC surgeon does not - he prefers the On-X based primarily on having implanted about 30 of them, I believe. I have no doubt that CC has a factory-like process. I think the local facility has a process, but it may not be as mature, though I believe they are striving hard to constantly improve it.

Hmm...

Thanks again,
pem

 

[pem]

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?

Thanks for asking this question. The other day, I found this related thread that seems to answer this question:
http://www.valvereplacement.org/forums/showthread.php?31127-Flying-Home&highlight=cleveland

I think most respondents said that if you prepare properly (call ahead, buy water after security, etc.), then traveling is not an issue.

pem

 

[pem]

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.

I think most if not all of the isolated AVRs are done by the same surgeon. He does about 200 procedures/year - not sure how many of those are AVRs combined with other things. Would that still give you pause? Or is the concern more about facility rate than surgeon rate?

Thanks,
pem

 

[pem]

My surgery was complex...

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.

Rob - seriously, I can't get enough of that photo you should make it into a poster.

So do you think you would have gone to CC if you had had just a straightforward AVR? Or was it because of the complexity of your surgery?

Also, do you think your quality of care at Nashville suffered at all because you had the procedure done elsewhere? (I don't know why it would, but just asking the question).

Thanks,
pem

 

[pem]

And while I have not answered your question I would have jumped at the chance to use the Cleveland Clinic.

Thanks for your comments! What do you think you would have gotten from Cleveland Clinic that you didn't get from your local surgery center?

Thanks again,
pem

 

[RobThatsMe]

Hi pem,

One additional factor to consider is the "risk of complications" during surgery.
If a person is facing a complicated, high risk surgery, this factor bears some thought.

What hospital has the best chance of successfully handling complications?
IMO.. The one that performs the most successful heart related surgeries has most likely seen, and handled every possible type of heart related complication you could throw at them. They are also larger, and have more staff on hand to draw from to assist.

Rob

 

[pem]

Hi pem,

One additional factor to consider is the "risk of complications" during surgery.
If a person is facing a complicated, high risk surgery, this factor bears some thought.

What hospital has the best chance of successfully handling complications?
IMO.. The one that performs the most successful heart related surgeries has most likely seen, and handled every possible type of heart related complication you could throw at them. They are also larger, and have more staff on hand to draw from to assist.

Rob

Very well taken - thank you.
pem

 

[Just ASK]

I guess one never expects complications...

Prepare for the worst, pray for the best. I didn't find out until 11 hours before my surgery that my aorta was severely stenotic and would need replacement. I spent 17 hours in the OR since the On-X valve they put in had subvalvular leakage so they had to remove it and put in the porcine tissue valve....then my Mitral valve leaked due to the newly increased pressure from the aortic valve....so they repaired the Mitral valve as well...then I had to be "left open" for 3 hours while the built-up fluids were allowed to drain. Up until 11 hours prior to this, I was thinking "simple" AVR with the possibility of a minimally invasive procedure. It didn't work out to be anything like what I was "prepared" for. Thankfully, I was at CCF....if I had been local, would I have been able to survive this long a time in the OR? Maybe and maybe not, but after I awoke and was told what happened by Dr. Pettersson (who admitted that I had him worried...that's for another thread and time) it sure felt damn good knowing I had made the trip to CCF. My cardiologist here in Pensacola - who had recommended UAB - also was glad that I was at CCF after he read the dossier from the surgical team on what went down during those 17 hours. I only have my experince at CCF to draw from, but I can say - without reserve - that I can't imagine a better place to go to to have OHS - both from the surgery itself and also the ICU and Step Down unit care. As someone else posted....if you have the choice to go to the #1 facility for heart related surgeries, why the heck wouldn't you? Don't take this wrong, but convenience for friends and family have very little marginal value compared to surviving a major surgical procedure such as OHS. Hope this helps.

 

[Jkm7]

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".

Absolultely. Without substantial reason (such as insurance refusal to pay or the like), why not have the best?

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

That is one fine cardiologist. If you weren't satisfied with your usual cardio, that is certainly one to consider switching to. That is an impressive 'man' let along doctor IMO

 

[pem]

Prepare for the worst, pray for the best....As someone else posted....if you have the choice to go to the #1 facility for heart related surgeries, why the heck wouldn't you? Don't take this wrong, but convenience for friends and family have very little marginal value compared to surviving a major surgical procedure such as OHS. Hope this helps.

Wow - you make a pretty strong case for going to a place like CC - it seems like it was a great choice for you. Thanks a lot for sharing your story.

Incidentally, in all of my readings about the On-X valve, the only finding that wasn't unilaterally positive was a slightly higher incidence of both transvalvular and perivalvular leakage (not sure what "subvalvular" means). But it isn't clear if that is related to the valve design or the non-standard sizing of the valves or something else. Did you ever get any closure on why you had the leakage with your On-X valve?

Thanks again for posting this. You have caused me to reconsider carefully.
pem

 

[Jkm7]

LionHeart (where did you get your lion valve - that sounds pretty powerful) - this is all well-taken and similar to my own thinking. The local facility has recently established an independent but attached structure for CTS and vascular stuff. I think they are working very hard to raise their organizational maturity - they have an independent ICU and step-down unit. I don't know process-wise, where they are though. Part of what makes the decision so difficult is that I think this is considered the best surgeon and best facility in the DC area to get AVR. Are the benefits of a "valve factory" sufficient to compel me in that direction?

For my decision process, I'm trying hard to pretend that both facilities are local and then ask the question which would I choose. In terms of technical competency for AVR, I would consider both surgeons equal. Once you get to their elite level, small differences may not matter for straightforward AVR. The local surgeon has experience with the valve I want, but the CC surgeon does not - he prefers the On-X based primarily on having implanted about 30 of them, I believe. I have no doubt that CC has a factory-like process. I think the local facility has a process, but it may not be as mature, though I believe they are striving hard to constantly improve it.

Hmm...

Thanks again,
pem

Given the difficulty you are having making this very hard decision, perhaps you should make an appointment, hop a plane and go see Cleveland and meet a surgeon or two. That doctor/patient connection matters a great deal IMO If I were so torn, I'd plan a quick visit.

 

[pem]

Given the difficulty you are having making this very hard decision, perhaps you should make an appointment, hop a plane and go see Cleveland and meet a surgeon or two. That doctor/patient connection matters a great deal IMO If I were so torn, I'd plan a quick visit.

Thanks for the suggestion. I did that back in November. I had a very positive meeting with Dr. Pettersson, who seems outstanding on many dimensions. He has also been very generous and patient in answering my questions via correspondence. I am still mindful though that he does not seem to have experience implanting the valve I want. However, for him that probably doesn't make much difference, and he is willing to implant it.

Also, my clock is ticking. My most recent echo indicated a valve area of 0.96 (first time it has dipped under 1.0). I think I may becoming symptomatic, but it's hard to tell. I have a history of stress-related vertigo and I can't tell if what I'm experiencing now is that or lightheadedness associated with the valve. My BP seems fine ranging from 110/65 to 140/90, but usually 125/75 (the pulse pressure stays between 30 and 40).

Thanks,
pem

 

[esvaja]

Hello,
I chose to go to Cleveland vs U of M hospital because of their stats. The surgeon is VERY important but the followup care is also as important. The experience of the staff, post-operative infections etc. I did have to go for followup care for pericardial effusion at the U, I stayed for 6 days. In those 6 days I knew I had made the right decision to go to Cleveland Not all the hospital staff was well versed in AVR followups & complications. It was very distressing. The only problem I now have is the attitude of some staff members towards me once they find out I went to Cleveland. I definitely have to sit at the back of the bus.

Daiva

 

[Lynlw]

I personally believe for a FIRST time surgery, in someone with out other comorbidities, like already having lung problems, kidney issues etc. IF there is one of the leading heart centers (not always but often found in larger teaching hosptal) "local" and not just small community hospitals, even if you run into bumps, you would do great and fully recovery, so I would and have for family members, really consider staying local. Yes flying or driving a few hours away is doable, but there are things that make being closer to home worth really considerring. Things I would look into is if they have dediciated Cardiiac ICUs and step down floor so all the staff takes care of and gett lots of expience, just taking care of heart patients and the bumps they can run into and not having to take care of all different kinds of surgical patients. For Justin is VERY high risk complex surgeries, and even for him the last last couple of surgeries, we were torn betwen the number 1 and 2 CHD centers, one was 'local' the other 5 hours away, we finanlly decided it would be better to stay local, since he was readmitted after 10 days and needed ER surgery, I was very glad we ween't 5 hours from the surgeons, place that did his surgery.

Over the years at VR there have been thousands of members who've had 1st and even 2nd OHS done in the local bigger heart hospitals and did great.

FWIW the ranking of the US news considers "All are experienced in treating difficult cases—a hospital is listed only if at least 1,244 inpatients who needed a high level of expertise in this specialty were treated there in 2006, 2007, and 2008. The top 50 hospitals are ranked by score. Those below the top 50 are listed alphabetically."

I like that they just count difficult cases and not all heart surgeries. I personally think the top 20 listed center would be be able to handle any valve surgeries or bumps you run into. I also like the ratings based on other specialists would recomend them for difficult cases.

Since there are about 90,000 valve surgeries done each year in the US and CCF only does about 3000 and the overall mortality is 1-2% Then that leave a whole lot of valve surgeries that the other centers are doing with very good morbidity, mortality rates. Also something to consider is how many surgeons are doing those surgeries, if some large centers only have 3-4 heart surgeons doing all their surgeies, they MIGHT have some doctors who actally do more of a certain surgery than say CCF that has what 20 surgeons dividing the number of surgeries between them


Beside it just being easier to get there and home, one of my thoughts is If you run into complications and need admitted after you get home. IF you have to go back to the oR, I rather the team that did your surgery and were involved in your post op period be the ones taking care of you if you are bad off and need to go to the OR, than a whole new set of docotors and staff who are trying to coordinate things with the center where you had your surgery. Especially for patients that have known about their hearts for quite a while so the local doctors really KNOW them and their hearts and know what you can normally do or can't- also know if you are someone who might worry or complain alot or say someone who never complains so if they say there is a problem there IS. I know of too many cases, where people got home, ran into problems and the local heart center (even bigger university ones) had a terrible time getting the centers that did the surgery to get back to them..and these are hospitals people often recomend patientts here travel too.

ps here is the link to the us news top rated heart hospitals http://health.usnews.com/best-hospitals/rankings/heart-and-heart-surgery?page=1
I wanted to add IF you are looking for Centers Congenital heart sugeries or CHD surgeons, for Children or Adults with CHD the latest(2011) list is http://health.usnews.com/best-hospitals/pediatric-rankings/cardiology-and-heart-surgery and quite different, (for example CCF isn't in the top 20 of Congenital Heart Centers)

 

[pem]

The only problem I now have is the attitude of some staff members towards me once they find out I went to Cleveland. I definitely have to sit at the back of the bus.

Daiva - Thanks a lot for sharing your experience. It seems relevant. Sorry to hear about this side-effect of going to Cleveland. I would hope that kind of response isn't pervasive.

Best,
pem

 

[pem]

IF you have to go back to the oR, I rather the team that did your surgery and were involved in your post op period be the ones taking care of you if you are bad off and need to go to the OR, thhan a whole new set of docotors and staff who are tryig to coordinate things with the center where you had your surgery. I know of too many cases, where people got home, ran into problems and the local heart center (even bigger university ones) had a terrible time getting the centers that did the surgery to get back to them..and these are hospitals people often recomend patientts here travel too. Especially for patients that have known about their hearts for quite a while so the loal doctors really KNOW them and their hearts and know what you can normally do or can't- also know if you are someone who might worry or complain alot or say someone who never complains so if they say there is a problem there IS.

I can tell there is a lot of experience behind your words. Thank you very much for sharing this wisdom. It seems there are tangible benefits to always taking your car to the same mechanic, as long as you trust your mechanic. So to speak

Thanks again,
pem

 

[Mentu]

Another Alternate View

Another Alternate View

Statistics are funny things. They tell you a great deal about large data sets but are less meaningful when the number of data points are smaller. The mortality rate at CC is based on the results of many surgeries performed by several surgeons and reflects the quality of the entire chain of care from pre-op to post op. They also suggest that there is a lot of ready response available for patients with unusual problems or multiple problems. As such the CC has become our gold standard.

Almost two years ago, I needed an AVR. I had no other cardiac problems, no arterial disease and my lungs were in great shape. I considered going to the CC but after sitting down with our local rep and going over my health insurance coverage, I learned that my personal costs were likely to be many times greater if I went out of state for surgery. From the beginning, my Cardiologist had recommended our local heart center so I spent some time looking into it and eventually did choose to stay here rather than travel to Cleveland. Our local center performs 300-400 valve replacements a year and the overall mortality rate is higher than in Cleveland, however, the statistics do need to be examined. Part of the reason the local rates are higher is that patients too ill to travel remain here. The distance to Cleveland by itself does tend to select for patients that are able to travel and not in need of "emergency" surgery. Patients who are most ill experience higher mortality rates than others so the basic statement of mortality rates may be somewhat misleading.

Here in Tulsa, I had an excellent experienced surgeon and an experienced hospital support staff that gave great care in a hospital with first rate infrastructure. Because I didn't have to travel I had the immediate support of friends and family which made the transition from home to hospital and back home uncomplicated and comfortable. As well, my Doctor and my Cardiologist with whom I've worked for the past decade were here ready to help and recovery my surgeon was only minutes away. For me, this worked out better than I would ever have imagined and I had a relatively uneventful recovery. In the time since my AVR, I have learned of no way in which my experience would have been improved by traveling away from home.

If you feel more comfortable traveling to Cleveland you should do so because you don't want to spend any time later second guessing yourself. Should you choose to use a local hospital, start by asking the Doctors you trust what they know of different facilities, check on potential surgeons' credentials and if possible speak to members of cardiac nursing staffs. One of the things that helped convince me to use my surgeon were comments from two nurses who had worked on his surgical team. They both said "He's the surgeon everyone wants to work with. He values his team members and maintains a calm professional work space where the focus is always on the patient." This worked for me.

Larry
Tulsa, OK

 

[DebbyA]

Hi,

If Inova Fairfax is your 'local' hospital, it's hard to imagine you'd need to travel to Cleveland Clinic unless you are a rare case. Is Dr Speir your Inova surgeon candidate? There are several of his AVRs on the forums besides me-JeffM and Superbob off the top of my head--who also think highly of him.
I am soon moving out of state, and I'm thinking I'd come back to Inova Fairfax if I should need a replacement in the next few years.

Please PM me if you want.