Looking for a heart surgeon?

Looking for a heart surgeon?

These ratings can help you find a good one

Published: August 2011

Introduction

It's sad but true that it's easier to make an informed choice about cars and refrigerators than it is about health-care providers. To help correct that problem, we’ve teamed with the Society of Thoracic Surgeons (STS) to publish ratings of heart-surgery groups based on their performance data for bypass surgery. Using this information, consumers can see how surgical groups compare with national benchmarks for overall performance, survival, complications, and other measures.

No organization is better poised to provide this snapshot of surgical outcomes than the STS, a nonprofit organization that represents some 5,400 surgeons worldwide who operate on the thorax, or chest. Its Adult Cardiac Surgery Database includes more than 4 million surgical records and covers roughly 90 percent of the more than 1,100 surgical groups in the U.S. that perform cardiac surgery, making it the largest such registry in the world. Participating groups add data four times a year, providing an up-to-date picture of their surgical practice.

The three-star rating system draws on this extensive database to show how well surgical groups performed in terms of survival rates, the absence of complications, and other key measures. Groups that score above average receive three stars, average performers get two stars, and those that are below average get one. Because the average performance of surgical groups has increased substantially in the past two decades, it’s possible to get very good care even from many two-star practices.

These ratings include only those groups that have agreed to let us publish their performance results. That includes 323 groups from 44 states, plus the District of Columbia. Eighty-one of those groups received three stars for their overall performance, 237 got two stars, and five got one star. We will periodically update the ratings with data from additional groups that agree to release their information to us.

In the meantime, if you are considering bypass surgery with a group that is not in the ratings, you should still ask for its results. That's because most surgical groups that have not yet agreed to share data with us do participate in the STS database. And they should be willing to provide those results to you. In fact, our medical experts say that if a group can't share that information—or won't—you should consider looking for a different one.

Our report also provides advice from our experts on treating heart disease, including basic medical management that every heart-disease patient should have as well as less-invasive alternatives to standard bypass surgery that might make sense for some people.

How is heart disease treated?

Most heart attacks are caused by blood clots.
Photo: medmovie.com

Heart disease used to be viewed as something of a plumbing problem. Under that model, doctors use tests to detect and then pinpoint blockages, which they "fix" using procedures to open up narrowed arteries or route blood flow around them.

Although that might help ease angina (aching, discomfort, or a burning or heavy sensation usually felt in the chest when you're active) in the short term, it won't necessarily prevent heart attacks. That's because those procedures usually treat isolated blockages, while diseased arteries typically have additional plaque deposits that are too small and numerous to be completely eradicated by them. And researchers now know that most heart attacks occur not when a large deposit blocks an artery but when other factors cause a smaller, less-stable deposit to rupture, producing an artery-blocking blood clot.

Those seeds are planted when high blood pressure, diabetes, smoking, or other factors injure the lining of the arteries, and cholesterol builds up at the damaged site. Treatment should always start by controlling those risk factors through diet, exercise, and medication.

Medical management. When appropriate testing confirms heart disease but shows no imminent threat of heart attack, the first step should be intensive medical therapy plus a long-term commitment to exercise and a heart-healthy diet. Current medical guidelines call for giving that conservative approach at least three to six months before resorting to more expensive and risky invasive measures.

Although some interventional cardiologists are quick to recommend angioplasty, also called percutaneous coronary intervention (PCI), to open constricted arteries, research has found that people who turn to lifestyle changes plus medical therapy are about as likely to be free of angina as those who also have angioplasty. More important, for people with stable coronary disease, there's no evidence that adding angioplasty, which tries to clear narrowed arteries by snaking in a tiny balloon and inflating it to crush plaque deposits, prevents heart attacks or other coronary events better than drugs and lifestyle changes.

Most people with heart disease will need to take several medications and at least one dietary supplement, as shown in the table below. For ACE inhibitors, beta-blockers, and statins, we've listed the specific drugs our experts recommend.

Drug Purpose
Angiotension-converting enzyme (ACE) inhibitors:
Generic captopril, enalapril, lisinopril, or ramipril
Lower blood pressure and relax the arteries, making it easier for the heart to pump.
Beta-blockers:
Generic atenolol, metoprolol tartrate, nadolol, or propranolol
Prevent angina and reduce blood pressure.
Low-dose aspirin Thin the blood and prevent clots.
Nitroglycerin:
isosorbide (Isordil)
Stop angina attacks by relaxing blood vessels.
Omega-3 fatty acid (fish oil) supplements:
1 gram daily. (Look for a “USP verified” product.)
Inhibit clotting, lower blood pressure and triglycerides, and help maintain normal heart rhythms.
Statins:
atorvastatin (Lipitor) or generic lovastatin, pravastatin, and simvastatin
Lower LDL (bad) cholesterol and perhaps reduces inflammation in the blood vessels.

More-invasive approaches. If testing reveals severe blockages, you might need immediate angioplasty or bypass surgery. Bypass is generally called for when the heart's main artery or three other major arteries are occluded; angioplasty might be an option if one or two vessels are blocked. Bypass or angioplasty can also be appropriate if symptoms don't improve with drug therapy.

Doctors pinpoint blockages using angiography, a procedure that threads a flexible tube from the groin into the coronary arteries and injects a dye so that obstructions show up on an X-ray. Then they use angioplasty to clear the blockages. In most cases, the cardiologist will also place a cylindrical insert called a stent to keep the vessel open. Stents used in angioplasty today are usually coated with a drug to help prevent the artery from narrowing again. People who get a coated stent must usually take a blood thinner such as clopidogrel (Plavix) or prasugrel (Effient) for at least a year and low-dose aspirin for life.

Weighing your options. Some interventional cardiologists recommend angioplasty immediately after angiography reveals coronary narrowing, often while the patient is still on the table. But unless it's an emergency situation—for example, if you've just had a heart attack—there should be time to discuss various options with your treatment team and arrive at a strategy that works best for you.

If your doctor recommends either angioplasty or bypass, ask why lifestyle changes plus drugs aren't sufficient. If he or she recommends angioplasty, ask why that's preferable to bypass. And if he or she suggests bypass, ask about angioplasty. If you're not satisfied with the answers, consider seeking a second opinion.

Also ask about the doctor's skill and experience. For angioplasty, look for an interventional cardiologist who does at least 75 of the procedures a year and a hospital that does at least 400 a year. When choosing a bypass surgeon, there's more reliable information to draw on. See the ratings for how surgical groups across the U.S. performed based on national benchmarks.

What is bypass surgery?

The ratings reflect results for standard bypass operations, known as coronary artery bypass grafting (CABG or "cabbage.") In that procedure, a surgeon opens the chest, reroutes blood through a heart-lung machine, stops the heart, grafts arteries or veins around the blockages, restarts the heart, and then wires the chest back together. Patients generally spend four or five days in the hospital and take one to three months to recover completely.

Versions of bypass that don't require stopping the heart or are less-invasive might be an option for some patients, but there's little long-term data on how safe and effective these newer procedures are. In an "off-pump" procedure, a surgeon immobilizes just the part of the heart receiving the graft, leaving the rest of the heart still beating. Minimally invasive procedures go a step further, operating through a three-inch incision and several puncture sites. One promising technique is a hybrid procedure. A cardiothoracic surgeon performs a minimally invasive bypass on the most important blocked coronary artery, and then an interventional cardiologist clears blockages in other arteries using angioplasty and stents.

Such minimal surgery might cost less, lead to a faster recovery, and pose lower short-term risk of major complications, notably stroke, kidney damage, and possibly mental impairment. But it's not for everyone. Our consultants say the new bypass techniques are most likely to help people who clearly need bypass of one or two blocked arteries on the heart's front but face a high risk of complications from standard surgery because of other risk factors.

You should question your doctor carefully about his or her experience when considering alternatives to standard bypass. According to our experts, results might be best at hospitals where surgeons specialize in those procedures.

How are bypass surgery groups rated?

The Society of Thoracic Surgeons (STS) rates surgical groups using standardized measures endorsed by the National Quality Forum, a nonprofit organization that has established national health-care standards for performance improvement. Those measures fall into four categories. Two of them—recommended medications and optimal surgical technique—reflect how well surgeons adhere to the best-established practices. The other two—patient survival and the absence of surgical complications—reflect how their patients fare.

Patient survival. This is based on the chance that a patient will both survive at least 30 days after the surgery and be discharged from the hospital.

Absence of surgical complications. This is based on the chance that a patient will not experience any of these five serious complications of heart-bypass surgery during their hospitalization: extended breathing support on a ventilator, an infection in the breastbone incision, kidney failure, a stroke, or a repeat operation for postoperative bleeding or other causes.

Recommended medications. This is based on the chance that a patient will get all of the following prescriptions: a beta-blocker before and after the procedure to prevent an abnormal heart rhythm and control blood pressure; and aspirin to prevent blood clots, and a statin or other medication to lower LDL (bad) cholesterol afterward.

Optimal surgical technique. This is based on the chance that a patient will receive at least one graft involving an internal mammary artery, which run under the breastbone. Such grafts improve long-term survival compared with grafts taken from veins, in part because they are more resistant to cholesterol buildup and can withstand the high pressure in the heart better.

Star ratings. For each of the measures, STS compares a group's performance with the average performance of all the groups in their database. For survival and complications, the results are statistically adjusted for the overall health of a group's patients, since some surgical groups treat older or sicker patients than others. (That adjustment is not necessary for medications and surgical technique, however, because the right drugs and best surgical approaches should be used with all eligible patients regardless of their health.)

The overall heart-bypass rating combines the scores from those four measures. For each individual performance measure, as well as the overall rating, groups that score significantly above average get three stars, average performers get two stars, and those that score significantly below average receive one star. Because the average performance of surgical groups has increased substantially in the past two decades, it's possible to get very good care from many two-star groups. In fact, the performance of all the groups on patient survival is so high, and so similar, that they received the same two-star rating for that measure. And some groups that received a two-star overall rating overall received three stars for medications, the absence of complications, or the optimal surgical technique.

If a group is not rated. If you are considering a group that is not in the ratings, you should still ask for performance data on the four measures listed above. Many surgical groups that have not yet agreed to share their data with Consumer Reports do participate in the STS database. So you can ask a surgical group whether it is involved with STS and, if so, ask about its results on the STS performance measures. Groups not involved with STS often report to state-run databases, so you can ask about those, too.

Bottom line. A group should be able tell you how its performance compares with national benchmarks. If it can't share that information—or won't—keep looking.

What's behind the heart bypass surgery ratings?

These ratings of surgical groups that perform coronary artery bypass (CABG) surgery are based on data from The Society of Thoracic Surgeons (STS). It's a not-for-profit organization that represents some 5,400 surgeons worldwide who operate on the chest (or thorax), including the heart, lungs, and esophagus.

STS has maintained the Adult Cardiac Surgery Database since 1989. It's now the largest such registry in the world, including more than 4 million surgical records and representing more than 90 percent of adult cardiac surgery groups in the U.S. Surgeons add new data to the registry four times a year, providing an up-to-date picture of cardiac surgical practice. Much of the information is collected at the point of care, making it more valid than data collected for administrative or insurance reasons or doctor ratings based on professional reputation.

STS contracts with an independent organization, the Duke Clinical Research Institute, to analyze the data and prepare reports for participating surgical groups, comparing their performance with national benchmarks for surgical quality. STS and surgeons from each group have agreed to share the reports on heart bypass surgery with Consumer Reports as part of their ongoing commitment to improving care and helping patients make informed decisions.

Here are answers to nine questions you might have about these ratings. (See our technical report for a more detailed description of the statistical methods used to determine the ratings.)

Which groups are included in the ratings?
There are over 1,000 surgical groups in the U.S. that perform heart bypass surgery. Roughly 90 percent of those voluntarily submit their performance data to the STS Adult Cardiac Surgery Database. The ratings on the Consumer Reports website include only those groups that have agreed to let us publish their performance results. We will periodically update the ratings with more current data as well as data from additional groups that agree to release their information to us.

What should I do if I can't find a particular group?
Many surgical groups that have not yet agreed to share their data with Consumer Reports do participate in the STS database. So you can ask a group whether it is involved with STS and, if so, ask about its results on the STS performance measures. Practices not involved with STS often report to similar state-run databases, so you can ask about those, too. Notably, New York heart bypass surgeons often participate only with their state database. If a group refuses to provide you with the information you need, or can't provide it, our medical experts say it's best to look elsewhere for medical care.

Why are surgical groups rated rather than individual surgeons?
The STS has currently agreed to release to us only the group information for several reasons. Pooling results from all the surgeons in each group provides more data, allowing for more statistically robust results. Individual surgeons within a group sometimes specialize in difficult cases while others work on simpler ones; combining data gives a more even view of their performance. Bypass surgery also depends on the performance of a team before, during, and after the operation, so group performance might be a better indicator of quality than individual performance. Finally, focusing on the entire group makes it easier to track the results over time, even if individual surgeons move or retire. When available, we do provide the names of the surgeons who are currently members of each group, so you can ask specific ones about their track record.

What kinds of procedures are the ratings based on?
The ratings reflect results from stand-alone, or isolated, heart-bypass operations called coronary artery bypass grafting (CABG, or "cabbage"). In the standard version of the operation, a surgeon opens the chest, reroutes blood through a heart-lung machine, stops the heart, grafts arteries or veins around the blockages, restarts the heart, and then wires the chest back together. The ratings can also include results on newer versions of that operation, such as off-pump bypass (in which surgeons immobilize just the part of the heart receiving the graft); minimally invasive bypass (in which they operate through a small incision and several puncture sites); or a hybrid procedure (in which a surgeon does a minimally invasive bypass on the major coronary arteries, and then an interventional cardiologist clears blockages in other arteries using angioplasty and stents). But the ratings don't include bypass operations that are combined with other major cardiac procedures, such as valve replacement.

What criteria are used to rate the surgical groups?
STS uses 11 standardized measures endorsed by the National Quality Forum, a nonprofit organization dedicated to establishing national health-care standards for performance improvement. Those measures fall into four broad categories. Two of them—recommended medications and optimal surgical technique—reflect how well surgeons adhere to the best established practices. The other two—patient survival and the absence of surgical complications—reflect how their patients fare.

  • Patient survival. This is based on the chance that a patient will survive at least 30 days after the surgery and will be discharged from the hospital.
  • Absence of surgical complications. This is based on the chance that a patient will not experience any of these five serious complications of heart bypass surgery during their hospitalization: extended breathing support on a ventilator, an infection in the breastbone incision, kidney failure, a stroke, or a repeat operation for postoperative bleeding or other causes.
  • Recommended medications. This is based on the chance that a patient will get all of the following drugs: a beta-blocker before the procedure and aspirin, a beta-blocker, and a statin or other medication to lower LDL (bad) cholesterol afterward.
  • Optimal surgical technique. This is based on the chance that a patient will receive at least one graft involving an internal mammary artery, which improve long-term survival compared with grafts taken from veins.

What do the star ratings mean?
For each of the four measures, STS compares a group's performance with the average performance of all the groups in the database. For survival and complications, the results are adjusted for the overall health of a group's patients, since some surgical groups treat older or sicker patients than others. (That adjustment is not necessary for medications and surgical technique, however, since the right drugs and best surgical approaches should be used with all eligible patients, regardless of their health.)

The overall heart bypass rating combines the scores from those four measures. For each individual performance measure, as well as the overall rating, groups that score significantly above average get three stars, average performers get two stars, and those that score significantly below average get one star. Since the average performance of surgical groups has increased substantially in the past two decades, it's possible to get very good care even from many two-star groups.

What should I do if I have an urgent problem and the only local option is a one-star surgical group?
Look at the surgical group's rating on each individual measure, identify the particular areas of concern, and discuss them with your surgeon. For example, if the group received one star in prescribing recommended drugs or using the proper surgical technique, ask that the surgeons take extra care on those issues when treating you.

Does it matter how many procedures a group performs?
Research has found that a group's performance depends far more on how well it adheres to established best practices than how many procedures it does each year. So volume is not one of the measures used by STS to rate groups. However, surgical volume is important for statistical reasons. Specifically, groups that do a relatively small number of heart bypass surgeries are statistically harder to differentiate from average, so these groups are more likely to get an average, or two-star, rating simply because there is less information about them.

What are the limitations of the ratings?

  • The ratings are currently limited to groups that voluntarily agree to participate in the STS database, and then agree to release the data to us.
  • The ratings do not include results from individual surgeons, only surgical groups.
  • Even though survival and complications are statistically adjusted for how sick a group's patients are, there are other factors that might have an impact on the differences between groups. That, together with other statistical issues, might sometimes make it difficult to compare surgical groups directly.
  • While these ratings are based on the most comprehensive set of data in the world regarding heart bypass surgery, some important quality measures might not be included in the STS ratings.
  • Some of the measures are difficult to define precisely, so differences might exist in how groups collect and report their data.
  • The percentages reported are not exact numbers but estimates based on the statistical model used, and have some a margin of error.
  • Practices that do a relatively small number of isolated heart bypass operations are statistically harder to differentiate from average than groups that do a larger number of them. So groups with fewer operations are more likely to get an average, or two-star, rating.
  • In some cases, a surgeon is part of more than one group, and the two (or more) groups might have different scores. These scores might differ because of the different patients treated at each of the groups, because of the mix of surgeons whose performance is reported together at each group, or because of other factors affecting the team performance of a group of surgeons.

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