Scrutinizing Heart Surgery
The Philadelphia Inquirer
Thursday, June 14, 2007
By: Josh Goldstein

Shortly after 7:30 yesterday morning at Doylestown Hospital, cardiac surgeon Joseph S. Auteri made the first incision of the three-hour operation to replace two diseased heart valves. It was an operation he has done hundreds of times in a career filled with thousands of open-heart procedures. But for Auteri, who grew up in Bucks County and moved back from Virginia only recently, the local medical environment is all new.

Unlike Virginia and 44 other states, people with heart disease in Pennsylvania and New Jersey can scrutinize reports grading surgeons and hospitals based on patient outcomes. The annual study due out today from the Pennsylvania Health Care Cost Containment Council examined heart surgery across the state in 2005, giving the public the ability to compare surgeons and hospitals.

For example, Lankenau Hospital in Wynnewood preformed more heart bypasses than any other center in Southeastern Pennsylvania. Numerous studies have shown that patients do better with high-volume surgeons and hospitals, and the new report's online listing do, indeed, show Lankenau had a low death rate.

Mercy Fitzgerald Hospital in Darby, by contrast, performed about a third as many bypasses - and had higher-than-expected mortality rates. For the 46-year-old surgeon in Doylestown, the transparency of Pennsylvania's results was both daunting and helpful. "I gave at least some consideration to the fact that I was moving to a state that would report my data publicly," he said.

Yet those same public reports enabled him to better assess the quality of Doylestown's program before deciding to come. Today's study analyzes valve operations for the first time since the council began reporting on heart surgery in 1992. And in a major shift, it also shows average payments to hospitals by Medicare and private insurers.

"You would think that we pay for health care the same way we pay for a car, by relating the quality of what you are getting with the cost," said Marc P. Volavka, executive director of the council, an independent state agency known as PHC4. Still, it's not that easy. "You cannot look at the quality side and the cost side of open-heart surgery at these hospitals and conclude that we are paying for health care in a simple, straightforward and logical manner," Volavka said.

At Lankenau, which had a lower-than-expected mortality rate for heart bypass, Medicare paid an average of $30,812. Yet the government paid Mercy Fitzgerald an average of $42,073, according to the new report. As more and more healthcare costs are shifted to patients, such differences are likely to play a larger role in individuals' decisions.

Most medical experts say the extensive information available from Pennsylvania's report and similar studies in New Jersey, New York, California and Massachusetts are good starting points for patients to ask questions of their doctors. But they caution that such reports should not be the sole deciding factor on where to go. "When you are looking at individual hospitals, the key thing to see is the trend over time," said Gus E. Agocha, chairman of the cardiovascular department at Deborah Heart and Lung Center in Burlington County.

Volume is also key. "The more a hospital does, the better the outcomes," Agocha said. "The same is true for individual surgeons." Since 1002, the number of open-heart procedures in the eight-county region has fallen 27%, following a nation-wide trend toward less-invasive angioplasty-stenting procedures.

Both New Jersey and Pennsylvania have had so-called certificate-of-needs laws, which required hospitals to show necessity before getting approval for a new program. As a result, only three South Jersey hospitals have open-heart centers, and all three have been able to maintain relatively high volumes. In Southeastern Pennsylvania, the number of open-heart programs has doubled since 1996, when the state's certificate-of-need law lapsed. Fewer of them now have high volumes.

In Pennsylvania as well as New Jersey - which issued its 2004 cardiac report last month - patients can also see death rates adjusted for severity of illness. Many quality experts argue that those adjustments cannot fully account for real differences among patients. The Hospital of the University of Pennsylvania and Penn's Presbyterian Medical Center, for instance, both had higher-than-expected mortality rates for patients undergoing valve and bypass operations together.

The University of Pennsylvania Health System noted that all of those deaths involved extremely sick patients, many of whom were transferred from other hospitals because their cases were complex. "I feel it is my responsibility to treat patients that won't get surgery elsewhere," said Michael Acker, the system's chief of cardiovascular surgery. "Yes, they are at higher risk of death, but we save a lot who would otherwise die."

Acker commended the council's efforts to make more information public. "Unfortunately," he added, "the risk adjustment hasn't quite reached the maturity to deal with these differences adequately." Statewide, 11,875 patients in Pennsylvania had heart bypasses in 2005. The in-hospital mortality rate declined to 1.9% from 2% the previous year and 2.4% in 2000. Private insurers paid an average of $30,247 per byp[ass, the council said. Surgeons' fees were not included.

Valve surgery was performed in 2005 on 5,456 patients, of whom 5.2% died in the hospital. An additional 7.2% were readmitted for more care within a week of discharge. The average private-insurance payment for a valve operation was $43,500. "As the call for greater transparency in health-care pricing and quality continues to grow," the council's Volavka said, "we believe this is the type of information consumers will need to make more informed choices."