‘Where’ can be more critical than ‘why’ in bypass surgery
Many patients might assume that when doctors recommend a relatively common surgical procedure such as a heart bypass, they are using some standard set of criteria. In reality, however, your chance of being referred for this operation varies dramatically depending on where you live and the way local doctors practice.
This fact is highlighted by recent news of a federal investigation into allegations that two doctors at a Redding hospital urged patients to undergo heart surgeries they didn’t need.
The investigation at Redding Medical Center was sparked by a complaint from a patient told he needed a triple-bypass; five other cardiologists told him it wasn’t required.
Yet health care researchers and cardiologists say that the decision whether to operate often comes down to a judgment call.
Among the variables are the doctor’s training, skill and practice philosophy, whether local doctors perform less-invasive and less-expensive angioplasties to open clogged arteries, along with the patient’s condition and willingness to undergo potentially risky procedures.
Researchers at Dartmouth University in Hanover, N.H., have long studied these variations in health care and compiled them in the Dartmouth Atlas of Health Care, first published in 1996. The differences in various parts of the country can be dramatic.
For example, in a 1999 study of Medicare recipients who underwent heart bypasses, the researchers found that the average national rate was 6.6 procedures per 1,000 people. The highest rate in the nation was 11.4 procedures per 1,000 people in Mobile, Ala.
The Redding area had the highest rate in California -- and the third highest in the nation -- at 10.8 procedures per 1,000. The state’s lowest rate was the Palm Springs and Rancho Mirage area, with 4.1 per 1,000.
Redding’s rate appears “excessive,” said Megan Cooper, co-editor of the Dartmouth Atlas. The high rate, however, doesn’t necessarily support the idea that a lot of unwarranted surgery occurred in Redding. Rates in communities may be heavily influenced by a single large heart center that performs a large number of procedures. Still, Cooper said Redding’s high rate should raise a red flag and cause health officials to take a closer look “at what their selection criteria are.”
In the absence of definitive science, practice patterns often are based more on doctors’ experience or that of their colleagues. “You don’t have slam-dunk evidence about whether bypass surgery extends life expectancy,” Cooper said. “You’re starting to get some now.”
Research shows that bypass prolongs the lives of patients with blockages of the left main artery, which frequently lead to fatal heart attacks, and the procedure clearly relieves chest pain.
But bypass patients also face significant surgical risks, long recovery and rehabilitation and potential long-term memory problems.
If your doctor has recommended bypass surgery, but your case is not considered an emergency, it’s wise to seek a second opinion from a cardiologist at a different institution or medical practice, said Dr. Gerald M. Pohost, chief of cardiovascular medicine at USC’s Keck School of Medicine in Los Angeles.
Choose someone who doesn’t perform invasive procedures so he or she doesn’t have a vested interest in your decision.
You should be evaluated with diagnostic testing, but be aware that results are subject to interpretation. You typically begin with a cardiac stress test, during which an electrocardiogram can pick up signs of abnormalities in blood flow, heart rhythm or blood pressure. These can indicate the severity of your condition.
If you develop chest pain during a stress test, you may be sent for a nuclear stress test, or nuclear scan, to determine how your heart is functioning. You’re given an infusion of radioactive dye, which should create an image in which most of the heart muscle appears bright, while areas with too little blood flow show up as “cold spots.”
A doctor may then recommend medication. Or, if the tests suggest extensive disease, the doctor may recommend an angiogram, in which a catheter is snaked inside the arteries to assess how badly they’re blocked.
The angiogram is key because it documents the degree of impaired blood flow, called ischemia, said Dr. Timothy D. Henry, research director at the Minneapolis Heart Institute.
In some cases, the cardiologist may recommend an angioplasty, a procedure in which a balloon-like device is used to open the artery and a small mesh tube, called a stent, is inserted to hold the artery open.
Here’s where the judgment and experience of the cardiologist come into play. Most perform an angioplasty when just one or two vessels are blocked; those with more experience and skill will work on three vessels.
Bypass surgery usually is recommended when the left main artery or left anterior descending artery are badly blocked, because these blockages can kill you, or if there are multiple blockages, especially in a diabetic patient.
“There is black and white, but there’s a lot of gray,” Pohost said. How often are patients referred for surgery when they don’t need it?: “That’s very difficult to answer,” he said. “The standards for whether somebody needs surgery versus other intervention or medication are not well-established.”
Henry said cardiologists as a group are conducting studies to determine the best option.
Although an angioplasty may cost half as much as bypass surgery initially, several studies have found that angioplasties often must be repeated, making the five-year costs of the two approaches nearly comparable. Mortality rates also are comparable, except in diabetics, who tend to do better with bypass surgery.
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How heart surgery rates vary
Research has shown that the likelihood that someone will undergo cardiac bypass surgery can vary significantly among communities, based on the way local doctors practice. Below are bypass surgery rates for select California communities, based on Medicare data for 1999.
*--* Area Surgery rate (per 1,000 people) Redding 10.8 Bakersfield 7.5 San Bernardino 7.3 U.S. average 6.6 Ventura 6.4 Los Angeles 5.9 Orange County 5.4 Santa Barbara 5.1 San Diego 5.0 San Francisco 4.6 Palm Springs/ Rancho Mirage 4.1 Source: The Dartmouth Atlas of Health Care Los Angeles Times
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