The south Texas border town of McAllen does a brisk business in heart surgery. Surgeons at McAllen Medical Center performed just over 800 bypass operations in 2003--fifth highest in the state--and did them well. The mortality rate, adjusted for the severity of patients' conditions, was 1.2 percent, less than one-third the state average of 4 percent. "I do a better job on these patients in my community hospital than I did when I was training in my university hospital," says McAllen's Lester Dyke, a cardiac surgeon who does between 500 and 600 of the procedures a year and cites a mortality rate of about 1 percent.
There's a strong link between volume and quality for coronary bypass surgery. There's also a fair amount of disagreement over the definition of high volume, although both McAllen and Dyke would satisfy any of the proposed numbers. The Leapfrog Group, a standard-setting consortium of large employers, puts the bar at 450 hospital surgeries annually. A large study published in Circulation in 2003 found that mortality risk is 29 percent lower in hospitals where at least 600 bypasses a year are performed by surgeons who do 125 or more than when neither the hospital nor its surgeons meet those volume thresholds.
Still, the line is blurry, say most researchers, and surgeons who perform fewer than these recommended numbers should not automatically be assumed to do them worse. "There's very little difference between a surgeon who does 300 versus 100," or even 50, says Fred Edwards, chair of cardiothoracic surgery at the University of Florida College of Medicine in Jacksonville and chairman of the Society of Thoracic Surgeons' national database of cardiac surgery outcomes.
The best hip joint
Vernon Memorial Hospital in Wisconsin, where Don Wilke had his hip replaced, highlights volume's slipperiness as an indicator of quality. The 25-bed hospital had no real orthopedic program until surgeon Jeffrey Lawrence moved his family from the tony Chicago suburb of Highland Park to the 4,000-person town. Now Lawrence is the program. He does about 80 hip replacements each year, which puts the hospital short of the 100 recommended by several studies. It is considerably above the suggested individual physician benchmark of 50, however.
Lawrence's hip joint patients also have an impressively low rate of infections--0.25 percent against a national average of 1.5 percent. Infection after joint replacement is a complication that prospective patients should always ask about, because the consequences, such as more surgery to replace the infected joint, can be serious. All surgeons and hospitals should know their infection rates and should be willing to discuss them, says Paul Pellicci, an orthopedic surgeon at the Hospital for Special Surgery in New York City. "That's data that every hospital has. If they say they don't know, it's either because they don't want to tell you or they don't think you have the right to ask the question."
Besides board certification in orthopedic surgery--a must when considering any major orthopedic operation--Lawrence did a post-residency fellowship in joint replacement, a strong indication of competence. Vernon employs physical therapists who work closely with the orthopedic department, something doctors say helps ensure that patients receive proper care in recovery.
Juggling the prostate options
Prostate cancer presents two issues: where to go and what to do. The two main choices are radiation or surgery. The radiation options are either external beams directed at the cancer or radioactive "seeds" implanted in the prostate. Surgery involves removing the prostate, or radical prostatectomy. About two thirds of patients opt for radiation.
That's what John Paul McMahon picked--specifically the seeds. The 68-year-old Franciscan friar lives in tiny Steubenville in eastern Ohio. Three years ago his level of prostate-specific antigen (PSA, measured by a blood test as an early warning of prostate cancer) began shooting up, and his doctor took snippets of prostate tissue. "I was shocked at the biopsy results," says McMahon. "And worried. Cancer is a scary thing." The good news was that his disease was confined to one part of his prostate. McMahon drove an hour away to the University of Pittsburgh Medical Center, where a surgeon told him he was an excellent candidate for a prostatectomy.
But Trinity Health System, the major source of hospital care for the area, had recently geared up a state-of-the-art seed implant, or brachytherapy, program. Trinity's radiation oncologist, Mark Trombetta, was affiliated with Allegheny General, a major medical center in Pittsburgh, and had assembled valuable new technology: ultrasound scanners to image the prostate and an advanced computer program to instruct Trombetta while he was in the operating room exactly where to place the seeds to hit the cancer but spare normal tissue.
"Boy, did I pray," says McMahon. "And I decided on radiation. Prostatectomy is routine, but it's still major, and there's some potential for incontinence and impotence afterwards. And I had great, great confidence in Trombetta."
A good team
McMahon knew Trombetta's record. By now, he has done over 200 brachytherapy cases at Trinity, with just one disease recurrence. That's identical to the rate at Allegheny General. And Trinity does about 25 a year, enough volume to produce good outcomes.
McMahon went in the morning of Oct. 22, 2003, went home that afternoon, and was back at work a few days later. His PSA gradually fell from 4 to a healthy 1. "I trusted in God, and I trusted in my doctors, and that's truly a good team," says the friar.
If McMahon had opted for surgery instead, he would have had to mull over Trinity's record of only two prostatectomies per year. For an operation in which more means better, that's low for any hospital. A typical urologist does 11 to 12 a year, says Peter Carroll, chair of urology at the University of California-San Francisco. "I think that doing between 20 to 30 of these each year makes you an experienced surgeon," says James Eastham, who researches prostatectomy outcomes. In several studies by Eastham and others, patients of surgeons who do fewer than 20 operations per year have a 10 percent to 30 percent higher rate of incontinence or impotence than do those whose surgeons do more than 33. "Those are real big differences," Eastham says.
Patients who elect surgery don't always need a Sloan-Kettering or a UCSF, where urologists do three or more a week. Paul Sieber, chief of urology at Lancaster General Hospital in Pennsylvania, averages about 50 a year. "We participate in a national database of more than 100 urologists," he says, "and our outcomes--continence, potency, and cancer recurrence--are at or above the average."
Still, advanced prostate disease or other challenging conditions may overmatch even good community hospitals. The more rare the diagnosis or the more difficult the procedure, the better off you'll be at a major referral center. Most of the time, however, your best choice could be just up the road.
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