KQED: What patients need to consider before risky surgery

This story originally aired on KQED Public Radio.

How should patients respond when a doctor recommends they undergo a major surgical procedure?

They should ask a lot of very pointed questions, says Dr. Tej Singh, chief of vascular surgery at the Palo Alto Medical Foundation.

This is especially true when the surgery carries significant risk.  A stroke prevention surgery, called a carotid endarterectomy, is one of them. This surgery removes plaque built up in the neck artery -- the goal being to prevent a blockage in the blood supply to the brain that could cause a stroke.

The issue, Singh said, is that opening the artery can sometimes cause the plaque to dislodge and rush to the brain, causing the very stroke the procedure is meant to prevent.

How likely is this to happen? Singh said patients run the risk of having a stroke or dying 3 percent of the time, and having a heart attack 4 percent of the time.

These are the kinds of questions Singh recommends for carotid endarterectomy, which is most often done as an elective procedure: 

  • What is the doctor’s education and training? Singh said a vascular surgeon is most qualified to perform the procedure.
  • How many carotid endarterectomies have he or she done? The surgeon should do a minimum of 25 per year.       
  • What is the doctor’s rate of stroke or death with this procedure? The national guideline is to have a combined stroke and death rate below 3 percent for all patients.      
  • Does the facility have an accredited imaging lab to provide the most accurate images to determine if surgery is needed?       
  • What quality measures are in place for before, during and after the surgery to prevent complications and rate of infection?
  • What are the alternatives to surgery, including taking medication? 

There are significant barriers to getting these questions answered.  In the first place, it’s hard for many patients to ask what might seem like impertinent questions. 

Beyond that, a surprising number of doctors don’t know their complication rates, said Dr. Jack Cronenwett, a professor of surgery at Dartmouth Medical School and national expert in patient safety. He said it’s often because doctors lack centralized medical records and databases. But Cronenwett said doctors do want this information.

“When giving any kind of a report card that indicates that they might not be quite as good as the next person, everyone is incented to do better,” he said. 

Cronenwett says he saw it happen in New England. In a 2003 pilot project, eight hospitals started sharing surgery outcomes. Through a data registry, doctors compared how often they gave a patient aspirin before surgery or used a patch to sew up the incision. Cronenwett said these both reduce complication rates but not all doctors were doing them. To change that he said it simply took showing doctors the data.

“The most amazing thing was that within a year the rate of aspirin usage among all users had dramatically increased,” he said.

Surgeons saw complication rates decline and in the future this could result in fewer surgeries, he said.

Now Cronenwett has helped the Society of Vascular Surgery launch this model in six regions around the country, including Southern California.

This Vascular Quality Initiative collects, compiles and reports complication rates, including death from surgery.

Betsy Imholz of Consumers Union says if this works between doctors, it can help the public too. But for Californians, much of this data isn’t readily available. 

“California led the way back in the mid 1970s,” she said. “It was really one of the first states to step out and say we want to collect this quality data and make it public. But it’s been halting since then.”

It’s been a constant struggle to get hospitals and doctors to track and report their data, Imholz said. But, she said, it can happen over time. For instance California hospitals are now required to tell the public how often patients get infections at their facilities. But compared to other industries, Imholz said, health care lags behind in quality controls. 

“We’ve been very careful about the airline industry as one example in checking safety, tracking it, going back and finding out what happened if something did go wrong and it’s been fairly public,” Imholz said. “Somebody dying in a operating room is not a public event. 

Some medical officials caution that consumers shouldn’t expect too much from health data.  “Just to release data because it’s there doesn’t always add value,” said Dr. David Perrott, senior vice president and chief medial officer of the California Hospital Association. 

Perrott said it’s not as easy as having hospitals do large data dumps of procedure results. For example, he says if you only report raw numbers they won’t give the whole picture unless they’re carefully adjusted to reflect how sick the patient was. 

Plus Perrott said hospitals already report more than 100 different quality measures to state and federal agencies.

Even with all of this, Perrott said it’s still difficult for patients to figure out the likelihood of having complications from surgery at their local hospital. 

But there is momentum to change this. The federal health care law includes measures to give patients better tools to help them decide if they should have a surgery or not. A big part of that is providing easy-to-understand and accurate information.

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Kelley Weiss

Broadcast reporter Kelley Weiss is based in our Sacramento office where she’s helping lead the center’s expansion into public broadcasting. Her stories have appeared on NPR,Marketplace, The World, KQED Public Radio, Southern California Public Radio and World Vision Report. She’s produced series about the illegal sale of prescription drugs at swap meets and preventable patient deaths and money mismanagement in Missouri’s mental health system. She won a 2009 national Edward R. Murrow award for investigative reporting and has received several honors in the Association of Health Care Journalists awards competition. She was named a Livingston Finalist in 2011 for a multi-platform project about how tribal sovereignty makes it nearly impossible for mothers to collect child support. Weiss previously worked as a health care reporter at Capital Public Radio in Sacramento and KCUR in Kansas City. Her work has also appeared in Reuters, the San Francisco Chronicle and theCenter for Investigative Reporting. She’s completed a health reporting fellowship from the Association of Health Care Journalists and has a journalism degree from the University of Kansas.

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