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.