Doctors and hospitals tussle over surgery for less-invasive heart valve repair

kaisertavr-300x175When big hospitals and their doctors jostle with competitors in smaller and medium-sized facilities over who gets to perform an important and booming kind of surgery, it’s not a pretty sight — nor might it be obvious with which institutions patients ought to side.

Phil Galewitz of the independent, nonpartisan Kaiser Health News Service does consumers a service with his reporting on recent bureaucratic brawling in Baltimore before federal regulators charged with determining where surgeons may replace leaky valves without open heart procedures.

As Galewitz explains, surgeons and medical device makers for a few years now have worked together to develop a new way to fix defective valves for tens of thousands of patients too frail to undergo open heart operations that, among other things, involve getting their chests cracked open. Surgeons, instead, can snake a catheter through patients’ blood vessels, into their heart, and shove aside the leaking valve, replacing it with a new model.

The operation, a transcatheter aortic valve replacement, or TAVR, has been performed on and benefited 135,000 or so patients, many of them elderly.

But even as the complex procedure has become more routine and safer — with its mortality rate plummeting to 1.5 percent of cases undertaken — it has become the exclusive province of big hospitals and academic medical centers where surgeons have performed TAVR more often and, apparently, have become skilled at it.

Some makers of the valves and doctors at small- and medium-sized hospitals, however, have contested Medicare rules that have paid $45,000 or so per case, including the $30,000 for the pricey valves, only to big institutions that federal regulators have deemed qualified to perform TAVR.

The institutional competition to increase the procedure’s use, as well as to spread it more widely across the country — where only half of the 1,100 hospitals that perform valve procedures at all also can do TAVR — becomes a bottom line, financial issue, Galewitz reported.

That’s because, over time, as the nation keeps getting grayer and their ailing hearts have demanded, tens of thousands of patients have had valve surgeries. Many of the devices fail, and TAVR, which carries its own risks and demands (including stroke and the necessity that patients also be outfitted with a pacemaker), has become a valued alternative.

Galewitz quotes the American College of Cardiology and other groups as estimating that 50,000 patients will undergo TAVR this year alone, and that the annual demand for the procedure will double that number by 2020.

If the need is so great, why isn’t it a snap decision to increase the number of doctors and hospitals that can offer it?

Currently, to qualify for Medicare coverage for the surgery, Galewitz reported, hospitals must “perform annually 50 open-heart valve repairs, 400 angioplasties and 1,000 cardiac catheterizations — a procedure in which medical teams use skills similar to those needed for TAVR. Doctors at larger hospitals say procedure volume is a good predictor for success.” Smaller and mid-sized institutions may not sustain those surgical statistics, so surgeons maintain high skills to ensure TAVR outcomes, experts say.

In my practice, I see the harms that patients suffer while seeking medical services, including when doctors and hospitals subject them to complex therapies and procedures that they may be ill-qualified to offer. All surgeries carry with them risks and potentials for harm, and, sadly, patients carry a huge burden in researching, in advance and as much as they practically can, about their doctors and hospitals. Research indicates that it can be key to patient outcomes as to a surgeon’s experience with the specific type of procedure. Patients need to know how to ask the tough, correct questions to determine this.

Choose your surgeon and hospital carefully, and know that they work with some real economic and practical constraints. Ask your regular doctor for referrals. Talk to friends and medical caregivers whose views you value. You may wish to consult online resources that rank both hospitals. You may wish to look at comparison sites that offer insights on hospitals’ infection and readmission rates. Some institutions issue their own data on their cardiology departments’ volumes and outcomes, and this is valuable information. You may want to look, with due care, at a journalistic project that pulled together data sources to let patients better evaluate surgeons.

All these metrics can be daunting: Don’t be swayed just by reputation or price. Studies show few differences in quality and efficiency in care between high- and lower-price physician practices.

Given the still-high demands for surgical expertise when performing TAVR, Medicare officials may wish to tread with care before expanding where the procedure may be done, disregarding arguments that many patients may want the convenience and ease of having the surgery — which also can require a few days’ hospital recuperation — near their homes, and not at distant, big hospitals or academic medical centers.

Galewitz also mentions in passing, however, what may be yet another compelling reason for more wide-spread TAVR: If Uncle Sam doesn’t expand coverage for this less invasive procedure, whose application is not confined just to high-risk, frail, and elderly patients but also can be a choice in more routine valve replacements, cardiac surgeons in small and mid-sized institutions may, as appropriate still, perform open-heart operations to fix leaky valves. Those operations cost more, carry high risks, and may require weeks of post-operative hospitalization.

That doesn’t seem like a great choice. But it also may be an illustration, too, how patients get false options in their care, while always bearing the risk and costs, if even less directly and through the taxes we all pay for a program like Medicare.

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