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Getting the Best Odds for Vascular Surgery

Hospital experience important, surgeon's experience more so

THURSDAY, Oct. 16, 2003 (HealthDayNews) -- When your family doctor says you need surgery to repair a weak spot in your aortic artery, the largest blood vessel in your body, you should ask the right questions about the hospital where the surgery will be done and the surgeon who will do it, a study finds.

Choosing the right hospital reduces the risk of dying by 30 percent, says the study by surgeons at the University of Michigan. Choosing the right surgeon reduces the risk by more than 50 percent. And the combination of the right hospital and the right surgeon gives the best results.

The basic question to ask about both the hospital and the surgeon: How much experience do you have?

It's a question that more and more Americans should be asking. Some 40,000 operations to repair what is formally called an abdominal aortic aneurysm will be done in the United States this year. Since the incidence increases with age, that number will be growing.

And this is a procedure that requires a lot of skill and experience, says Dr. Gilbert R. Upchurch Jr., an assistant professor of vascular surgery at the University of Michigan. His research team went through the National Inpatient Sample, which holds national hospital data, collecting information on 3,912 patients who had surgery to repair abdominal aortic aneurysms in 1997. Their findings appear in the October issue of the Journal of Vascular Surgery.

To no one's surprise, the survey reinforces the age-old adage that practice makes perfect. The hospitals that did the most operations, and the surgeons with specialized training, had the best results. But there are questions within questions about those numbers, Upchurch says.

"The experience of the individual surgeon may count more than the sheer number of abdominal aortic aneurysms at an individual hospital," he says. "This is important for individual patients as well as policy makers to understand."

The survey classifies a hospital as having a high volume if it had 35 or more operations a year. Surgeons were classified as high-volume if they did more than 10 operations a year.

For patients who had aneurysm surgery at a low-volume hospital, the death rate was 5.5 percent; in high-volume hospitals, it was 3 percent.

The study classifies surgeons in two ways. One is based on the number of abdominal aortic aneurysm operations done annually; 10 operations a year puts a surgeon in the high-volume category. The risk of dying for patients operated on by a high-volume surgeon was 40 percent lower than when the operation was done by a low-volume surgeon.

The researchers went further, classifying doctors as general surgeons, vascular surgeons or cardiac surgeons, on the basis of the kinds of surgery they most often did. That produced a different set of numbers. The death rate was 5.5 percent when the operation was done by a general surgeon, 4 percent for cardiac surgeons and 2.2 percent for vascular surgeons.

Overall, the best outcomes were for surgery done by high-volume surgeons in high-volume hospitals. Only 2.4 percent of those patients died, compared to 6.4 percent for surgery done in low-volume hospitals by low-volume surgeons.

"It is logical that when a particular condition is treated in significant numbers by people who specialize in it, the results tend to be better," says Dr. Patrick J. Lamparello, chief of the division of vascular surgery at the New York University School of Medicine. "And because you are dealing with a complex procedure, teamwork is important as well."

Anyone facing aneurysm surgery should ask about the level of expertise of the surgeon, specifically whether the physician is a vascular disease specialist and is board-certified, Lamparello says. "If he is not board-certified, I would run away," he says.

But patient participation that starts much earlier can help improve the outcome, Lamparello says. Detecting an aneurysm when it is small can set the stage for successful surgery, he says. But most aneurysms do not cause symptoms, so people at higher risk should inquire about a screening test, such as an ultrasound or CAT scan.

Aneurysms are five times more common in men than women, and are most common in older men, Lamparello says. One of every 20 American men aged 60 and older will have an aneurysm. Smoking, high blood pressure, a family history of aneurysms and having other blood vessel problems are additional risk factors that indicate the need for screening, he says.

More information

An overview of abdominal aortic (and other types of) aneurysms can be found at the Cleveland Clinic Foundation or the American Heart Association.

SOURCES: Gilbert R. Upchurch Jr., assistant professor, vascular surgery, University of Michigan Health System, Ann Arbor; Patrick J. Lamparello, M.D., director, division of vascular surgery, New York University School of Medicine, New York City; October 2003 Journal of Vascular Surgery
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