they vary in quality due to differences in their training, experience and services. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.
A surgeon, for example, who performs a complex procedure often, has better success with it than a surgeon who does the same procedure only occasionally. The complication rate and the death rate for the same procedure may be many times higher at one hospital than another.
Clearly, the doctor and hospital that you choose have a direct impact on how well you do - especially when you need treatment for a condition, such as heart disease, which is this country's number-one cause of death.
Approximately 68 million Americans - one out of four of us - have some form of heart or blood vessel disease. More specifically, some 65,000 Americans with diseased heart valves require surgery each year. Although this is a sobering statistic, you can be comforted by the fact that there are many treatment options available to help you get well.
But this means making some difficult and important decisions such as choosing a doctor and a hospital for your treatment. No one has more at stake than you; it's one of the most important decisions of your life.
This brochure deals with a particular form of heart disease - heart valve disease. You may be reading this because you have been told you have a high risk of developing heart valve disease, because your doctor suspects you have already developed this condition, or because you're considering surgery. Comparisons like those we talk about making are not possible in emergencies. If you make these comparisons early, however, you will be prepared should the need for treatment arise.
Most of us do more research when we buy a car or a television set than when we choose a doctor and a hospital. That may be because we don't know what questions to ask or what to base our evaluation on. There is no consumer magazine that rates doctors and hospitals the way Consumer Reports rates air conditioners.
There are many different ways to measure quality care, and there is no universal agreement on which should be used. However, at The Cleveland Clinic Foundation, we believe you can use the following six points, or quality indicators, to compare health care providers:
Choosing a doctor or hospital is often influenced by values. You may want to go to a hospital that is close to home. You may want a hospital with a specific religious affiliation. But when you need specialized medical care for heart disease, it is essential that you also include in your decision a doctor's qualifications and a hospital's track record. These quality indicators will help you with that kind of evaluation should you require treatment for valve disease.
This guide helps you choose a doctor and hospital by:
The valves of the heart are made up of two or three very strong flaps of tissue, called leaflets, that open and close as the heart contracts and relaxes. When working properly, these leaflets keep blood flowing in the right direction in the heart.
The mitral and tricuspid valves control the flow of blood from the upper chambers of the heart to the lower chambers; the aortic and pulmonary valves control the flow of blood out of the lower pumping chambers.
Heart valve disease prevents the valves from opening or closing properly, thus interfering with the flow of blood. Symptoms of valve disease may include shortness of breath, chest pain, unusual tiring, dizziness or fainting.
The two main types of heart valve disease are:
In heart valve disease, the aortic and mitral valves are most commonly affected, although the pulmonary and tricuspid valves sometimes malfunction.
Mitral valve problems may be the result of damage caused by rheumatic fever, infections, and heart attacks as a consequence of heart muscle problems. Or they may be caused by problems that are present from birth (congenital).
Aortic valve disease may be congenital, or it may be caused by rheumatic fever, infections, atherosclerosis or hardening caused by aging.
In the past, when rheumatic fever was more prevalent, it caused most valve problems. Today, as the frequency of rheumatic fever has declined, most valve defects are the result of other problems.
Valve disease can be treated both medically and surgically. Some people with valve disease can live normal lives with carefully supervised medical management; others may have to limit how much they can exert themselves. The need for surgery depends on how severe the problem is.
The decision whether, when and how to do valve surgery is a major one and ideally should be made along with cardiologists and cardiothoracic surgeons who have experience with the diseases involved, the diagnostic tests required, and the operations that may be needed.
When medical or surgical treatment is being considered, or when the disease worsens, the following tests and procedures may be discussed:
Echocardiography is a painless test used routinely to diagnose and determine the cause of valve disease. It enables the cardiologist to get a close-up view of the inside of the heart from the outside. During this procedure, some gel and a smooth probe are placed on the outside of the chest and ultrasound is used to take images of the heart while it's beating.
Doppler echocardiography is used to view the blood flow through the heart and diagnose valve abnormalities. It's a helpful technique in determining the best approach to fixing the valve problem - whether with medication, balloon valvulotomy or surgery.
Transesophageal Echo (TEE) provides an image of the heart from behind by passing a probe down the esophagus. It is used in selected patients when surgery is being considered. TEE can also be used during surgery to allow the surgeon to see precisely any valve regurgitation.
Balloon Valvulotomy. Percutaneous balloon valvulotomy is used to relieve stenosis of the heart valves in selected patients. During this procedure, a balloon is passed through the narrowed valve and inflated. This procedure usually takes less than two hours and requires only mild sedation and local anesthesia. Balloon valvulotomy provides long-term improvement in patients with mitral stenosis and limited relief in patients with aortic stenosis.
Valve Repair Surgery. This procedure uses plastic surgery techniques to fix the way the valve opens and closes. To do this, the surgeon trims the valve or sews it together tighter, or patches the valve with a piece of pericardium, the tissue near the heart. Surgeons at the Cleveland Clinic try to use repair techniques whenever possible. However, repair can't always be done.
Valve Replacement Surgery. When a valve is too badly deformed, valve repair is not an option. In these cases, the old, damaged valve is removed and replaced with one of three types of valves: a mechanical (metal) valve; a valve made from animal tissue; or a human valve that has been frozen (cryo-preserved). Each has its advantages and disadvantages.
The mechanical valve has the advantage of being very durable. It is not, however, a natural part of the body, and there is a danger that blood clots may form on it. To prevent this normal blood clotting, patients require daily medication. This is a distinct problem during pregnancy, eliminating these valves as an option in women who wish to have children.
Tissue valves from animals have the advantage of not requiring the long-term use of blood-thinning medications. However, since the durability of these valves is limited, they are less attractive options in young patients, but a good choice in older patients.
Human valves have the advantage of not being associated with rejection by the body and providing normal heart valve function. These valves, however, are in short supply, and the 20-year results of this type of replacement are not yet known.
Repair vs. Replacement. Currently, valve repair offers substantial advantages over replacement as it leaves patients with their own normally functioning tissue which is resistant to infection and does not require blood-thinning medications. There are two main disadvantages to valve repair: Repair is not possible for all valves, and it is a technically more demanding procedure for the surgeon.
Reoperations. Neither valve repairs nor replacements last forever. Valve disease may recur, requiring valve repair or replacement to be redone. Valve replacements may wear out or stretch. Scar tissue may gradually reduce an artificial valve's function over time. Valves may have to be redone several times during a person's life, depending on the risks and benefits.
A common cause of mitral regurgitation is mitral valve prolapse. This condition occurs when a valve loses its shape and becomes weakened or stretched, ballooning out and sometimes causing a backflow of blood.
This common condition, which may exist in as many as one in 10 Americans, rarely requires surgery.
In a small percentage of cases, however, mitral valve prolapse may become severe enough to require regular medical attention or surgery.
Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, it may not be possible to get complete information for each of these quality indicators. But when providers are willing to give you as much information as possible, it's a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capability.
If you are told that you have heart valve disease or that you need surgery, talk to your family doctor or cardiologist. Get the names of several doctors and hospitals with the most experience with diagnosing and treating this condition. Ask the questions that we suggest. Make comparisons. Then make your decision. Be an informed consumer for yourself and your family.
How can you use the indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to a report, "The Quality of Medical Care: Information for Consumers," produced by the U.S. Congress, Office of Technology Assessment.
According to the report, patients about to have heart surgery can be confident if the hospital performs a high number of heart surgeries, if it has a low mortality rate, and if the surgeon has extensive training and experience in the procedure.
On the other hand, the report states: "...if a hospital had a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals required longer travel."
Credentials have been set by nationally recognized medical professional organizations to verify that doctors and hospitals meet certain standards in the delivery of health care.
Board certification, or an international equivalent, is a sign that doctors are highly trained in their field. Doctors who specialize, such as cardiologists and heart surgeons, should also be board certified in the specialty in which they are practicing. Each specialty has a national board which is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialty have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty, and have passed a difficult examination in their specialty area. Some excellent doctors are not board certified. Board certification, however, is generally a good indication of competence and experience.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps or loses accreditation based on its meeting certain criteria for staffing, equipment and facility safety. Although accreditation is voluntary, most hospitals go through the process. If the hospital you are considering is not accredited, it is important to know why.
Hospitals that measure up are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital's reputation is available through the mass media, books such as The Best Hospitals in America, the government, and consumer groups.
For information about a hospital's status, call the Joint Commission on Accreditation of Healthcare Organizations at 708/916-5800.
Is the heart surgeon board certified in thoracic surgery?
At the Cleveland Clinic, all 9 surgeons who perform heart valve surgery are either board certified in their specialty or have the international equivalent.
Is the cardiologist who does the TEE or balloon valvuloplasty board certified in cardiology?
The 7 cardiologists who perform these highly specialized procedures at the Cleveland Clinic are all board certified.
Board certification became a requirement at the Cleveland Clinic in 1989 for doctors who receive a full appointment to the medical staff.
Is the hospital accredited by the JCAHO?
Has the hospital been positively and consistently recognized for medical excellence and leadership?
For the last four years (1990 through 1993), U.S. News & World Report has named the Cleveland Clinic one of "America's Best Hospitals."
The Cleveland Clinic has also been singled out for excellence in "The Best Hospitals in America" (Henry Holt and Co., 1987); and "The Best in Medicine: Where to Get the Finest Health Care For You and Your Family" (Crown, 1990).
Most recently the Cleveland Clinic was recognized as having one of the two best cardiology departments in the U.S. in the July 12, 1993 issue of U.S. News & World Report. Previous issues of the magazine in 1992, 1991 and 1990 also recognized the Cleveland Clinic for excellence in cardiology.
In the case of complex, specialized medical care for heart disease, the more experience the doctor and hospital have with the necessary procedures, the better the results usually will be.
It may be important to ask whether the doctor performs all procedures at one hospital or at several. If the doctor performs procedures at more than one hospital, this increases the volume but means the doctor is working with different teams. The teams, therefore, don't have as much experience working together as they would if the doctor were working with the same team at the same hospital all the time.
It is important for the doctor and hospital you choose to have experience with the full range of options available to treat heart valve disease.
How many transesophageal echocardiograms (TEEs) are performed each year?
The Cleveland Clinic did 1,521 TEEs in 1992.
How many valvulotomies are performed each year?
The Cleveland Clinic performed 55 balloon valvulotomies in 1992.
How many valve surgeries are performed each year?
In 1992, the Cleveland Clinic performed 3,424 open heart operations. Of these, 1,039 were valve repairs and replacements.
A total of 296 valve repairs were done. Of this number, 196 were isolated repairs (meaning that no other operations were done at the same time) and 100 were valve repairs done along with revascularization procedures such as coronary artery bypass surgery.
A total of 594 replacements were done. Of these, 357 were isolated valve replacements; the other 237 were operations in which both replacements and revascularizations were done.
A total of 149 were operations that combined both valve repair and replacement because more than one valve was diseased.
How experienced is the anesthesia staff who will be providing anesthesia during valve surgery?
The Department of Cardiothoracic Anesthesiology at the Cleveland Clinic provides anesthesia to more than 3,000 patients undergoing all types of open heart surgery each year.
How long has the hospital been performing valve surgery?
The Cleveland Clinic, a pioneer in valve surgery, has been performing this procedure since 1961.
Some organizations have suggested volume requirements for the number of times a procedure should be performed in order to be performed competently.
Guidelines specific to heart valve surgery have not been developed. However, guidelines for open heart operations in general state:
Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur. If complications arise, you want the best care available, and you want it immediately.
Range of specialty departments:
Problems that involve the heart and circulatory system don't exist in isolation. Related conditions, such as diabetes and high blood pressure, could endanger the kidneys, brain and other organs. Therefore, immediate access to a full range of specialty departments within a facility is critical.
Availability of a full range of specialty departments is also important if complications arise that are related to diagnosing and treating your heart disease.
Range of diagnostic and treatment options:
Surgery for heart valve disease is not the only treatment option available. And even when surgery is required, it is usually preceded by a long period of medical treatment. In addition, people with valve disease may have other forms of heart disease such as coronary artery disease. In some cases, revascularization procedures, such as coronary artery bypass surgery, are done at the same time as valve surgery.
For these reasons, and because there are several different ways to treat valve disease, it's important to choose a facility that can provide the full range of options. That way you will get the most effective, appropriate and cost-effective treatment available.
Is help available from a full range of specialty departments should complications arise from related conditions?
The Cleveland Clinic's more than 500 salaried physicians - all on staff full time - provide care in 100 specialties and subspecialties. Because all these specialties are represented at one facility, prompt consultation, diagnosis and treatment are available.
Adults with congenital valve disease are treated in the Clinic's Adult Congenital Heart Disease Program, which is designed to meet the unique needs of adults with congenital valve defects.
Is an experienced heart surgery team available within the facility for emergency surgery?
If complications or unforeseen situations arise at any time requiring emergency surgery, experienced heart surgery teams are available 24 hours a day at the Cleveland Clinic.
Does the hospital offer a variety of options for diagnosing and treating heart valve disease?
The Cleveland Clinic offers a full range of options for diagnosing and treating all forms of heart disease, especially valve and coronary artery disease. These include those listed in the box at the left.
Range of Options
State-of-the-art drug regimens
Echocardiography, including TEE
A full range of cardiac nuclear medicine procedures, including positron emission tomography (PET scans)
Magnetic resonance imaging and spectroscopy
Stress testing and Holter monitoring
Outpatient cardiac catheterization
Coronary artery bypass surgery
Left ventricular mapping
Combined bypass surgery and valve operation
Congenital heart surgery
Coronary atherectomy (Rotablator)
Pacemakers and implantable defibrillators
There are many advantages to selecting a hospital that combines patient care with research and education.
Ideally, the individuals engaged in patient care, research and teaching are organized around a given disease or class of patients, facilitating the sharing of knowledge, research and clinical findings. This approach results in the most rapid transfer of basic scientific knowledge from the laboratory to care delivered at the patient's bedside.
Access to many research projects provides patients with additional opportunities to receive state-of-the-art care and technology.
Those individuals on the staff of such a hospital are exposed to an important interchange of ideas. They are also exposed to the newest treatments and forms of technology. At teaching hospitals, physicians are available 24 hours a day.
There may be other advantages to choosing a teaching hospital. Private, not-for-profit, teaching hospitals had lower mortality rates than other types of hospitals, a study in the December 1989 issue of the New England Journal of Medicine suggested.
Yes. Incorporated in 1935, The Cleveland Clinic Educational Foundation sponsors one of the nation's largest physician postgraduate training programs.
The Cleveland Clinic affiliated with the Ohio State University to create a total biomedical health sciences complex in Cleveland that draws upon the highest quality education and research programs of both institutions. The formal affiliation with a major research university enables us to further advance biomedical knowledge while educating future generations of health professionals.
The Accreditation Council on Graduate Medical Education has accredited our residency training programs in cardiology, anesthesiology, and thoracic and cardiovascular surgery. Currently, 72 physicians are being trained in these programs.
The Cleveland Clinic is beginning to measure and determine the health status and quality of life patients experience following their treatment here. Returning to work, being able to perform the usual activities of daily living and being free from pain are some of these important indicators of successful care.
We asked approximately 250 patients with a variety of medical conditions to tell us their health status before, during and after treatment.
More than 80% responded.
All of the patients who responded (100%) thought their ability to function and quality of life generally improved following their care here.
Approximately 70% experienced substantial improvement in physical function, pain relief and energy.
If you ask one person about his or her experience with a doctor or a hospital, you get one person's point of view. Patient satisfaction surveys allow you to judge quality based on the experience of many previous patients. This provides you with a more objective measure to use.
Most hospitals routinely use surveys to learn if patients are satisfied with their medical experience. They can use these results to improve their services.
Patient satisfaction often reflects the personal side of care. Surveys ask questions such as, How willing are the doctors and nurses to listen? Do they answer questions and explain treatments? How much time does the doctor spend with the patient? Is the hospital clean? Is the food good?
Patient satisfaction information can predict what your experience in a particular hospital is likely to be.
How satisfied are hospitalized patients with their experience at this facility?
93% of patients who are hospitalized at the Cleveland Clinic for treatment of a heart condition, such as heart valve disease, are either very satisfied or satisfied with their hospital care.
93% say they would return.
How satisfied are outpatients with their experience at this facility?
94% of patients with heart problems, such as heart valve disease, who come to the Cleveland Clinic for outpatient services are either very satisfied or satisfied with their experience.
97% say they definitely or probably would return.
Is there a program to help patients and their families with difficulties that may arise during a hospital stay?
Cleveland Clinic Foundation patients may call an ombudsman - another name for a patient-relations representative - if they have concerns about their care.
Patients in the Cleveland Clinic hospital may also dial a 24-hour Helpline if they have any problems, questions, suggestions or concerns regarding service.
The Family Resource Group was developed by members of the Clinic's Thoracic and Cardiovascular Surgery Department for the friends and families of heart surgery patients. This free program offers a supportive environment in which they can express concerns, share experiences and acquire information.
All risks of death and complications associated with a procedure can't be eliminated, especially for seriously ill patients. However, your risk can be reduced by choosing a hospital with a low mortality rate.
The mortality rate, or the death rate associated, with a procedure, is the most important measure of your risk and a sensitive measure of quality.
Although the greatest period of risk is during the hospital stay, your risks are also affected by the type of patient you are. Mortality rates generally will be higher for patients who are over age 65; who have other medical conditions, such as diabetes; who are having a repeat coronary procedure; or who are undergoing multiple procedures, for example, bypass surgery with a valve repair.
Ask the doctor and the hospital for their mortality rates. Try to compare rates for patients most like yourself. It's important to try to compare apples with apples so that you know what your risks really are. This may be difficult, however, because mortality rates may be reported differently. If a doctor or hospital can't give you mortality rates or is reluctant to give information, look at alternatives.
We are providing our rates on the facing page. Except for people who are covered by Medicare, no comparable benchmarks exist. No nationally recognized studies or national registries have reported outcomes on large groups of similar patients that we can provide for comparison.
Because hospitals report mortality data to the federal government for their Medicare patients, mortality rates for patients age 65 and over can be compared from hospital to hospital. It still isn't an exact apples-to-apples comparison, but it's one of the few measures available to see how one hospital rates against others.
We are also including some preliminary data on quality of life following surgery for valve disease.
What is the hospital's mortality* rate for valvulotomy?
The Cleveland Clinic's 1992 mortality rate was 0% for 55 valvulotomies.
What is the hospital's mortality* rate for isolated valve repair surgery?
The Cleveland Clinic's 1992 mortality rate for isolated valve repair surgery was 0% for 196 cases.
What is the hospital's mortality* rate for isolated valve replacement surgery?
The Cleveland Clinic's 1992 mortality rate for isolated valve replacement surgery was 3.1% for 357 cases.
What is the hospital's mortality** rate for valve operations performed in people age 65 and over?
In 1991, the Cleveland Clinic's Medicare mortality rate for these procedures was 6.2% for 452 discharges and 28 deaths.
For hospitals in the U.S. that performed more than 30 cases, the Medicare mortality rate was 9.1% in 1991, the most recent year for which Medicare data is available. (This was based on 19,790 discharges and 1,798 deaths.)
* This rate is for mortality at discharge from the hospital and for patients of all ages, including those age 65 and over.
**This is the mortality rate at the time of discharge for valve operations of all types done with and without catheterization.
A mortality rate of zero may look good at first glance. But it may be meaningless if only two procedures have been done. If the sample is too small, statistics lose their significance.
That's why mortality information must be looked at in light of provider experience - the volume of procedures done at the hospital and by the doctor. A zero mortality rate may be more an indication of good luck than skill if only two procedures were performed. And just the opposite. If the hospital does one procedure and the patient dies, a 100 percent mortality rate doesn't tell you anything.
The Cleveland Clinic Foundation is recognized worldwide for its comprehensive commitment to understanding, controlling and preventing diseases of the heart and circulatory system. Doctors and scientists here have pioneered many advances in cardiovascular care:
Leaders in coronary artery bypass surgery. Heart Center specialists at the Cleveland Clinic, which pioneered bypass surgery, perform nearly 2,000 bypass operations annually.
Treating coronary artery disease without surgery. Heart Center specialists offer experience with an unparalleled range of newer and less invasive alternatives to surgery, including balloon angioplasty, atherectomy and stenting. The Heart Center is involved in patient trials of a new coronary laser delivery system as well as in the testing of promising new medications to treat heart attack victims.
Extensive experience with heart disease recurrence. The Cleveland Clinic is recognized worldwide for its expertise in re-operations - surgery performed because heart disease has recurred over time. Heart Center specialists perform one of the largest numbers of re-operations (814 in 1992) in the United States. Because re-operations are often more technically difficult and patients are often older, provider experience is very important.
Leadership in congenital heart care. Pediatric heart specialists at the Clinic see 1,600 children annually, 200 of whom - some as young as newborns - require heart surgery. With the addition of new Heart Center staff in 1993, the Clinic has expanded its capability to operate on very complex congenital heart problems in both children and adults, and to correct some congenital malformations without surgery.
Expertise in heart transplantation. Between August 1984 and April 1993, Cleveland Clinic surgeons have performed 254 heart transplants. Current survival rates are 84% for one year.
Providing leadership nationally. Four past presidents of the American Heart Association have been physicians on the Cleveland Clinic staff.
Working toward an artificial heart. The National Institutes of Health awarded a contract to a joint venture between the Cleveland Clinic and Nimbus Inc., a California-based biotechnology firm, to develop a totally implantable artificial heart over a three- to seven-year period.
State-of-the-art electrophysiology capabilities. The Clinic has three newly equipped electrophysiology laboratories for the evaluation and treatment of heart rhythm problems that lead to sudden death.
Expertise in anesthesia delivery. The Cleveland Clinic has the first and largest department in the world specializing in cardiothoracic anesthesiology. It has pioneered the testing of new anesthetic agents to be used in cardiac anesthesia.
If you need more information to make a fully informed choice, please call us at one of the numbers below:
(toll-free outside Cleveland)
Cleveland Clinic Florida
Through such activities, The Cleveland Clinic Foundation continues to maintain its international reputation for excellence and innovation in the diagnosis and treatment of heart disease. Its affiliated Cleveland Clinic Florida is drawing upon this experience and expertise to establish corresponding state-of-the-art programs in cardiology and cardiac surgery.
For more information or to make an appointment at Cleveland Clinic Florida, call 800/359-5101.
Reprinted with permission by: Med Help International