If you needed a good hospital for especially high-quality heart-related care, what would you do? Would you go wherever your doctor sends you, figuring she knows best? That's what most people do. But your doctor might not know best. Patients with challenging heart problems are routinely referred to hospitals with limited experience in dealing with them—situations like diagnosing and treating a rare heart rhythm, or inserting a stent in a tortuous coronary artery, or replacing a dangerously leaky aortic valve. By contrast, patients with thorny problems are not at all uncommon at the heart and heart surgery centers ranked in the latest edition of Best Hospitals, released last month by U.S. News & World Report. The bigger the problem, the more urgent the need to seek out a hospital like those in the rankings. One or more is likely to be within a short flight or a reasonable drive. The 50 heart hospitals in the latest heart rankings are scattered across 24 states and the District of Columbia, and the top 10, listed here, are in nine different pockets of the country. Following the list is guidance on understanding the qualities of an excellent heart hospital, deciding whether you need one, and explaining how to get in if you do.
The Best Hospitals in Heart & Heart Surgery
- Cleveland Clinic
- Mayo Clinic, Rochester, Minn.
- Johns Hopkins Hospital, Baltimore
- Texas Heart Institute at St. Luke's Episcopal Hospital, Houston
- Massachusetts General Hospital, Boston
- New York-Presbyterian University Hospital of Columbia and Cornell
- Brigham and Women's Hospital, Boston
- Ronald Reagan UCLA Medical Center, Los Angeles
- Duke University Medical Center, Durham, N.C.
- Hospital of the University of Pennsylvania, Philadelphia
[See full list of Best Hospitals in Heart & Heart Surgery]
What makes these hospitals the best?
They do difficult cases—and lots of them. Take coronary artery bypass surgery, the most common major heart procedure. The rankings don't factor in care of low-risk bypass patients—only those who are very sick or who come to the OR with major complications that pose added risk, like diabetes or a bleeding disorder. Such patients are overrepresented at ranked hospitals because that is where they are more likely to be referred or transferred. To even be considered for the 2010-11 rankings in heart and heart surgery, a hospital had to have treated at least 1,244 high-risk heart patients, 500 of them surgical cases, based on the latest three years of Medicare data. Out of 4,852 hospitals in the nation, just 670—not even 15 percent—made the cut.
But only 50 of the 670 are ranked. How do the ranked hospitals stand out?
A quick scan of the top 10 might suggest that it's because of their reputation. More than 70 percent of the cardiologists and heart surgeons who responded to U.S. News surveys over the last three years, for example, nominated the Cleveland Clinic as one of the places they would send their most difficult heart patients if money and geography were not issues. A closer look beyond the top 10 or so, however, shows that reputation generally is not the key. Of the remaining 40 hospitals, 21 were cited by no more than 2 percent of the specialists; six hospitals got no nominations at all.
The numbers tell the story: Ranked hospitals generally had lower death rates, higher nursing standards, and a commitment to advanced technology. Their average mortality ratio of 0.69 means that heart patients died about 30 percent less often than would be expected for their age, severity of their condition, and other risk factors; by comparison, the mortality ratio at several unranked hospitals was above 1.50—a death rate more than 50 percent higher than expected. Nearly three-fourths of the ranked facilities are recognized by the American Nurses Credentialing Center as "Nurse Magnet" hospitals for their high-quality nursing care, a distinction that only about one in 15 U.S. hospitals can claim. Two-thirds of the ranked hospitals have all seven of the heart-related technologies U.S. News considers important in caring for high-risk patients, such as a separate cardiac intensive-care unit, a PET/CT scanner, and transplant services—and most of the others have six. Many unranked hospitals have three or fewer of the items on the list.
Isn't volume important, too?
Very important. A hospital needs to see enough challenging cases to keep the skills of doctors, nurses, and other clinical caregivers sharp. That's why Best Hospitals requires at least 500 procedures and 1,244 complex cases overall to qualify for the heart rankings. Beyond a threshold number, however, more does not necessarily mean better. Of the 50 hospitals with the highest volumes of difficult heart patients, only 14 were ranked—and some of the facilities with the worst mortality ratios also registered off-the-chart volumes.
How can that be? Explain, please.
There's no single answer. Some high-volume centers could have problems with killer infections. Some may not be fully capable of handling high-risk patients but take them rather than referring them elsewhere. Some may be pushing more patients through the OR than can be safely handled, with residents doing most of the work, monitored by veteran surgeons overseeing two or three procedures at a time. These are only a few of the possibilities.
Can I find out death rates and other important information about the hospital where I was referred if it isn't ranked?
It may be one of the 620 that was unranked but had enough volume to qualify for consideration, and if so, the information is available by searching for the hospital on the Best Hospitals page. (That is also true for unranked hospitals in the 15 other Best Hospitals specialties.)
What if it isn't listed?
Do a little detective work. You can contact the medical director, chief medical officer, or chief of surgery and ask how many procedures like the one you need were performed at the hospital in the past year, and the number of deaths and complications. When you see the surgeon to whom you were referred, or in a conversation beforehand, ask how many procedures similar to yours he has performed in the most recent 12 months, how many patients similar to you died within 30 days from when they were admitted, how many had serious complications, and his rate of surgical infections for the procedure. Almost every hospital has a designated infection-control officer who can tell you the hospital's overall infection rate. You should expect specific and courteous responses to all of these questions.
If the hospital reports no deaths at all, is that where I want to go?
A hospital that reports a mortality rate of zero in the latest year for your procedure should not be an automatic choice. Be sure to ask for the volume. The lower the number of patients, the greater the possibility of a death rate of zero (or one that's very high, since only one or two deaths would tilt the rate dramatically upward). In a 2008 study reported in the Journal of the American College of Surgeons, researchers checked death rates for heart bypass surgery and four other high-risk procedures at hospitals, most of which had low volumes, the year following three straight years of zero mortality. They found that the death rates in the year following that spotless track record were about at the national average for bypass surgery and three of the other procedures, and was even higher than that benchmark for the fifth. "Patients considering surgery should not consider a reported mortality of zero as being a reliable indicator of future performance," the investigators concluded.
Can I get into a Best Hospital?
Almost always. Patients can often do it themselves by calling a patient referral number or sending an E-mail; information on both will be on the hospital's website. You should first check to see if your health insurance carrier will cover the cost. If there is any doubt, your physician should make the referral. She can deal with a health insurer's resistance better than you can—she's used to it.
How do I know I need a Best Hospital?
Most of the time you won't, unless you are very ill, very old, have conditions such as advanced diabetes or congestive heart failure that add risk, or need surgery that is particularly demanding. An example is the Ross procedure, which involves removing a diseased aortic valve, replacing it with another heart valve, and replacing that one with a valve taken from a cadaver. It is complex and calls for advanced technical skills. Few community hospitals do it. But if you're reasonably healthy and need routine heart care, your hometown hospital should do fine.