Good Help, Close to Home
There's a strong link between volume and quality for coronary bypass surgery. There's also a fair amount of disagreement over the definition of high volume, although both McAllen and Dyke would satisfy any of the proposed numbers. The Leapfrog Group, a standard-setting consortium of large employers, puts the bar at 450 hospital surgeries annually. A large study published in Circulation in 2003 found that mortality risk is 29 percent lower in hospitals where at least 600 bypasses a year are performed by surgeons who do 125 or more than when neither the hospital nor its surgeons meet those volume thresholds.
Still, the line is blurry, say most researchers, and surgeons who perform fewer than these recommended numbers should not automatically be assumed to do them worse. "There's very little difference between a surgeon who does 300 versus 100," or even 50, says Fred Edwards, chair of cardiothoracic surgery at the University of Florida College of Medicine in Jacksonville and chairman of the Society of Thoracic Surgeons' national database of cardiac surgery outcomes.
THE BEST HIP JOINT
Vernon Memorial Hospital in Wisconsin, where Don Wilke had his hip replaced, highlights volume's slipperiness as an indicator of quality. The 25-bed hospital had no real orthopedic program until surgeon Jeffrey Lawrence moved his family from the tony Chicago suburb of Highland Park to the 4,000-person town. Now Lawrence is the program. He does about 80 hip replacements each year, which puts the hospital short of the 100 recommended by several studies. It is considerably above the suggested individual physician benchmark of 50, however.
Lawrence's hip joint patients also have an impressively low rate of infections--0.25 percent against a national average of 1.5 percent. Infection after joint replacement is a complication that prospective patients should always ask about, because the consequences, such as more surgery to replace the infected joint, can be serious. All surgeons and hospitals should know their infection rates and should be willing to discuss them, says Paul Pellicci, an orthopedic surgeon at the Hospital for Special Surgery in New York City. "That's data that every hospital has. If they say they don't know, it's either because they don't want to tell you or they don't think you have the right to ask the question."
Besides board certification in orthopedic surgery--a must when considering any major orthopedic operation--Lawrence did a post-residency fellowship in joint replacement, a strong indication of competence. Vernon employs physical therapists who work closely with the orthopedic department, something doctors say helps ensure that patients receive proper care in recovery.
JUGGLING THE PROSTATE OPTIONS
Prostate cancer presents two issues: where to go and what to do. The two main choices are radiation or surgery. The radiation options are either external beams directed at the cancer or radioactive "seeds" implanted in the prostate. Surgery involves removing the prostate, or radical prostatectomy. About two thirds of patients opt for radiation.
That's what John Paul McMahon picked--specifically the seeds. The 68-year-old Franciscan friar lives in tiny Steubenville in eastern Ohio. Three years ago his level of prostate-specific antigen (PSA, measured by a blood test as an early warning of prostate cancer) began shooting up, and his doctor took snippets of prostate tissue. "I was shocked at the biopsy results," says McMahon. "And worried. Cancer is a scary thing."The good news was that his disease was confined to one part of his prostate. McMahon drove an hour away to the University of Pittsburgh Medical Center, where a surgeon told him he was an excellent candidate for a prostatectomy.
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