When you buy a car: Inappropriate surgery

Here's an idea that should both empower consumers and nudge costs down.

When you buy a car, critical information for this major purchase decision is immediately available, and clearly and prominently displayed on key features of the product, e.g., the miles per gallon. The decision of whether to have surgery is just as important, but information as clear and objective as that is usually absent.

The National Priorities Partnership is a broad group of experts, convened by the National Quality Forum, who have agreed that certain operations are often unwarranted.

Patients who are considering a coronary artery bypass graft (CABG), hysterectomy, knee/hip replacement, prostatectomy, percutaneous transluminal coronary angioplasty (PTCA), or spinal surgery should carefully consider beforehand whether the surgery is appropriate for them. To enable them to do so, patient advocates should find out and tell them the:

Survival rate;

Identification and frequency of the most common adverse effect;

Fraction of patients who need the operation to be performed again;

Best alternative to surgery; and

Cost to be billed by the surgeon and hospital.


I wish I had this information when I considered surgery. A friend's father also would probably have wanted to know it, as it might have saved him from an ineffective operation that left him incontinent. When consumers learn this information, many will probably consider alternatives to surgery, which may well be less expensive.

Fish, buffalo, salad, and Air Force 2: Dick Cheney's Fifth Heart Attack

Katie Drummond writes engagingly on "How Does Dick Cheney’s Ticker Keep on Ticking?"

The recent Vice President suffered another mild heart attack – his fifth – and was released from the hospital earlier this week. He has had eight cardiac events, which have been treated with a quadruple bypass (a CABG), an implanted stent, an implanted cardioverter defibrillator, which was later replaced, and many medications.

The secret of his survival? Cheney has performed aggressive and sustained self-care. After his first heart attack, at age 37, Cheney ended his 20-year heavy smoking habit. Later, before becoming Vice President, he lost 25 pounds. When he flew on Air Force 2, he often brought his elliptical trainer. Aides say his diet now consists of "fish, buffalo, and salad."

Another secret to his survival has been his top-flight, 24/7 medical attention. While he was Vice President, the White House Medical Unit accompanied him with a fully loaded medical bag. As Cheney commented in 2003, "I've got a doc with me 24 hours a day who watches me very carefully."

Advice to heart patients who don't have Air Force 2 and your own 24-hour doctor: Safeguard your own health as actively as Dick Cheney.

Read a story about former president George W. Bush. Thanks to Katie Driscoll for the source story in the AOL News of Feb. 24.

The former Commander in Chief toed the line: Bill Clinton's self-care

Former President Bill Clinton, now 63, has a history of heart trouble. In 2004, he experienced chest pain and shortness of breath, and had quadruple coronary artery bypass graft (CABG) surgery. Later, feeling that it was hard to breathe because of a rare complication of scar tissue and fluid build-up in his lung, he had another operation, in March 2005.

He experienced chest pain again a few days ago, and had another operation on Thursday. Surgeons in a New York hospital placed two stents (metal mesh tubes) inside a blocked heart artery to prop it open, after his bypass graft had become obstructed. Such vein segments taken from the patient's leg often become clogged in this way after a few years, requiring another operation.

I've seen stent surgery, and it's magical. The surgeon snakes a long narrow tube up several feet through a tiny incision in the inside upper thigh of the patient, while the surgeon watches a monitor that shows the patient's arteries and the progress of the long sheath, illuminated as needed by puffs of a fluoroscopic dye. The stent, initially compressed, is slid through the sheath, opening itself as it leaves the sheath. The only analogy is the way that a model ship in a bottle snaps out into its final form after emerging through the bottleneck. Finally, only a Bandaid is needed to protect the site of the incision.

Mr. Clinton did not suffer a heart attack. (Indeed, he was continuing to talk on a cell phone about relief and recovery efforts in Haiti, even as he was being wheeled into the operating room.) Rather, he heeded his body's signals by seeking medical attention promptly.

The head of Cardiology at New York-Presbyterian/Columbia hospital, Dr. Allan Schwartz, noted that "President Clinton has really toed the line in terms of diet and exercise," and said his cholesterol numbers were normal.

Advice to middle-aged men with chest pain: Don't ignore your body's pain signals.

Read another story of a famous person’s successful heart surgery. Thanks to Peter Baker and Angela Macropoulos for the source story in today's New York Times.

Many of the doctors groaned: Patient’s choice of heart treatment options

Cynthia Cooper’s cardiac surgeon recommended surgery to treat her blocked and narrowed heart arteries. But her cardiologist told her to have a stent (a short tube made from a wire mesh) implanted instead.

"It can be extremely frustrating to have these different options thrown at you," said the 72-year-old resident of a Boston suburb. "Why not meet with all the doctors at one time? It would be much easier for the patient."

Three years ago, a surgeon recommended a coronary artery bypass graft (CABG) for her because he believed it was the safest and most reliable option. But Cynthia had already undergone several abdominal surgeries, and was reluctant to have another operation.

So she asked her cardiologist. "I said to him, 'If I was your mother or your sister, what would you tell me to do?'" He advised a stent. She chose an angioplasty, a procedure that inflates a balloon inside the artery to clear the blockage. A stent was implanted to keep it open.

Several weeks later, surgeons and cardiologists discussed her case during Clinical Crossroads, while she sat in the audience, anonymous. The group overwhelmingly decided that her situation warranted surgery. When she told them she had chosen a stent instead, many of the doctors groaned. The Journal of the American Medical Association published the debate over her case in November 2004, and plans a follow-up article.

Cynthia still believes she made the right choice. Her last checkup, three months ago, showed the stent is working perfectly.

Advice to patients considering diverse options: Get a patient advocate to help you decide.

Read another of our stories about a patient’s correct and difficult choice, or read Liz Kowalczyk’s source story in the May 29 issue of the Boston Globe.