Another case of underprovision of mitral valve repair surgery : Lessons from the Veterans Affairs health system

Abstract: The article in this issue of the Journal by Bakaeen and colleagues reports trends in the practice and outcomes of patients who underwent mitral valve surgery in the Veterans Affairs (VA) health system of the United States. Their observations confirm that there remains great disparity in care of patients with mitral valve disease and give indications that mitral valve surgery in the VA system may not be achieving key guideline-directed goals. For example, half the patients were in New York Heart Association functional class III or IV, and 15% had severe left ventricular dysfunction at time of surgery. These findings are contrary to current guidelines, which recommend earlier surgical intervention. The most disquieting observation, however, was a repair rate of 58% in patients with presumed degenerative disease. Although the repair rate improved with time, it was only 65% in 2013 (the final year of study), a time at which expert opinion and contemporary data suggest that repair rates should be in excess of 95%. Indeed several authors of the report of Bakaeen and colleagues are expert surgeons who have reported very high repair rates in their academic centers, which their groups were not able to replicate in affiliated VA hospitals. This dichotomy highlights the difference between real-world practice and reference center practice, and it suggests that mitral valve surgical expertise is not necessarily transferrable from a high-volume hospital to an affiliated low-volume hospital, even if an expert mitral surgeon is overseeing both systems. We have recently demonstrated the converse; low-volume surgeons in high-volume reference centers have higher valve repair rates than do other low-volume surgeons, suggesting an important center effect and also a probable Hawthorne effect, whereby low-volume surgeons benefit from being in the immediate vicinity of high-volume surgeons. Both experiences support the critical importance of consolidating center volume and expertise.