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Hospital Halts Heart Surgeries Due to Deaths

Posted on: Thursday, 22 September 2005, 18:00 CDT

Sep. 22--UMass Memorial Medical Center abruptly stopped doing open heart surgeries this week because an unusually high percentage of cardiac patients have died after bypass operations since 2003.

Doctors at the hospital in Worcester have known for two years about problems in the heart surgery program, including, at one time, a high infection rate. But they did not alert patients or the public or suspend operations until after state public health officials presented them with a detailed analysis last week showing that the hospital's death rate for coronary artery bypass surgery patients was nearly twice the average for Massachusetts hospitals.

The hospital says that from 2003 through this August, 38 patients have died within a month of undergoing the surgery, out of 917 such operations.

UMass canceled about 10 surgeries scheduled for this week, following a telephone call last Friday during which the hospital and state health officials agreed that the program should be suspended. UMass surgeons will still be able to perform bypass operations on emergency patients who cannot wait.

The state Department of Public Health, which regulates hospitals, is enlisting three cardiac surgeons from other hospitals to look for patterns in the deaths, and determine whether the hospital and its three heart surgeons can lower the mortality rate or whether the higher-than-average deaths result from factors beyond their control, such as socioeconomic status. Yesterday, Paul Dreyer, director of the Division of Health Care Quality, said he also will send investigators to the hospital to determine when executives became aware of the high death rate, and what they did to address the problems.

Dr. Walter Ettinger Jr., president of UMass Memorial, said that hospital executives and doctors realized in 2003 that more than 4 percent of patients who had undergone coronary artery bypass surgery died within 30 days of their operations, and that the rate of chest infections among heart surgery patients was 6.4 percent. Hospitals on average report mortality rates between 2 percent and 2.5 percent and chest infection rates of between 1 percent and 4 percent, public health and hospital officials said.

Ettinger, who did not work at the hospital at the time, said that executives in late 2003 hired outside consultants to review the program and recommend improvements. As a result, the hospital changed a number of procedures, including making sure patients received intravenous antibiotics within an hour before the surgeon makes his incision, a precaution known to help prevent infections but that studies indicate is not followed consistently at many hospitals.

After adopting the antibiotic regimen and other strategies in 2004, Ettinger said, the hospital was able to lower its chest infection rate to 1.5 percent, but has not been able to reduce mortality.

He said he did not suspend surgeries until seeing the state's analysis because he thought the death rate might be within the norm when adjusted for factors such as patients' age and the severity of their illnesses. The state's analysis showed, however, that the UMass mortality rate in 2003 was above the state average even after it was adjusted for these factors.

"We have spent a lot of time over the last 18 months looking at ways to improve the care," Ettinger said. The Worcester Telegram & Gazette first reported the suspension of the heart program yesterday.

The cardiac surgery department, like the hospital as a whole, has suffered financial turmoil and staff turnover in the past several years. The hospital stopped doing heart transplants in May 2002, following the departure of several key surgeons. In 2005, the chief of cardiac surgery left and has not been replaced.

Dr. Stephen Lahey ran the heart surgery program from early 2002 until this February. In a telephone interview last night, Lahey said he was recruited to the hospital with the express mission of addressing concerns about death rates and complications related to heart operations.

"It had been known to be a longstanding problem," Lahey said.

Lahey, now chief of cardiothoracic surgery at Maimonides Medical Center in New York, said he introduced initiatives to standardize treatment of heart surgery patients. But he said those efforts met with varying acceptance from doctors, nurses, and other hospital staff.

Ettinger, who arrived at UMass in 2004, disputed Lahey's account of why he was hired. "I can tell you pretty unequivocally that's just not true," he said. "He was not specifically brought in for these reasons."

Public health officials last October began making available to the public adjusted mortality rates for the 13 Massachusetts hospitals that perform cardiac surgery, both to help patients make decisions about where to seek care and to push hospitals to improve their results. Consultants for the public health department provided the agency with the analysis of the 2003 hospital data last week.

During 2003, 16 patients who had coronary artery bypass surgery at UMass Memorial died within 30 days of their surgery, out of 371 cases, a rate of 4.3 percent, according to UMass. Statewide, 99 patients died, out of 4,393 cases, a rate of 2.25 percent. UMass had similar mortality rates in 2002, 2004, and so far in 2005.

The state could not provide the adjusted mortality rates to the Globe yesterday.

"We were very concerned that the data suggested that over a four-year period they've been consistently showing unadjusted mortality outcomes around twice the state average," Dreyer said.

The time gap between 2003 -- when UMass learned of its high death rate-- and suspension of the program raises questions about how quickly hospitals and the state are able to respond to potential problems.

Though hospitals report the number of patients and deaths at least every six months, the lag in public reporting is 18 months to two years. Next month, public health officials will report the 2003 rates, meaning a patient using the data to decide where to have surgery will be relying on two-year-old information.

Sharon-Lise Normand of the Harvard School of Public Health, which collects and analyzes the data for the state, said it's not possible to provide it more quickly and that the time gap is similar to that in New York, which also publishes cardiac surgery mortality rates. She said it takes that long to review patient records at each hospital to verify the accuracy of their reports.

Dreyer said that hospitals should not be dependent on the state data to know there's a problem.

"A hospital should be on top of this through the quality-assurance process," he said. "Hospitals and surgeons looking at unadjusted data should have a sense of whether their patients are unusually sick or not."

But Ettinger said that the number of patients who died is so small that it is difficult to spot trends. And he said other tools the hospital has used to compare its adjusted data with national data have shown the mortality rate at UMass Memorial to be near average.

Dr. Richard Nesto, chairman of cardiovascular medicine at the Lahey Clinic, said a 4 percent mortality rate should be treated as an important warning sign.

"That's a red light," Nesto said. "This is clearly a divergence from what you might expect at this level. It's a university hospital, a teaching hospital."

Ettinger said he does not know when UMass Memorial will reopen the cardiac surgery program.

"If there were an easy fix, I think, we would have found it by now," he said.

By Liz Kowalczyk and Stephen Smith

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Source: The Boston Globe

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