Hospital's Kidney Transplant Death Rate Raises Concerns

Kidney transplant patients at St. Vincent Medical Center have died at a higher-than-expected rate over the last several years, raising questions about the quality of care at one of the nation's oldest and busiest transplant programs.

Thirty-six people who received transplants from January 2002 to June 2004 died within a year of surgery. That is 15 more than would be expected, based largely on the quality of donated organs and the condition of recipients, according to the agency that analyzes data from all transplant centers on behalf of the federal government.

In fact, St. Vincent's is one of only four programs in the United States whose death rate was consistently higher than expected for patients dating to 1999. None of the others is in California.

As a result, two insurance companies, Aetna and Humana, say they have stopped sending kidney transplant patients to St. Vincent, west of downtown Los Angeles. The United Network for Organ Sharing, which oversees the national organ transplant system, dispatched a team of reviewers to the hospital last month to look into the problem.

St. Vincent recently closed its liver transplant program after a scandal in which staff members let a patient jump the line for an organ, then tried to cover it up.

But the hospital has long touted the prowess of its much larger kidney program, which performed 216 transplants last year and has more than 1,100 on its waiting list. It was the ninth-busiest last year among the 242 kidney transplant programs in the U.S.

"Survival statistics are consistently above the national average," its website has claimed.

That statement was removed this week, however, after Times reporters questioned hospital officials about its accuracy.

Transplant administrator Deborah Maurer and co-medical director Dr. Robert Mendez said this week that the hospital's statistics had suffered because the program has been deliberately aggressive, treating sicker and older patients, who have fewer options for care. The program has also served the less-educated and non-English-speaking, who may have difficulty following doctor's orders in the months after their operations.

St. Vincent has also regularly accepted lower-quality kidneys refused by other programs.

In 2004, more than 25% of the kidneys accepted for transplant at the hospital were of marginal quality, according to the Scientific Registry of Transplant Recipients, which analyzes transplant data for the government. The national rate was about 15%.

In recent months, hospital officials said, doctors have become more selective in accepting patients and donated organs.

They have also improved their treatment of patients after their transplants, they said.

Although it's too early to tell if the changes will work, "we are starting to see some improvements," said Maurer, who started work in July.

But Mendez said he was worried that the recent preoccupation with statistics would harm his patients.

"We're being corralled into a center in which perhaps we won't be able to take care of the most needy," he said. "Who's going to fend for them?"

Troubles in the kidney program are the latest sign of stress in Southern California's transplantation system. In addition to the liver scandal at St. Vincent, UCI Medical Center was forced to close its liver program last month because it was performing too few surgeries to maintain proficiency and had a subpar survival rate. The program had been rejecting nearly every liver it was offered, often citing poor quality.

Indeed, the recent spate of problems illustrates the variety of ways a transplant center can go astray -- by perhaps being too aggressive or too conservative, or by violating ethical standards.

St. Vincent performed its first kidney transplant in 1970, and a year later recruited Drs. Robert and Rafael Mendez, identical twin surgeons, to run the program.

The brothers have been in charge ever since, drawing thousands of patients from California and beyond. Statewide, only UC San Francisco Medical Center has performed more kidney transplants since 1988.

The St. Vincent website, which has pointed out that "statistics in organ transplantation are extremely important," has reported a one-year kidney survival rate of 97%.

In fact, 92.77% of the patients who received kidneys from January 2002 to June 2004 lived at least a year, according to the Scientific Registry.

The U.S. rate was 95.9%, about the same as the expected rate for St. Vincent. At large transplant centers, small differences in such figures can translate into numerous patient deaths. At St. Vincent, the gap between the expected and actual rates amounted to 15 deaths in 2 1/2 years.

The other large programs in California met their targets. The most recent survival rate at UCLA Medical Center was 95.43%, and UCSF's was 96.54%.

Organ quality and dozens of other factors that affect survival are taken into account in determining expected survival rates. The adjustments are made so programs that take more risks to stretch the available organ supply aren't penalized.

Mendez said the formula did not capture his patients' true disadvantages, including conditions unrelated to kidney failure, such as diabetes and heart disease.

Of the 16 patients who died after transplants in 2004 and '05, the cause of death for 12 was heart problems and not kidney failure, St. Vincent officials said.

That does not explain, however, why kidneys transplanted at St. Vincent also failed at a greater rate than expected. Only 86% of the kidneys that were transplanted into patients from January 2002 to June 2004 functioned for at least a year, below the expected rate of 91%, according to the Scientific Registry. Not all of the patients died, but some needed to begin dialysis and required another transplant.

Although the survival and other data are posted online -- at several patients on St. Vincent's kidney waiting list said they were unaware of the statistics.

"We didn't ask much, and they didn't mention it," said Teresa Chavez de Oliva, 68, who joined the list in 2004 and undergoes dialysis three times a week while she awaits a transplant.

The federal government, however, is proposing to use patient and organ survival statistics to decide which transplant programs are certified, a move that could doom St. Vincent's center.

But transplant experts cautioned that poor numbers alone don't necessarily mean a program is bad.

"It raises a flag, and it is something that needs to be looked at," said Dr. Arthur Matas, a University of Minnesota kidney transplant surgeon and president-elect of the American Society of Transplant Surgeons.

Insurers, though, pay close attention. Aetna said it stopped sending new patients to the St. Vincent program in December 2004. Humana followed suit in July of this year. In addition, UnitedHealthcare and PacifiCare Health Systems suspended coverage for transplants at St. Vincent, including hearts and kidneys, after the liver scandal became public this fall.

"Inappropriate activity in one program may be an indication of problems elsewhere in their facility," said Dr. Sam Ho, senior vice president and chief medical officer at PacifiCare. "We have no plans to reinstate" the programs.

St. Vincent is already downsizing its kidney program as it becomes more selective of patients and organs. This year the hospital expects to perform 165 kidney transplants, 51 fewer than last year.

Transplant staff will now make a point of telling all patients about the center's lower-than-expected survival rate, Maurer said.