Survival Rates Climb, Study Finds : Busy Hospitals Linked to Successful Bypasses
Patients who have heart bypass surgery, particularly the elderly and those who undergo the procedure on an emergency basis, are more likely to survive and to avoid complications if they go to a hospital that performs more than 200 such operations a year, according to a University of California, San Francisco Medical Center, study of state hospitals.
The report was accompanied by a list of hospitals ranked according to the number of bypass surgeries that they performed in 1983, the year that was studied.
If bypass surgery were only performed at the busier hospitals, the researchers estimated, up to 300 lives, 75,000 “hospital days” and $166 million might be saved annually in the United States. The study released Wednesday was prepared for Blue Shield of California.
The report recommended that the lowest volume hospitals, instead of trying to perform more bypass operations, stop doing them altogether.
Three of eight Orange County hospitals on the list performed more than 200 surgeries in the studied year. UCI Medical Center, with 20 surgeries, performed the fewest of all the hospitals listed.
But Dr. Walter Henry, UCI professor of medicine and chief of cardiology, said the hospital’s operating rooms were under renovation during the first part of 1983 and all bypass surgical patients instead were transferred to St. Joseph Hospital in Orange, which has a teaching affiliation with the hospital. St. Joseph performed 264 bypass surgeries that year, according to the report.
Further, UCI surgeons divide their time among three hospitals--the medical center, St. Joseph and the Veterans Administration Medical Center-Long Beach--so the surgeons are experienced despite the low statistics for the hospital, UCI physicians said.
“What’s more important, the experience of the (surgical) team or how many cases a hospital runs through its operating rooms?” asked Dr. John E. Connolly, a UCI professor of medicine. He echoed the sentiment of several Orange County hospital spokesmen and physicians contacted Wednesday about the study.
According to the study, in hospitals that performed fewer than 100 bypass surgeries a year, 5% of patients died and 22% had “poor outcomes,” including deaths and longer stays in the hospital resulting from complications, such as infections. Among the largest and best known of the 12 hospitals in this group are Harbor-UCLA Medical Center, Hollywood Presbyterian Medical Center and Los Angeles County-USC Medical Center.
In hospitals that performed more than 350 operations a year, 3% of patients died and 11% had poor outcomes.
“These results are pretty startling,” said Jonathan A. Showstack, assistant professor of health policy at UC San Francisco and principal author of the study.
Death rates at hospitals that performed between 100 and 350 operations averaged 4%. In the hospitals that performed 101 to 200 surgeries a year, 16% of the patients had poor outcomes, as contrasted with 13% in hospitals that performed 201 to 350 surgeries a year.
The busier hospitals also tended to have the lowest costs, in part because their patients had fewer complications and could leave the hospital sooner, the researchers found.
The worst results were for emergency cases in the group of hospitals that did fewer than 100 of the surgeries a year. In such cases, 7% of patients at these hospitals died and 36% had poor outcomes.
UCI’s Henry said that despite the university medical center’s low volume, the institution in Orange had a 2.6% death rate associated with the 116 bypass surgeries performed there between March, 1983, and March, 1986, which compares favorably with the mortality rates at high-volume hospitals. Still, UCI’s figures are skewed low because it does not include bypass surgeries that accompanied heart valve replacements, a type of operation performed often at UCI Medical Center, he said.
Surgeons at these hospitals had mixed reactions to the study.
“I agree that we . . . should have centers for major surgeries, such as trauma, transplantation and heart surgery,” said Dr. M. Hadi Salem, chief of thoracic surgery at Hollywood Presbyterian.
Disputed Conclusion
Dr. Ronald J. Nelson, the chief cardiac surgeon at Harbor-UCLA, disputed the conclusion that bypass surgery should be done only at the busiest hospitals.
“One has to look very carefully at (the patients served) by individual institutions,” he said. “To simply look at the numbers is fraught with hazard.”
The best results for emergency cases were in the 17 hospitals that performed more than 350 surgeries a year. Four percent of the patients at such hospitals died, and 20% had poor outcomes. These hospitals included St. Vincent Medical Center, Cedars-Sinai Medical Center, Memorial Medical Center of Long Beach, the Kaiser Foundation Hospital on Sunset Boulevard and five others in Southern California.
“Patients should probably not have these operations at very low-volume hospitals,” Showstack said in an interview. “Many of these patients may do better if they are stabilized and transferred to a higher-volume local hospital.”
For many complicated surgeries, success is related to the experience of the surgeons and other hospital personnel. The UC study expanded on earlier studies showing that death rates from bypass surgery decrease as the number of operations at a hospital increases. It used more complete data and examined such additional factors as emergency surgery, days in the hospital and the costs of care.
In a heart bypass operation, surgeons relieve blockages in the coronary arteries that supply blood to the heart by replacing sections of these arteries with undamaged blood vessels from elsewhere in the body.
Doctor Charges
The procedure is one of the most common and expensive of all operations. More than 175,000 such surgeries will be performed in the United States this year, accounting for total hospital and physician charges of about $7 billion, according to the researchers.
The operation has been shown to increase survival for some patients with severe coronary artery disease and to provide more effective pain relief than medicines for some patients with angina, a chest pain caused by an inadequate blood supply to the the heart. However, some health policy experts contend that the surgery is performed more frequently than is necessary.
In the San Francisco study, data was analyzed on nearly 19,000 patients at 77 hospitals in the state that performed more than 20 of the procedures. Veterans Administration hospitals were not included in the study. The results were adjusted for such factors as the age and sex of the patients, as well as the severity of their heart disease.
Total hospital charges for an average surgery in 1983 dollars was $25,400, and the patients spent an average of 13 days in the hospital.
In the study, deaths and complication rates were reported only for groups of hospitals that had similar numbers of operations but not for individual hospitals. The low-volume hospitals each had too few surgeries to permit meaningful comparisons between institutions.
sh Decision Defended
The decision not to list death rates for individual hospitals was defended by Dr. Ralph Schaffarzick, Blue Shield senior vice president and medical director.
The goal was to point out the many “well-qualified” hospitals throughout the state, not “to identify the bad hospitals,” Schaffarzick said. “Most of the low-volume hospitals are within 40 miles of a center doing more than 200 operations.”
In March, the federal Health Care Financing Administration released death rates for Medicare patients at hospitals throughout the country, including deaths from bypass surgery and eight other common conditions.
Schaffarzick said many Blue Shield “preferred hospitals” in the state performed more than 200 bypass surgeries a year.
“We are already encouraging (our subscribers) to use them, “ he said.
Anaheim Memorial Hospital performed the most bypass surgeries in Orange County for the studied year--379. Its large volume “is an important thing (for patients) to consider,” hospital spokeswoman Katherine Dopler said. “They probably already have their own doctors, but if they have a choice of hospitals and need this to be done, it would behoove them to ask . . . ‘Where would I get the best treatment?’ ” she said.
About 25% to 30% of the patients at the 240-bed Anaheim Memorial are there for heart procedures, she said. In addition to experienced surgeons, a successful recovery also depends on “a strong and well-tuned nursing team, the most up-to-date equipment and facilities, and support services” that are found at hospitals that perform a high number of bypass surgeries, she said.
UCI’s Henry said he would agree in general that larger-volume hospitals are likely to produce better results, but “you have to look at the specific programs, and there clearly will be exceptions.” Teaching institutions, he said, “tend to attract more complicated cases” but are staffed with surgeons who are “quite well trained and from strong backgrounds.”
Further, he and other health care officials said Wednesday that the growth of bypass surgery is being slowed by new technologies and procedures. One of the procedures is angioplasty, in which a catheter is inserted into the blocked heart artery and a small balloon is inflated to smooth the built-up plaque along the vessel walls.
“I would agree you need to do a certain number (of surgeries) to be proficient. It’s just like playing chess or golf. The more you play, the better you become,” said James Haden, executive vice president of Hoag Memorial Hospital Presbyterian in Newport Beach, where 135 bypasses were performed in 1983.
But Hoag’s surgical team also works at St. Joseph and Saddleback Community Hospital, he said. While hospitals need a “base-line number” to stay proficient, “without a doubt it’s the surgeons who are most proficient,” he said.
Wayne Schroeder, president of United Western Medical Centers, agreed. Cardiac surgeons who operate at Western Medical Center-Santa Ana, which had 159 bypasses in the studied year, also work at the sister hospital, Western Medical Center-Anaheim. The Anaheim hospital had only 34 bypasses in 1983, the second lowest in the study, but the institution, formerly Good Samaritan Hospital, had just been taken over by United Western Medical Centers and was in transition, he said.
Even a cardiologist associated with one of the county’s high-volume hospitals said the expertise of the surgical team is the primary determinant of a successful recovery.
“I think in any endeavor, the more you do, the better you are,” said Dr. Alan Borsari, a Fullerton cardiologist who practices out of several hospitals, including St. Jude, which performed 334 open-heart surgeries in 1983.
The expertise of the operating room nursing staff and other hospital services are bound to improve when there is a high volume of bypass surgeries, he said.
“But in this community, it’s quite true surgeons don’t operate solely at one hospital. So you need to look at the expertise of the surgery team and the cardiology team in total,” Borsari said. The morbidity and mortality rates associated with surgery depend “primarily on the skill of the operating team, not the institution itself,” he said.
HEART BYPASS SURGERY
BYPASS OPERATIONS AT SOUTHERN CALIFORNIA HOSPITALS Patients have a significantly better chance of surviving coronary artery bypass graft surgery and making a good recovery if they are treated at a hospital where more than 200 of the operations are performed each year, according to a new study by researchers at the UC Medical Center, San Francisco. These are the Southern California hospitals which performed 20 or more heart bypass surgeries during the study year of 1983 and the number of operations at each.
20 TO 100 OPERATIONS A YEAR
UC Irvine Medical Center Orange 20
Good Samaritan Hospital Anaheim 34
LA County-Harbor UCLA Torrance 46
Hollywood Presby. Los Angeles 62
LA County-USC Los Angeles 68
Beverly Hospital Montebello 89
Long Beach Comm. Long Beach 94
Los Robles Regional Thousand Oaks 98
St. John’s Regional Oxnard 99
101 TO 200 OPERATIONS
White Memorial Los Angeles 101
Granada Hills Granada Hills 104
Community Mem. Hosp. Ventura 107
Santa Monica Hospital Santa Monica 108
St. John’s Hospital Santa Monica 115
Garfield Medical Center Monterey Park 118
Goleta Valley Comm. Santa Barbara 118
St. Mary Med. Center Long Beach 122
St. Francis Med. Center Lynwood 133
Hoag Mem. Presby. Newpt. Beach 135
Lancaster Comm. Hospital Lancaster 138
Glendale Adventist Glendale 146
Fountain Valley Fountain Valley 149
Western Medical Center Santa Ana 159
Northridge Hospital Northridge 166
St. Joseph Burbank 168
Valley Presbyterian Van Nuys 175
Brotman Medical Center Culver City 188
Presbyterian Intercommunity Whittier 189
201 TO 350 OPERATIONS UCLA Medical Center Los Angeles 202
Torrance Memorial Hospital Torrance 220
UC San Diego San Diego 226
St. Bernardine Hospital San Bernardino 244
Eisenhower Med. Center R. Mirage 256
St. Joseph Hospital Orange 264
S. Barbara Cottage Hosp. S. Barbara 285
Little Company of Mary Torrance 286
Daniel Freeman Hospital Inglewood 287
Huntington Mem. Hospital Pasadena 295
Hospital of Good Sam. Los Angeles 306
Mercy Hospital San Diego 310
San Joaquin Hospital Bakersfield 316
Encino Hospital Encino 323
St. Jude Hospital Fullerton 334
351 OR MORE OPERATIONS Kaiser Foundation Hosp. Los Angeles 355
Memorial Medical Center Long Beach 363
Scripps Memorial Hospital La Jolla 374
Anaheim Memorial Hospital Anaheim 379
Loma Linda Med. Center Loma Linda 385
Alvarado Hospital San Diego 386
Cedars-Sinai Los Angeles 572
Sharp Memorial Hospital San Diego 852
St. Vincent Med. Center Los Angeles 1016
Source: California Health Facilities Commission
