Heart Surgery Death Rates Found High in 1 in 6 Hospitals

Nearly one-sixth of California hospitals with heart surgery programs had significantly high death rates for heart bypass patients in 1986, according to a Times analysis of data covering nearly all such operations in the state.

At 10 of these hospitals, the percentage of bypass surgery patients who died before leaving the hospital was at least double the statewide average death rate of 5.3%. The facilities included Valley Presbyterian Hospital in Van Nuys, Daniel Freeman Memorial Hospital in Inglewood, Hollywood Presbyterian Medical Center, and two hospitals in Long Beach.

Most of the hospitals with the highest death rates had relatively few bypass operations, suggesting, according to some experts, that patients might be better off at busier heart surgery hospitals.

Some Had Low Death Rates

Eight other institutions, including three in Los Angeles and one in San Diego, had significantly low bypass surgery death rates.

The Times analysis also revealed tremendous variations in typical hospital charges for bypass patients--from a high of nearly $59,000 a case at Hollywood Presbyterian to a low of about $16,000 a case at nearby St. Vincent Medical Center in Los Angeles, the busiest bypass surgery hospital in the state. The statewide median charge was $27,700.

The Times prepared the computerized hospital-by-hospital study of heart bypass surgery in collaboration with expert consultants from the Institute for Health Policy Studies at UC San Francisco.

“These data can help to point out hospitals with possible problems with quality of care,” said Jonathan A. Showstack, a UCSF associate professor of health policy and one of three experts retained by The Times. “Patients and physicians have a right to know these data. Hospitals with high mortality rates should be asked to provide explanations.”

Almost all of the hospitals with high death rates said that their statistics reflected a high number of difficult cases, not quality-of-care problems. But Dr. John W. Kirklin, who is considered an expert on the subject, said bypass surgery patients at most hospitals are “more alike than different” and explanations of high death rates based on sicker patients are “usually not easy to support.”

With a typical mix of patients, a hospital’s mortality rate for bypass surgery ought to be about 3.5% to 4% in 1988, said Kirklin, a professor of cardiac surgery at the University of Alabama at Birmingham, who has reviewed the performance of a number of institutions. “Some people will object that this mortality rate is not realistic. But for programs of undoubted merit, that figure is probably pretty reasonable.”

Among The Times’ most significant findings are the lower death rates at hospitals that had many bypass surgeries compared to facilities that performed fewer surgeries.

The average death rate varied from 4.3% for hospitals with more than 350 surgeries during 1986 to 7.4% for those with fewer than 100 surgeries. The state’s 23 lowest-volume hospitals included 13 in Los Angeles County.

More Cases, Lower Rate

The average death rate was 5.2% for facilities with between 200 and 350 surgeries and 6.8% for those with between 100 and 200 cases.

Because of the relationship between high volume and low mortality, a significant number of deaths might be prevented by concentrating heart surgery in a smaller number of busier hospitals, Showstack said. “The data imply that low volume hospitals probably should not be doing heart surgery,” he said.

The Times analysis covers 18,315 adults who underwent heart bypass surgery in 1986, the most recent year for which complete information is available. (The Times published a similar analysis of 1985 data on heart bypass and four other common surgeries in March.)

This expensive, technically complex and frequently performed operation is considered one of the most important to study in assessing the quality of hospital care. Surgeons restore an adequate blood supply to heart tissue by grafting blood vessels from elsewhere in the body around blockages in the arteries supplying blood to the heart.

The analysis is based on computer tapes compiled by the Office of Statewide Health Planning and Development. The data is supplied and verified by individual hospitals and is considered highly accurate; in addition, the data were reconfirmed with all the hospitals with high death rates.

The Times compared the mortality rates for individual hospitals to the statewide average, after correcting for variations between hospitals in the age, sex and race of patients. The death rates indicate the percentage of bypass patients who died in the hospital out of all such patients who were admitted.

Similar results were obtained when other factors were taken into account, such as whether a hospital had a high percentage of patients with acute heart attacks or a high percentage of emergency cases. But a high death rate at a hospital does not necessarily indicate bad performance, nor a low death rate good performance. This is because factors that could not be measured may also be important in explaining the variations in death rates, such as the efficiency of the heart in pumping blood and the percentage of patients with prior angioplasty or heart bypass surgery.

In addition, The Times studied the number of operations performed at each hospital, total hospital charges and the number of days patients remained in the hospital after surgery. When a hospital has a high percentage of patients with prolonged hospitalizations, this suggests “an unusually high rate of complications,” Showstack said.

4 Categories Studied

Two hospitals, St. Vincent Medical Center and Eisenhower Medical Center in Rancho Mirage, had favorable statistics in three of the four categories studied--low death rate, high volume and low median charges--under $21,000. Comparable charge data were not available for the Kaiser Foundation Hospitals in Los Angeles and San Francisco, both of which had low death rates and a high volume of cases.

One hospital, Hollywood Presbyterian, had unfavorable statistics in all four categories studied--high death rate, low volume, long lengths of stay and high median charges.

Between 1983 and 1987, Hollywood Presbyterian averaged about 40 bypass surgeries and a 10.7% death rate each year. In 1986, its surgical length of stay was 13.7 days, according to the hospital, compared to the statewide median of 7.5 days. The lowest total hospital charge in 1986 was $40,944, according to the state computer tapes, nearly 50% higher than the median total charge for all bypass patients in the state.

Hollywood Presbyterian administrators and physicians declined to be interviewed. In a written statement, Katherine Newell Smith, the hospital’s director of public relations, said a “large percentage of high-risk patients” appeared to be an important factor in explaining the results.

The “surgeon responsible for over two-thirds of the operations in question” is no longer affiliated with Hollywood Presbyterian, according to Smith. She declined to disclose the surgeon’s name and said she did not know where he is practicing. In addition, Smith said that the hospital has hired a new cardiology medical director, Dr. Christian Posner. She added: Hollywood Presbyterian “anticipates a significant change in our results and an increase in the volume of cases.”

As in 1985, Kaiser Foundation Hospital, San Francisco, had the lowest bypass surgery mortality rate among all California hospitals, 1.0%. Between 1983 and 1987, surgeons performed 1,875 bypasses with 32 deaths, for an overall 1.7% mortality rate, according to Kaiser statistics.

In Southern California, Kaiser Foundation Hospital, Los Angeles had the lowest bypass death rate in 1986, 1.3%, or five deaths after 394 surgeries. The hospital is a regional referral center, providing most of the cardiac surgery services, as well as heart catheterization and angioplasty, for the health maintenance organization’s 1.8 million members throughout Southern California.

Dr. Siavosh Khonsari, the hospital’s chief of cardiac surgery, said surgical skill, comprehensive post-operative care and a high volume of cases all contributed to the favorable results. He said the patients were as sick as those operated on in most other California hospitals. “It is just like golf,” Khonsari said. “If you don’t practice your art everyday, you are not going to be as slick.”

Cardiologists on 24-Hour Shifts

The primary responsibility for post-operative care is shared by three staff cardiologists. They work 24-hour shifts, caring for the patients in the 16-bed cardiac surgery intensive care unit. As at Kaiser, San Francisco, the nurses, anesthesiologists and other medical professionals that care for heart surgery patients spend most of their time doing so.

At many other hospitals, physicians in training, such as residents and cardiology fellows, assume primary responsibility for post-operative care. In addition, particularly at hospitals with fewer heart surgeries, nurses and other medical personnel may not be able to specialize in caring for heart surgery patients.

“It is rare for a patient to die in the operating room now days,” Khonsari said. “What happens is these guys (the cardiologists) really sweat it out with the patients who are very sick and (provide) excellent care.”

Khonsari also made available to a reporter a “cardiac surgery annual report” for 1986, which analyzes in detail the hospital’s deaths and complications following heart surgery as well as similar problems following angioplasty procedures. No other hospital contacted by The Times provided such detailed performance information.

Dameron Hospital in Stockton had the highest mortality rate for heart bypass cases among all California hospitals in 1986, 17.6% or 12 deaths following 68 surgeries, according to the state computer tapes. All the deaths occurred after July, when the hospital first began to offer bypass surgery, according to Mary Armstrong, an assistant administrator. In a telephone interview, she said a 1988 review of patient records showed only 66 cases and nine deaths, or a 13.6% death rate.

The hospital’s death rate is “considered acceptable” by Medicare and MediCal, Armstrong said. “Given the classification (severity of illness) of the patients, we have no problem here. . . . There are no issues related to quality of care.”

Armstrong added that the surgeons at Dameron were the same as those at nearby St. Joseph’s Medical Center of Stockton. During the last half of 1986, St. Joseph’s had 9 deaths after 128 surgeries, or a 7% mortality rate, according to the state computer tapes.

In Southern California, Valley Presbyterian Hospital in Van Nuys had the highest death rate, 15.3%, or 13 deaths after 85 surgeries. “There is no denying that 1986 was a bad year for our open heart surgery program in reference to mortality rates,” hospital spokeswoman Ann Kirkpatrick said in a written statement. “In fact, 1986 was our worst year to date.”

Death Rate Defended

Kirkpatrick said many of the deaths involved patients in an “extreme high-risk category” and that Valley Presbyterian was now “more selective” in operating on such patients. For 1987 the hospital had a 7% death rate for bypass surgery and for the first six months of 1988, one death in 56 cases, she said.

Dr. Norman L. Whitman, chief of surgery at Valley Presbyterian in 1986 and 1987, said the hospital’s heart surgeons “had a run of difficult cases” during an “unusual year” but were now “doing great.” He added: “You have competent people doing surgery which is legitimate surgery. . . . I don’t think that there was any fundamental flaw there.”

The other Southern California hospitals with high death rates were St. Mary Medical Center in Long Beach, Daniel Freeman Memorial Hospital, St. Joseph Medical Center in Burbank, Torrance Memorial Hospital Medical Center and Long Beach Community Hospital. In interviews, officials of all these hospitals maintained that their high death rates did not reflect quality-of-care problems.

The Times analysis also found:

- The number of bypass surgeries in California increased about 9% from 16,846 to 18,315 between 1985 and 1986 and the number of hospitals with more than 10 surgeries increased from 82 to 89.

- The statewide bypass surgery death rate increased from 4.6% to 5.3%. The reasons for the higher death rate are uncertain. It may reflect a larger number of patients undergoing repeat bypass surgery and a larger percentage of operations on sicker patients.

- Stanford University Medical Center, world renowned as a heart transplant center, had a 9% bypass surgery mortality rate in 1986. By comparison, the medical center’s mortality rate between 1983 and 1985 averaged 4.5%. When informed of this increase, Dr. Philip E. Oyer, a professor of cardiovascular surgery, said a detailed review would probably be conducted. The higher death rate at Stanford “reflects the pipeline of higher-risk patients being referred here,” Oyer said.

- St. Vincent Medical Center in Los Angeles was the busiest bypass surgery in the state in 1986, performing 770 bypass surgeries with a 3.8% mortality rate. In 1987, St. Vincent surgeons performed 530 bypass operations and had a 4.3% mortality rate, according to a hospital spokeswoman.

The decrease in volume occurred after Dr. Jerry Kay, considered one of the most successful and talented heart surgeons in the West, and his team of 60 nurses, technicians and doctors, moved to the nearby Hospital of the Good Samaritan in October, 1986.

In 1987, Hospital of the Good Samaritan had 747 bypass surgeries, with a 4.1% mortality rate, according to hospital statistics. By comparison, the hospital had 305 surgeries with a 5.2% mortality rate in 1986, according to the state computer tapes.

- Six hospitals had median total charges for bypass surgery of more than $40,000 and 11 hospitals had median charges of $21,000 or less.

“Total hospital charges are a reasonably good reflection of the relative costs of care at two hospitals,” Showstack said. He cautioned, however, that this statistic should not be used to estimate a hospital’s actual costs for a hospitalization or what a facility is reimbursed by insurance carriers.

“A hospital doing 300 bypass surgeries a year, with appropriate economies of scale and a normal proportion of high-risk patients, could probably charge between $15,000 and $20,000 case and still make a profit,” Showstack said.

- Cedars-Sinai Medical Center in Los Angeles was the only hospital in the state to have a low overall mortality rate for bypass surgery but a high percentage of prolonged hospitalizations and high median hospital charges--nearly $41,000 a year.

Dr. James Klinenberg, vice president for professional services at Cedars-Sinai, said that the hospital’s length of stay for bypass patients was about three days longer than the statewide average and that its daily hospital charges were about 12% higher than average. Because the Medicare program and most private insurers reimburse Cedars at the same rate as nearby facilities, the hospital, not the patient, ends up “eating the difference” in most cases, he said.

The longer lengths of stay and higher charges “may not be bad,” Klinenberg said. He suggested that the hospital’s “better survival statistics” may be related to “keeping patients longer and doing more things for them.”

Three experts from the Institute for Health Policy Studies at UC San Francisco were hired by The Times for assistance in analyzing the data and interpreting the results. They are: Jonathan A. Showstack, associate professor of health policy, Harold S. Luft, professor of health economics, and Deborah W. Garnick, senior research associate.

Times systems analyst Detlef D. Matthies did the computer programming for this story. Times researcher Tracy Thomas assisted in preparing the story.

HEART BYPASS SURGERY IN CALIFORNIA IN 1986

MORTALITY RATES

These California hospitals had significantly high or low death rates for adult patients undergoing heart bypass surgery in 1986, according to a Times computer analysis of data compiled by the Office of Statewide Health Planning and Development. High Mortality Rates

Total Deaths Hospital Patients By % STATEWIDE 18,315 5.3% Dameron Hospital, Stockton 68 17.6% Valley Presbyterian Hospital, Van Nuys 85 15.3% *Santa Clara Valley Medical Center, San Jose 53 13.2% St. Mary Medical Center, Long Beach 118 11.9% *Daniel Freeman Mem. Hosp., Inglewood 139 11.5% *Hollywood Presbyterian Medical Center 44 11.4% St. Joseph Medical Center, Burbank 154 11.0% Torrance Memorial Hospital Medical Center 163 11.0% N. T. Enloe Memorial Hospital, Chico 146 10.9% Long Beach Community Hospital 56 10.7% *UC Medical Center, San Francisco 179 9.5% Stanford University Hospital 378 9.0% Fresno Community Hospital 207 8.7% St. Agnes Hospital, Fresno 457 7.2%

Hospitals that also had high mortality rates in 1985 are in bold type with asterisk. Low Mortality Rates

Total Deaths Hospital Patients By % *Kaiser Foundation Hospital, San Francisco 383 1.0% El Camino Hospital, Mountain View 171 1.2% *Kaiser Foundation Hospital, Los Angeles 394 1.3% Eisenhower Medical Center, Rancho Mirage 293 1.7% *Alvarado Community Hospital, San Diego 362 2.2% *Sutter Memorial Hospital, Sacramento 719 2.6% *Cedars-Sinai Medical Center, Los Angeles 415 3.4% St. Vincent Medical Center, Los Angeles 770 3.8%

Hospitals that also had low mortality rates in 1985 are in bold type with asterisk .

PROLONGED HOSPITALIZATIONS

The median post-operative hospitalization for bypass surgery patients was 7.5 days. These hospitals had an unusually high number of survivors with post-operative stays of 15 days or more, which suggests a high complication rate.

Prolonged Total Hosp. Hospital Survivors By % STATEWIDE 17,342 10.7% Harbor UCLA Medical Center 53 41.5% *Daniel Freeman Mem. Hosp., Inglewood 123 29.3% LA County--USC Medical Center 65 27.7% Cedars-Sinai Medical Center, Los Angeles 401 23.4% *Hollywood Presbyterian Med. Ctr., Los Angeles 39 23.1% Pacific Presbyterian Med. Ctr., San Francisco 149 22.1% Mt. Zion Medical Center, San Francisco 51 21.6% Brotman Medical Center, Culver City 142 19.7% *Santa Clara Valley Medical Center, San Jose 46 19.6% Lancaster Community Hospital 93 19.4% John Muir Memorial Hospital, Walnut Creek 47 19.1% Seton Medical Center, Daly City 568 18.7% *UC Medical Center, San Francisco 164 18.3%

Hospitals that also had high mortality rates are in bold type with asterisk .

CHARGES

The median total hospital charge for bypass surgery patients was $27,700. These hospitals had median total charges of $40,000 or more. Charges for patients who died are not included.

Total Median Hospital Survivors Charges *Hollywood Presbyterian Medical Center 39 $58,578 UC Irvine Medical Center, Orange 21 $43,251 Mount Zion Hospital, San Francisco 51 $42,463 Cedars-Sinai Medical Center, Los Angeles 401 $40,860 *Daniel Freeman Mem. Hosp., Inglewood 123 $40,193 White Memorial Medical Center, Los Angeles 70 $40,085

Hospitals that also had high mortality rates are in bold type with asterisk. These hospitals had median total charges of $21,000 or less.

Total Median Hospital Survivors Charges St. Vincent Medical Center, Los Angeles 741 $16,321 St. Bernardine Hospital, San Bernardino 390 $17,110 Goleta Valley Community Hospital, Santa Barbara 57 $17,907 *El Camino Hospital, Mountain View 169 $18,466 Hospital of the Good Samaritan, Los Angeles 289 $19,739 Santa Barbara Cottage Hospital 199 $19,877 Comm. Mem. Hosp. of S. Buenaventura 98 $20,115 LA County-USC Medical Center 65 $20,438 Sequoia Hospital, Redwood City 353 $20,575 *Eisenhower Medical Center, Rancho Mirage 288 $20,777 St Joseph’s Hospital, Stockton 236 $20,871

Hospitals that also had low mortality rates are in bold type with asterisk . VOLUME

As a group, California hospitals that had more than 200 bypass surgeries in 1986 had significantly lower death rates than those that had fewer surgeries. 35 hospitals had more than 200 bypass surgeries, including 10 Southern California hospitals with more than 300 surgeries.

Total Hospital Surgeries St. Vincent Medical Center, Los Angeles 874 Sharp Memorial Hospital, San Diego 714 Cedars-Sinai Medical Center, Los Angeles 481 Kaiser Foundation Hospital, Los Angeles 432 St. Bernardine Hospital, San Bernardino 432 Scripps Memorial Hospital, La Jolla 413 Alvarado Community Hospital, San Diego 384 Memorial Medical Center of Long Beach 374 Hospital of the Good Samaritan, Los Angeles 329 Eisenhower Medical Center, Rancho Mirage 317