Third of Hospitals Perform Too Few Heart Operations

More than a third of California’s heart surgery hospitals in 1987 did not meet the minimum number of open-heart operations recommended to maintain the skills of their doctors and nurses, according to a Times analysis of data covering nearly all such operations in the state.

The problem of low-volume heart surgery hospitals is particularly acute in Los Angeles County, where many such facilities are concentrated. About half of the hospitals in Los Angeles County that offer heart surgery were below the 150-cases-a-year minimum recommended by the state Department of Health Services and the American College of Surgeons.

24 Above 350 Surgeries

By contrast, 24 of California’s approximately 100 heart surgery hospitals reported more than 350 heart surgeries, including six in Los Angeles County, three in San Diego County and two in San Bernardino County.

The Times analysis also revealed that many hospitals reported small numbers of cases for other specialized heart services, such as cardiac catheterizations and coronary angioplasties.

The duplication of cardiac services within communities illustrates how the often fierce competition among hospitals seeking to develop prestigious programs may lower the number of procedures at each hospital and thereby jeopardize the quality of medical care, according to health policy experts and leading heart surgeons.

This so-called “medical arms race” may also result in more instances where patients undergo unnecessary or inappropriate heart surgeries or angioplasties.

‘Case-by-Case Basis’

Dr. Patricia Chase, a medical consultant to the licensing and certification division of the state Department of Health Services, said: “The statistics are very supportive of the fact that something needs to be done. . . . We are literally going to have to go in on a case-by-case basis and then decide about any potential rescinding of licenses.”

Chase and Teresa Hawkes, a deputy director of the department who is in charge of the licensing and services division, acknowledged in interviews that the state has apparently never attempted to enforce the section of its own regulations that calls for the 150 heart surgeries a year, an average of three cases a week, minimum. This regulation has been on the books since 1975.

But last week Hawkes, after an inquiry from The Times, said the Department of Health Services plans to conduct a “concerted” statewide review of heart surgery programs beginning early next year. She said the review was triggered by articles in The Times earlier this year that identified low-volume and high-mortality heart surgery hospitals.

Hawkes said the review will include detailed quality audits of individual facilities and a comprehensive reexamination of all state regulations for heart-care services. The review is to start with the hospitals with the “lowest volumes and highest mortalities” and later is to be expanded to include other institutions.

Over the last decade, numerous studies have shown that, on average, hospitals with large numbers of heart surgeries are likely to have proportionately fewer deaths, fewer complications and lower costs than those where small numbers of surgeries are performed, according to James C. Robinson, an assistant professor of health economics at the UC Berkeley School of Public Health, and to Jonathan Showstack of the Institute for Health Policy Studies at UC San Francisco.

This is because surgeons, other physicians and nurses can specialize in the care of such patients, which usually results in more skilled and efficient care.

“We have made heart surgery a drugstore, cottage type of industry,” said Dr. Paul A. Ebert, an internationally known heart specialist who is the director of the American College of Surgeons. “I don’t believe that is the way it should go. I would be happy if the minimum (at a hospital) was 150 cases, and everybody did at least 250 surgeries.”

Dr. Sidney M. Wolfe of the Washington-based Public Citizen Health Research Group said low-volume heart surgery hospitals should be closed unless it is clear that they have “very low morbidity and mortality.” Letting them remain in operation is “wasting money and killing people,” he said.

Other health policy experts said hospitals should be required to release more detailed performance statistics than are now made public so patients and their physicians could more easily identify the leading cardiac-care hospitals. The federal Medicare program and large insurers such as Blue Cross and Blue Shield are also considering using such data to direct patients to high-quality facilities.

Use Expands Dramatically

Over the last two decades, heart surgery has emerged as one of medicine’s most potent life-saving technologies. Operations have become safer and their use has expanded dramatically. At the same time, comprehensive data has been gathered about the risks and benefits of the surgery and statistical techniques have been developed to determine which hospitals have the best results in comparable groups of patients.

During an open-heart operation, the heartbeat is stopped and the patient is kept alive on a “heart-lung machine.” In adults, the most common procedures are heart valve replacements and coronary artery bypass surgery, in which surgeons restore an adequate blood supply to diseased heart tissue by grafting blood vessels from elsewhere in the body around blockages in the arteries supplying blood to the heart.

To operate a heart surgery program in California, a hospital must obtain a special permit from the state Department of Health Services. A special permit is granted only to hospitals that meet specific requirements in terms of staffing, training, facilities and quality control.

In addition, Department of Health Services regulations state that “an adequate service base shall support the provision of these services.” The “recommended minimums,” set forth in Title 22 of the California Administrative Code, are 150 open-heart surgeries and 260 cardiac catheterizations a year.

The American College of Surgeons made a similar recommendation in its “Guidelines for Minimal Standards in Cardiac Surgery.” These 1984 guidelines call the performance of at least 150 open-heart operations per year by an independent surgical team “desirable” to maintain an “adequate standard of practice.”

The American College of Surgeons acknowledged that the surgical team might operate in more than one hospital but noted that “effective use of equipment and support personnel generally requires at least 150 cases per year in each hospital.” For pediatric cases, the minimum was set at 75 cases per year. (State statistics only indicate how many heart surgeries were performed at each hospital, not how many were performed by each surgical team.)

‘Proficient and Competent’

Three cases a week “would be a minimum to keep the team proficient and competent in the various problems that might come along,” said Dr. Dwight C. McGoon, a professor of surgery at the Mayo Clinic who served as editor of the Journal of Thoracic and Cardiovascular Surgery between 1977 and 1987. McGoon said surgeons, like athletes, artists and pianists, also had to “keep at it in order to remain at the peak of their competence.”

The Times prepared its analysis of heart surgery volume by reviewing data contained in the “Annual Report of Hospitals, 1987,” which is published by the office of statewide health planning and development. The document contains summary statistics on such topics as admissions and surgeries for most hospitals in the state. The statistics are based on reports compiled by each hospital. Veterans Administration and military hospitals are not included.

Throughout the state, 37 heart surgery hospitals reported fewer than 150 heart surgeries in 1987, The Times found. In Los Angeles County, 19 of the 37 heart surgery hospitals reported fewer than 150 heart surgeries. An additional nine institutions had between 151 and 250 cases.

The situation in Los Angeles--considered one of the most competitive health-care markets in the United States--appears to have changed little over the last five years. In 1983, 19 of the 37 Los Angeles hospitals offering heart surgery had fewer than 150 heart bypass cases, according to a study by Harold S. Luft and colleagues from UC San Francisco published in the fall, 1987, issue of the Journal of Health Politics, Policy and Law.

The UC San Francisco study suggested that the “substantial duplication” of services in Los Angeles was “costly and undesirable on clinical grounds.” It pointed out that “none of the hospitals with under 150 patients is more than 7 miles from a hospital with over 150 patients per year.”

In Orange County, two of 10 hospitals with heart surgery programs had fewer than 150 surgeries in 1987, and an additional five had between 151 and 250 cases, The Times found. In San Diego County, three of 10 hospitals had fewer than 150 surgeries and an additional four had between 151 and 250 cases.

21% Increase

The analysis also found that the number of California hospitals offering heart surgery increased 21% between 1985 and 1987, from 85 to 103. By contrast, the number of heart surgeries performed in the state increased by only 7%.

In a related development, the number of Southern California hospitals offering heart transplants has also increased dramatically--from two to six. Loma Linda University Medical Center and UCLA Medical Center have had longstanding heart-transplant programs. Within the last year, however, programs have been started at Cedars-Sinai Medical Center in Los Angeles, Hoag Memorial Hospital Presbyterian in Newport Beach, St. Vincent Medical Center in Los Angeles and UC Irvine Medical Center in Orange.

Roger Smith, the administrator of the Regional Organ Procurement Agency of Southern California, said the region probably does not need six heart-transplant centers at this time.

A key reason, Smith said, is that only about 60 hearts suitable for transplant are becoming available in the region each year. As with open-heart surgery, studies have shown that busy heart-transplant centers have better results than hospitals which perform only a few transplants each year. In 1987, UCLA alone performed 39 heart transplants and in 1988, 26 heart transplants. It has an average of 15 patients on its waiting list at any time, Smith said.

The sharp increase in the number of heart surgery hospitals coincided with the end of California’s so-called “certificate of need” program, which was phased out during the Deukmejian Administration and suspended at the end of 1986.

This controversial program required hospitals to both meet state licensing requirements for programs such as heart surgery and to prove at public hearings that the new services were actually “needed.”

For example, a hospital might have had to show that a new heart surgery program would reach about 300 surgeries a year within three years and that existing programs in nearby communities were already above the 150-case-a-year minimum, according to Henry Zaretsky, a Sacramento-based health-care consultant who served as the director of the office of statewide health planning and development between 1978 and 1981.

But the “certificate of need” program was criticized for being cumbersome and for stifling competition. In addition, some said it might harm quality by, for example, preventing a superior hospital from introducing a new program that was only being offered by an inferior hospital.

After the “certificate of need” era, Chase and Hawkes of the Department of Health Services told The Times that hospitals seeking to open heart surgery programs are being asked to prove that they have “an adequate service base,” including a projected minimum number of surgeries.

This information was disputed by Ann Klein, executive director of AMI Community Hospital of Santa Cruz, who said Hawkes had told her within the last several weeks that the state was “not going to enforce” this regulation.

The hospital, which opened a heart surgery unit last year, is asking the state to block nearby Dominican Santa Cruz Hospital from opening a similar unit on the grounds that the community is too small to support two such facilities. It has filed a lawsuit seeking to force the Department of Health Services to enforce its regulations. Health policy experts say the controversy has emerged as a key test case of state policy.

To support her view, Klein supplied The Times with a copy of a Dec. 5 letter written by Hawkes that acknowledged that 150 heart surgeries was the minimum annual volume that “might be expected to maintain the skills of the staff so that quality is optimized.” But the letter added that a heart surgery permit “shall not be denied solely on the basis that a facility fails to project the recommended minimum” number of cases.

The Times analysis also found:

The state’s 37 low-volume heart surgery hospitals include nine that first performed open-heart surgery in 1987. Additional statistics covering part of 1988 were obtained from each of these hospitals. Only one, Downey Community Hospital, reported more than 150 surgeries during the first year its heart surgery unit was in operation. Between September, 1987, and September, 1988, Downey Community Hospital said it had 520 catheterizations, 58 angioplasties and 170 open-heart surgeries.

The Hospital of the Good Samaritan in Los Angeles was the busiest heart surgery hospital in the state in 1987, reporting 1,081 operations, or about 20 cases a week. Ten other hospitals reported more than 600 surgeries. Medical experts caution, however, that there is no evidence that the highest-volume facilities are necessarily superior. “There is a point where the volume may be so great that the individual patient may not get the individual attention that would be best,” said McGoon of the Mayo Clinic.

Fifteen of the 80 Southern California hospitals offering adult heart catheterizations reported fewer than the minimum of 260 catheterizations recommended in state regulations. An additional two had fewer than the 300-case minimum recommended for each catheterization laboratory by the American Heart Assn. In contrast, 29 Southern California hospitals reported more than 1,000 catheterizations. Catheterization is a technique used by cardiologists to diagnose heart diseases. A fine tube called a catheter is passed into the heart through a large blood vessel in the arm or leg. Dye can be injected through the tube to diagnose, for example, blockages of the heart arteries or heart valve defects.

Thirty-five of the 62 Southern California hospitals offering coronary angioplasty reported fewer than 150 cases, including 25 with fewer than 100 cases. In contrast, 13 Southern California hospitals reported more than 300 angioplasties. Angioplasty is an increasingly used alternative to coronary artery bypass surgery. It is performed by cardiologists who are trained in internal medicine, not in surgery. During an angioplasty, clogged heart arteries are opened with a balloon-tipped hollow tube inserted through the skin and threaded through a groin vein to the heart. The state, the American Heart Assn. and the American College of Cardiology have not set standards for the minimum number of coronary angioplasties.

Times researcher Tracy Thomas assisted in preparing this story.

DECIDING ABOUT HEART SURGERY

Here are some topics that patients for whom heart surgery is recommended and their families may wish to discuss with their physician. The list was compiled from interviews with cardiologists, cardiac surgeons and health policy researchers.

Is the surgery necessary? Have all the potentially beneficial medications been tried? Is angioplasty, in which clogged heart arteries are opened with a balloon-tipped hollow tube inserted through the skin and threaded through a vein to the heart, a possible alternative to surgery?

Should a second opinion from an independent cardiologist or cardiac surgeon be obtained?

What is the performance record of the recommended surgeons and the recommended hospital? How many operations are performed each year? What are the surgeons’ and the hospital’s mortality rates for similar patients? Do other nearby hospitals have better performance records for similar patients? Is the hospital a referral center that routinely handles difficult cases?

Do the surgeons spend all their time at the one hospital or operate at several different hospitals? If an emergency develops, are the surgeons or an equally skilled colleague available around the clock?

Does the hospital have comprehensive post-operative care facilities, such as a cardiac surgery intensive-care unit, specialized nurses and 24-hour coverage by senior physicians? Does the hospital have strong departments of cardiology and anesthesia?

1987 HEART SURGERIES AND HEART CATHETERIZATIONS IN CALIFORNIA

These are the number of heart catheterizations, coronary angioplasties and open-heart surgeries in adults in 1987 at California hospitals performing heart surgeries, according to a Times analysis of data compiled by the Office of Statewide Health Planning and Development. To maintain an adequate standard of practice, the American College of Surgeons as well as state Department of Health Services regulations recommend that at least 150 open-heart operations be performed annually at each hospital that offers heart surgery. State regulations also recommend that at least 260 heart catheterizations be performed annually in hospitals that offer this procedure. Neither the state nor the American College of Cardiology have set standards for the minimum number of coronary angioplasties.

Catheter- Angio- izations plasties STATEWIDE 130,800 21,500 LOS ANGELES COUNTY 41,000 6,500 Less than 150 Heart Surgeries Methodist Hosp of S. California, Arcadia** 180 1 Centinela Hospital Med Center, Inglewood* 381 7 Humana Hospital West Hills, Canoga Park** 95 11 Hollywood Presbyterian Med Center* 268 0 Downey Community Hospital** 121 9 Santa Monica Hospital Medical Center* 533 121 St. Francis Med Center, Lynwood 567 62 White Memorial Med Center, Los Angeles* 833 101 Granada Hills Community HospitaL* 675 152 Beverly Hospital, Montebello* 513 32 Glendale Memorial Hosp & Health Center* 434 35 Valley Presbyterian Hospital, Van Nuys* 778 94 St. Mary Medical Center, Long Beach* 660 69 Garfield Medical Center, Monterey Park* 580 69 St. John’s Hospital, Santa Monica* 1,324 121 Glendale Adventist Medical Center* 1,051 243 Lancaster Community Hospital* 837 147 Brotman Medical Center, Culver City 548 64 Harbor/UCLA Medical Center, Torrance* 505 75

More than 150 Heart Surgeries

Hosp of the Good Samaritan, Los Angeles 2,754 388 St. Vincent Medical Center, Los Angeles 1,222 297 Kaiser Foundation Hospital, Los Angeles 2,945 347 Cedars-Sinai Medical Center, Los Angeles 2,323 401 Memorial Medical Center, Long Beach 2,068 268 Pomona Valley Community Hospital* 1,401 171 Little Company of Mary Hospital, Torrance 1,527 379 UCLA Medical Center, Westwood 891 99 Huntington Memorial Hospital, Pasadena 1,490 402 Inter-Community Medical Center, Covina 940 142 Torrance Memorial Hosp Med Center 2,175 384 Daniel Freeman Memorial Hosp, Inglewood* 2,197 542 Northridge Hospital Medical Center 922 240 Presbyterian Intercommunity Hosp., Whittier 1,145 198 Long Beach Community Hospital* 622 91 Encino Hospital 690 139 County-USC Medical Center, Los Angeles* 1,186 61 St. Joseph Medical Center, Burbank 1,425 361

SOUTHERN CALIFORNIA 30,000 5,000

Less than 150 Heart Surgeries

Mission Hosp Reg Med Cent, Mission Viejo** 330 16 Community Hospital of Chula Vista** 209 0 Palomar Medical Center, Escondido** 549 19 UC Irvine Medical Center, Orange* 348 52 Comm Mem of San Buenaventura, Ventura* 628 98 Desert Hospital, Palm Springs* 812 38 St. John’s Regional Med Center, Oxnard* 500 83 Green Hosp of Scripps Clinic, La Jolla** 571 16

More than 150 Heart Surgeries

Sharp Memorial Hospital, San Diego 2,261 561 St. Bernardine Med Cent, San Bernardino 1,701 419 Scripps Memorial Hospital, La Jolla 1,742 572 Alvarado Hosp Med Center, San Diego 1,208 94 Loma Linda University Medical Center 2,203 224 Mercy Hosp and Med Center, San Diego 1,602 232 Eisenhower Medical Center, Rancho Mirage 839 120 Anaheim Memorial Hospital 1,348 214 St. Joseph Hospital, Orange 1,181 227 St. Jude Hospital & Rehab Cent, Fullerton 1,550 281 Western Medical Center, Anaheim 1,525 422 Tri-City Medical Center, Oceanside* 647 0 Hoag Mem. Hosp. Presby, Newport Beach* 1,053 144 Fountain Valley Regional Hosp Med Cent* 1,166 265 Riverside Comm. Hospital 851 66 Saddleback Comm. Hosp, Laguna Hills* 802 118 Western Medical Center, Santa Ana 1,053 144 Grossmont District Hospital, La Mesa* 689 73 UC San Diego Medical Center, La Jolla 850 153 Los Robles Reg Med Center, Thous. Oaks 1,683 342

OTHER CALIFORNIA HOSPITALS

Less than 150 Heart Surgeries Catheter- Angio- izations plasties AMI Community Hospital of Santa Cruz** 107 6 Bakersfield Memorial Hospital** 175 11 Mt. Zion Hospital, San Francisco* 383 102 Santa Clara Vy. Med. Ctr., San Jose* 382 67 Goleta Valley Comm. Hosp., S. Barbara* 450 63 Washington Hospital, Fremont* 982 180 San Jose Medical Center* 1,020 311 John Muir Med. Center, Walnut Creek* 784 180

More than 350 Heart Surgeries*

Mercy Hospital of Sacramento 2,697 511 Sutter Memorial Hospital, Sacramento 2,642 547 Doctors Medical Center, Modesto 3,093 437 Stanford University Medical Center 1,179 175 Seton Medical Center, Daly City 2,812 1,127 Kaiser Foundation Hosp, San Francisco 1,566 1 St. Agnes Hospital, Fresno 2672 317 Sequoia Hospital, Redwood City 2,095 557 Good Samaritan Hospital, San Jose 1,899 479 Mt. Diablo Hosp Med Center, Concord 1,745 314 Samuel Merritt Hospital, Oakland 2,265 816 St. Helena Hosp & Health Cent, Deer Park 1,472 374 San Joaquin Commty. Hosp., Bakersfield 1,914 438

Open-Heart Surgeries STATEWIDE 25,500 LOS ANGELES COUNTY 7,800

Less than 150 Heart Surgeries

Methodist Hosp of S. California, Arcadia** 1 Centinela Hospital Med Center, Inglewood* 5 Humana Hospital West Hills, Canoga Park** 5 Hollywood Presbyterian Med Center* 31 Downey Community Hospital** 42 Santa Monica Hospital Medical Center* 46 St. Francis Med Center, Lynwood 59 White Memorial Med Center, Los Angeles* 62 Granada Hills Community HospitaL* 72 Beverly Hospital, Montebello* 85 Glendale Memorial Hosp & Health Center* 94 Valley Presbyterian Hospital, Van Nuys* 95 St. Mary Medical Center, Long Beach* 105 Garfield Medical Center, Monterey Park* 107 St. John’s Hospital, Santa Monica* 116 Glendale Adventist Medical Center* 126 Lancaster Community Hospital* 128 Brotman Medical Center, Culver City 133 Harbor/UCLA Medical Center, Torrance* 145

More than 150 Heart Surgeries

Hosp of the Good Samaritan, Los Angeles 1,081 St. Vincent Medical Center, Los Angeles 642 Kaiser Foundation Hospital, Los Angeles 606 Cedars-Sinai Medical Center, Los Angeles 601 Memorial Medical Center, Long Beach 474 Pomona Valley Community Hospital* 353 Little Company of Mary Hospital, Torrance 328 UCLA Medical Center, Westwood 283 Huntington Memorial Hospital, Pasadena 265 Inter-Community Medical Center, Covina 232 Torrance Memorial Hosp Med Center 226 Daniel Freeman Memorial Hosp, Inglewood* 211 Northridge Hospital Medical Center 202 Presbyterian Intercommunity Hosp., Whittier 200 Long Beach Community Hospital* 187 Encino Hospital 174 County-USC Medical Center, Los Angeles* 156 St. Joseph Medical Center, Burbank 152

SOUTHERN CALIFORNIA 6,500

Less than 150 Heart Surgeries

Mission Hosp Reg Med Cent, Mission Viejo** 26 Community Hospital of Chula Vista** 38 Palomar Medical Center, Escondido** 44 UC Irvine Medical Center, Orange* 57 Comm Mem of San Buenaventura, Ventura* 97 Desert Hospital, Palm Springs* 105 St. John’s Regional Med Center, Oxnard* 129 Green Hosp of Scripps Clinic, La Jolla** 142

More than 150 Heart Surgeries

Sharp Memorial Hospital, San Diego 793 St. Bernardine Med Cent, San Bernardino 471 Scripps Memorial Hospital, La Jolla 434 Alvarado Hosp Med Center, San Diego 398 Loma Linda University Medical Center 370 Mercy Hosp and Med Center, San Diego 338 Eisenhower Medical Center, Rancho Mirage 335 Anaheim Memorial Hospital 332 St. Joseph Hospital, Orange 319 St. Jude Hospital & Rehab Cent, Fullerton 273 Western Medical Center, Anaheim 208 Tri-City Medical Center, Oceanside* 202 Hoag Mem. Hosp. Presby, Newport Beach* 195 Fountain Valley Regional Hosp Med Cent* 178 Riverside Comm. Hospital 175 Saddleback Comm. Hosp, Laguna Hills* 171 Western Medical Center, Santa Ana 170 Grossmont District Hospital, La Mesa* 168 UC San Diego Medical Center, La Jolla 168 Los Robles Reg Med Center, Thous. Oaks 160

OTHER CALIFORNIA HOSPITALS

Less than 150 Heart Surgeries Open-Heart Surgeries AMI Community Hospital of Santa Cruz** 7 Bakersfield Memorial Hospital** 24 Mt. Zion Hospital, San Francisco* 53 Santa Clara Vy. Med. Ctr., San Jose* 76 Goleta Valley Comm. Hosp., S. Barbara* 85 Washington Hospital, Fremont* 86 San Jose Medical Center* 118 John Muir Med. Center, Walnut Creek* 141

More than 350 Heart Surgeries*

Mercy Hospital of Sacramento 961 Sutter Memorial Hospital, Sacramento 943 Doctors Medical Center, Modesto 655 Stanford University Medical Center 649 Seton Medical Center, Daly City 644 Kaiser Foundation Hosp, San Francisco 612 St. Agnes Hospital, Fresno 541 Sequoia Hospital, Redwood City 539 Good Samaritan Hospital, San Jose 454 Mt. Diablo Hosp Med Center, Concord 422 Samuel Merritt Hospital, Oakland 419 St. Helena Hosp & Health Cent, Deer Park 401 San Joaquin Commty. Hosp., Bakersfield 378

Angioplasties are included in the total number of catheterizations. * Hospitals that had less than 150 open-heart surgeries in 1986. ** Hospitals that first performed open-heart surgery in 1987.

ADULT HEART CATHETERIZATIONS

In 1987, 15 of the 80 Southern California hospitals offering adult heart catheterizations had fewer cases than the recommended minimum of 260, including 11 of the 15 hospitals with no heart surgeries.

HOSPITAL CATHETERIZATIONS Valley Hospital Med. Center, Van Nuys 56 Nu-Med Regional Med. Ctr., Canoga Park 66 City of Hope Nat’l Medical Center, Duarte* 90 Martin Luther King Jr-Drew Med. Center, Los Angeles 99 Charter Suburban Hospital, Paramount 100 Memorial Hospital of Gardena* 101 AMI Tarzana Regional Medical Ctr. 116 Dominguez Medical Center, Long Beach 150 Holy Cross Hospital, Mission Hills* 228 Scripps Memorial Hospital, Encinitas 241 Kaiser Foundation Hospital, Anaheim* 251 San Gabriel Valley Medical Center 266 San Pedro Peninsula Hospital* 334 San Bernardino County Medical Center 350 Doctors Hospital of Lakewood 420

* Hospitals that had less than 260 catheterizations in 1986. ** Hospital that resumed heart catheterizations in 1987.

PEDIATRIC HEART SURGERY

About 1,500 pediatric open-heart surgeries were performed in California in 1987. About two-thirds of the operations were performed in these seven hospitals; each reported more than 75 surgeries.

Hospital Catheterizations Surgeries UCLA Medical Center, Westwood 346 244 UC Medical Center, San Francisco 370 184 St. Vincent Med Center, Los Angeles 149 144 Childrens Hospital of Los Angeles 333 124 Loma Linda University Medical Center 113 102 Stanford University Medical Center 123 98 Sharp Memorial Hospital, San Diego 168 90

* Hospitals outside Southern California that performed between 150 and 350 heart surgeries have been omitted for lack of space. HEART SURGERIES AND CATHETERIZATIONS CARDIOVASCULAR SURGERIES

The number of California hospitals offering open-heart surgery increased by 26% between 1983 and 1987, while the number of surgeries has increased by only 10%. Medical experts say that the quality of medical care may suffer when too many hospitals offer this specialized service.

Number of Number of Hospitals Surgeries 1983 82 24,698 1984 84 23,383 1985 85 23,329 1986 94 25,452 1987 103 27,246

CARDIAC CATHETERIZATIONS

The number of hospitals offering cardiac catheterization increased by 28% over the five-year period while the number of catheterizations was up 79%.

Number of Number of Hospitals Catheterizations 1983 110 72,957 1984 114 84,043 1985 117 93,899 1986 128 111,057 1987 141 130,871

Source: Office of Statewide Health Planning and Development, Annual Report of Hospitals, 1987