Infant Death Rate Highest at King Hospital

Martin Luther King Jr./Drew Medical Center in Los Angeles had the highest standardized death rate for newborn babies of all California hospitals in 1986, according to a sophisticated analysis of perinatal death-rate data by researchers at UC Santa Barbara, which is being made public today.

King and three other Southern California hospitals with more than 600 deliveries had significantly higher-than-expected perinatal death rates when compared to the statewide average, the report said. The other hospitals were County-USC Medical Center and California Medical Center in Los Angeles, and Humana Hospital-West Anaheim in Anaheim.

Officials at both King and County-USC acknowledged the accuracy of the figures, but said their facilities were overtaxed and underfunded in the areas of obstetrics and neonatal care.

A spokesman for California Medical Center said the death rate reflected its high-risk patient population and an official at Humana Hospital-West Anaheim described the figure as a statistical abnormality.

Eight Southern California hospitals, including AMI Tarzana Regional Medical Center, the U.S. Naval Hospital in San Diego, Riverside General Hospital and White Memorial Medical Center in Los Angles, had significantly low standardized perinatal death rates in 1986, the most recent year for which complete information is available.

The UC Santa Barbara “Maternal and Child Health Data Base” is considered by many health care experts to be the best perinatal mortality information system in the United States. The data base is not an all-encompassing index that can be used to rank the overall performance hospitals in newborn care, according to Ronald L. Williams, the UC Santa Barbara health policy researcher who devised the measure. But for the most part, a lower-than-average adjusted death rate indicates better-than-average care.

Release of the analysis is likely to continue the debate about the shortcomings of maternity and neonatal care at King and County-USC. The two large public hospitals deliver more babies than any other hospitals in the state and care for a disproportionate number of high-risk mothers and newborns. For more than a decade, they have had consistently high perinatal mortality rates.

“It seems clear that (County-USC and King) are having too many births for their facilities,” said Frank P. Rust of UC Santa Barbara’s Community and Organization Research Institute, the project coordinator for the report.

“High-risk patients need the best care that medical science can provide,” the UC Santa Barbara researchers said in written comments on King’s data that were made available to The Times. “It is unclear if these kinds of services can be provided in what appears to be an overcrowded and understaffed facility.”

They added: “We believe that of the babies born at King/Drew that die, most would have died even had they been born at another hospital. However, our data also suggest that some of the babies born at King/Drew that did die would not have died if born in a hospital providing more effective perinatal care.”

Obstetrical and newborn care at county hospitals “has been of major concern to us,” said Robert Gates, the director of the Los Angeles County Department of Health Services. In recent years, the department has been financially responsible for about 25% of all births in the county, a percentage that is likely to continue to increase.

Gates said the county wanted to “relieve the pressure on our own facilities” by sending more patients to private hospitals but was hampered by the “inadequacy of funding under the state Medi-Cal program.” Some private hospitals, he said, are taking low-risk obstetric patients under Medi-Cal but are reluctant to accept high-risk patients because of inadequate reimbursement rates for additional care that might be required.

The study looks at deaths from around the time of birth until the 28th day of life. While the death-rate data may reflect the ability of hospital physicians in promptly diagnosing and treating medical problems, they do not measure other important factors influencing long-term infant survival and well-being, such as prenatal care and inherited birth defects.

Differences among hospitals are most likely to be significant for mothers who are at high risk of delivering a sick or premature baby. Such mothers, including women who use intravenous drugs or receive inadequate prenatal care, may benefit most from the highest quality hospital care.

According to the UC Santa Barbara statistics, County-USC had 17,088 births in 1986 and 319 perinatal deaths. This was 61 more deaths than was predicted statistically, and on a standardized scale was 22.2% higher than expected.

“The requirement to deliver 17,000 or 18,000 births a year is unreal in terms of the resources that are made available to us,” said Dr. Robert E. Tranquada, the dean of the USC Medical School. He cited the lack of space and the limited availability of nursing and anesthesia personnel.

King had 8,121 births in 1986 and 138 perinatal deaths, according to the analysis. This was 43 more deaths than was predicted.

King’s perinatal death rate for 1986, when expressed on a standardized scale, was 37.7% higher than its expected death rate, the report said. In addition, between 1984 and 1986, the number of births increased by more than 25%.

In September, a series of articles in The Times detailed numerous patient-care and administrative deficiencies at King, and state and federal health officials cited the hospital for scores of deficiencies throughout the facility. County health officials have pledged to correct these problems by Dec. 21 in order to avoid a threatened cutoff of $60 million in public health care funding.

In a written response to the report, Dr. Teiichiro Fukushima, the director of King’s obstetrics management information system, said “this database report must be interpreted with caution” and “should not be used as a measure of hosital performance.”

Fukishima added: “It does show a rising perinatal moratlity rate in 1986 as compared to a decling trend in the preceeding years. This disturbing tendency . . . parallels the increasing rate of no care and drug-abusing patients.”

Dr. William Taeusch, the director of the division of neonatology at King, acknowledged that “quality of care” problems at the hospital contributed to King’s unfavorable statistics. He said division estimates indicate that the neonatal mortality rate would remain “among the highest in the state” for both 1988 and 1989.

“It makes us angry that this seems to be such a surprise,” Taeusch said in a telephone interview. “We want to get these problems solved. We feel underserved by the government agencies and the state and county legislators really responsible for us outside the hospital.”

While pointing out that the statistical analysis could “not fully account for the increased risk” of King’s patients, Taeusch said the overall analysis was “probably among the best that are being done on a statewide or national scale.”

The 532-page Santa Barbara study, prepared under a contract from the state Department of Health Services by Williams, Rust, and Kam J. Rust, is designed to compare the mortality rate for individual hospitals to the statewide average.

Between 1982 and 1986, the statewide average perinatal mortality rate declined from 11.6 deaths per 1,000 births to 9.8 deaths per 1,000 births, the report said. The number of births increased from 432,118 to 484,598.

The report substantially improves upon the raw mortality data by “standardizing,” or adjusting for factors that influence the perinatal death rate.

By far the most important of these factors is the infant’s birth weight; very low birth weight babies, those weighing fewer than 3.3 pounds, are about 130 times more likely to die around the time of birth than babies of normal weight.

The other factors are the sex and race of the baby, multiple births and the number of babies born at each institution. Together, these factors account for more than 80% of the variation in the raw mortality rates, the researchers said.

Taking all of these factors and the statewide average death rate into account, an expected perinatal death rate is calculated for each hospital, which is then compared to the hospital’s actual death rate. If the actual rate significantly surpasses the expected rate, then the hospital is listed as having a high standardized death rate.

The two other Southern California hospitals with high standardized perinatal death rates in 1986, California Medical Center in Los Angeles and Humana Hospital in Anaheim, did not have high death rates for newborns in earlier years, unlike County-USC and King.

A spokeswoman for California Medical Center said the hospital’s unfavorable statistics reflected its center-city location and its high-risk patient population.

Humana Hospital in West Anaheim had 11 fetal deaths out of 954 births in 1986, compared to 4 fetal deaths out of 1,133 births in 1985 and two fetal deaths out of 611 deliveries in the first 10 months of 1989.

John Hanshaw, the hospital’s executive director, said a case-by-case review indicated that all of the 11 fetal deaths in 1986 were “expected.” The deaths included five cases where fetal death occurred before the mother reached the hospital and three anencephalic infants, who were born missing parts of the brain and skull. “It was just an abnormal statistical cluster,” Hanshaw said.

PERINATAL DEATHS IN SOUTHERN CALIFORNIA: 1986 These Southern California hospitals had statistically significant high or low perinatal mortality rates as compared to the statewide average in 1986, according to an analysis of birth and death certificate data by the Community and Organization Research Institute at UC Santa Barbara. Perinatal deaths are those around the time of death or during the first 28 days of life.

A computerized statistical analysis was used to “standardize” raw mortality data. It was designed to account for factors beyond the control of a hospital that influence the death rate, such as the infant’s birth weight, sex, race and multiple births (twins for example). A standardized death rate of 100 represents average performance. A value of more than 100 represents more deaths than expected, while a value of less than 100 represents fewer deaths than expected. For example, a value of 110 means that, on the average, for every 100 deaths expected, 110 deaths occurred, or 10% more than would be expected on the basis of the statewide average.

There is a less than 5% probability that a hospital would be listed as having a high or low perinatal mortality rate because of chance variations in its death rate.

HIGH MORTALITY RATES

STANDARDIZED DEATHS/1,000 DEATH NO. OF BIRTHS BIRTHS RATE M.L. King Jr./ Drew Med. Cent., L.A. 8,121 17.0 137.7 Humana Hospital, West Anaheim 954 16.8 133.0 County-USC Med. Center, L.A. 17,088 18.7 122.2 California Med. Center, L.A. 2,902 20.3 121.2

LOW MORTALITY RATES

DEATHS/1,000 NO. OF BIRTHS BIRTHS U.S. Naval Hospital, San Diego 2,543 3.9 White Memorial Med. Center, L.A. 4,676 5.3 Riverside General Hospital 2,565 10.5 Ventura County Medical Center 2,537 9.5 AMI Tarzana Regional Med. Center 2,055 7.3 Cedars-Sinai Med. Cent., L.A. 6,586 7.3 Medical Center of La Mirada 1,907 1.0 Memorial Hosp. Med. Cent., Long Beach 5,377 18.2 STATEWIDE 484,598 9.8

STANDARDIZED DEATH RATE U.S. Naval Hospital, San Diego 69.2 White Memorial Med. Center, L.A. 71.4 Riverside General Hospital 73.7 Ventura County Medical Center 77.3 AMI Tarzana Regional Med. Center 77.5 Cedars-Sinai Med. Cent., L.A. 78.5 Medical Center of La Mirada 79.2 Memorial Hosp. Med. Cent., Long Beach 82.2 STATEWIDE 100.0

NOTES:

Bold type indicates hospitals that did not report birth weights for more than 10% of their total neonatal deaths. As a result, the standardized death rates at these hospitals “may be artificially low,” according to the UC Santa Barbara researchers.

Births and deaths are listed under the hospital where the baby was born, even if the baby was subsequently transferred to another facility. Hospitals with fewer than 600 births or fewer than six expected perinatal deaths are not listed.

Copies of the “1982-1986 Maternal and Child Health Data Base” are available from the Community and Organization Research Institute, 2201 North Hall, University of California, Santa Barbara, CA 93106. The statistical appendix, which includes the individual hospital statistics, costs $30 and the descriptive narrative costs an additional $20.