Heart Operations Remain Risky at Many Hospitals : Medicine: One in eight had high death rates for bypass patients in 1987.

One-eighth of California hospitals with heart surgery programs had significantly high death rates for heart bypass patients in 1987, according to a Times analysis of data covering nearly all such operations in the state.

At seven of these hospitals, the death rate--the percentage of bypass surgery patients who died before leaving the hospital--was at least 10%, or more than double the statewide average death rate of 4.9%. The facilities included St. Joseph Medical Center in Burbank and UC Irvine Medical Center in Orange.

The Times also found that three hospitals with high death rates in 1987 had overall heart bypass death rates of more than 10% for the four-year period between 1985 and 1988. These hospitals are Santa Clara Valley Medical Center in San Jose, UC San Francisco Medical Center and Dameron Hospital in Stockton.

“Hospitals with consistently high mortality rates should perform internal reviews of their programs and possibly bring in independent experts to provide advice on how to improve their performance,” said Jonathan A. Showstack, a UCSF associate professor of health policy and one of two experts retained by The Times to assist in preparing the computerized hospital-by-hospital study.

“These data point out hospitals that are performing significantly better or worse than the average hospital,” Showstack said.

Twelve other hospitals, including Kaiser Foundation Hospital, San Francisco, Sutter Memorial Hospital in Sacramento and Cedars-Sinai Medical Center in Los Angeles, had significantly low bypass surgery death rates in 1987, the latest year for which complete state statistics are available. These three hospitals also had significantly low death rates in both 1985 and 1986.

Hospitals with many bypass surgeries tend to have substantially lower death rates than hospitals with fewer surgeries. This suggests, according to Showstack and other experts, that some deaths might be prevented by concentrating heart surgery in a smaller number of busier hospitals.

In 1988, The Times published a series of articles that identified low-volume and high-mortality heart surgery hospitals. The state Department of Health Services, prompted in part by these articles, said last December that it would conduct a comprehensive re-examination of all state regulations for heart-care services. That review has yet to be completed.

Officials from some hospitals with high death rates said their statistics reflected a high number of high-risk cases, not quality-of-care problems. For example, Dr. Alan B. Gazzaniga, chief heart surgeon at UC Irvine, said the three patients who died in 1987 included two who were turned down by surgeons at other hospitals and another who had a “predicted mortality of 70%” because of severe heart, lung and kidney problems.

Other hospitals said that publicity about their unfavorable statistics has spurred efforts to improve the quality of care.

An August, 1988, Times article indicating that Dameron Hospital in Stockton had a 17% bypass mortality rate in 1986, the highest in the state, “gave us a real impetus,” said Dr. Luis Arismendi, the hospital’s administrator. “We lined up the . . . surgeons and we had quite a discussion.”

Arismendi said some surgeons, two of whom are no longer practicing at the hospital, were not paying attention to “the selection of cases” and “the intricacies of operative and post-operative work.”

When UCSF, one of the nation’s most prestigious medical centers, reviewed its heart bypass statistics for 1987, “we knew that there was a problem that we needed to deal with,” said Dr. Kevin Turley, the medical center’s acting chief of cardiac surgery. Medical center officials realized that if their surgeons were going to operate on high-risk patients, they had to find “methods of lowering that mortality.”

In the fall of 1988, steps to reduce the mortality rate began, Turley said. These included closer consultation with anesthesiologists, increased use of intra-aortic balloon pumps to support the heartbeat before, during and after surgery, and placing some patients on waiting lists for heart transplants.

Turley said the death rate for bypass surgery patients at UCSF has dropped markedly, although the patients appear to be as sick as in previous years. The death rate was 10% in the first half of 1988 and 6.8% in the second half of the year, he said. No fatalities were recorded in the first half of 1989, although UCSF officials said some patients have died since then.

Bettina Kurowski, associate administrator of St. Joseph Medical Center, said that in response to high mortality rates the hospital had improved its quality assurance process and had changed some of its heart surgeons. The changes “have resulted in a significant decline in the mortality rates,” she said.

Because bypass surgery is an expensive, technically complex and frequently performed operation, it is considered one of the most important to study in evaluating the quality of hospital care. During the operation, surgeons improve the blood supply to heart tissue by grafting blood vessels from elsewhere in the body around blockages in the arteries that supply blood to the heart.

Using computer tapes from the Office of Statewide Health Planning and Development, The Times compared the mortality rates for individual hospitals to the statewide average.

The Times’ consultants said that comparing an individual hospital’s death rate with the statewide average death rate was a “relatively lenient” standard. This is because the average death rate includes the statistics for hospitals with poor performance as well as those with good performance.

The data on the computer tapes was supplied and verified by individual hospitals and is considered accurate. In addition, The Times reconfirmed the data with all the hospitals with high death rates.

The data was corrected for variations among hospitals in the age, sex and race of patients, as well as variations in the number of patients with heart attacks and the number who had coronary angioplasties, a non-surgical procedure for opening blocked heart arteries. Similar results were obtained when variations in the number of emergency cases were taken into account. Such statistical corrections significantly reduce the possibility that hospitals will be listed as having a high or low death rate because of chance or factors unrelated to the quality of care.

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 amount of pre-existing heart damage and the percentage of patients with prior heart bypass surgery.

The Times analysis also found:

* The number of bypass surgeries in California increased about 11% from 18,123 to 20,156 between 1986 and 1987. The statewide bypass surgery death rate, which increased from 4.6% in 1985 to 5.3% in 1986, declined to 4.9% in 1987.

* As in previous years, death rates were lowest for the hospitals that performed the largest number of heart surgeries. More than a third of California hospitals that perform heart surgery--and half the heart surgery hospitals in Los Angeles County--do not meet the 150-cases-a-year minimum for all open-heart operations that is recommended by the state Department of Health Services and the American College of Surgeons.

UC Irvine has consistently been a low-volume hospital. Gazzaniga, UC Irvine’s chief heart surgeon, said that after the renovation of the hospital’s cardiac catheterization facilities, 53 bypass surgeries had been performed through October, almost twice the number performed last year. But he explained that because more than a dozen hospitals are competing for about 1,300 to 1,500 open-heart cases in Orange County each year, it is very difficult for most of the hospitals, including UC Irvine, to achieve an adequate volume.

“In California, every hospital wants to have an open-heart program,” Gazzaniga said. “Practically every (heart) surgeon in Orange County operates at more than one hospital.”

* Santa Clara Valley Medical Center, a public hospital in San Jose, had the highest mortality rate for heart bypass cases among all California hospitals in 1987--11.6%--as well as the highest death rate for the 1985 to 1988 period--12.8%. Over the four-year period, it has averaged only 55 surgeries a year.

After years of “recruitment difficulties,” Santa Clara Valley hired a full-time cardiac surgeon in 1988 and subsequently has made other changes in its surgical staff, said Dr. Phillip Benaron, the hospital’s medical director.

* Many hospitals cited statistics showing that most of their deaths occurred in high-risk heart surgery patients, such as emergency cases or elderly patients with severely damaged hearts. It was difficult, however, to interpret these statistics because the hospitals did not use uniform standards to determine such risk.

The Society of Thoracic Surgeons is developing uniform standards and practice guidelines for heart surgery. This will make it easier for surgeons to communicate among themselves and to advise patients and their families about the risks of surgery.

* Typical hospital charges for bypass patients ranged from a high of about $71,000 a case at Hollywood Presbyterian Medical Center--which in 1988 merged with Queen of Angels Medical Center--to a low of $18,643 at nearby St. Vincent Medical Center in Los Angeles. The median charge was about $31,000.

Showstack said a hospital doing 300 bypass surgeries a year, with a normal proportion of high-risk patients, could probably charge between $15,000 and $20,000 a case and still make a profit. He said the total hospital bills for bypass surgery were “a reasonably good reflection of the relative costs of care” between two hospitals. Hospital charges, however, are often higher than actual costs and what the hospital is reimbursed by insurance carriers.

Jonathan A. Showstack, associate professor of health policy, and Harold S. Luft, professor of health economics, 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. Systems analyst Detlef D. Matthies, statistical analyst Maureen Lyons and researcher Tracy Thomas assisted in preparing the story.

HEART BYPASS SURGERY IN CALIFORNIA--1987

MORTALITY RATES

These California hospitals had significantly high or low death rates for adult patients undergoing heart bypass surgery in 1987, according to a Times analysis of computer data tapes compiled by the Office of Statewide Health Planning and Development.

Statewide, there were 20,156 patients and a 4.9% mortality rate.

HIGH MORTALITY RATES

Bold type indicates hospitals that also had high mortality rates in 1986.

HOSPITAL TOTAL PATIENTS DEATHS BY % Santa Clara Valley Medical Center, San Jose 69 11.6 Dameron Hospital, Stockton 139 11.5 St. Joseph Medical Center, Burbank 122 11.5 San Jose Medical Center 102 10.8 UC Irvine Medical Center, Orange 29 10.3 Samuel Merritt Hospital, Oakland 321 10.0 White Memorial Medical Center, Los Angeles 49 10.0 Stanford University Hospital 293 9.6 UC Medical Center, San Francisco 146 9.6 Long Beach Community Hospital 97 9.3 Garfield Medical Center, Monterey Park 99 9.1 St. Agnes Medical Center, Fresno 447 7.8

LOW MORTALITY RATES

Bold type indicates hospitals which also had low mortality rates in 1986.

HOSPITAL TOTAL PATIENTS DEATHS BY % Kaiser Foundation Hospital, San Francisco 429 1.2 Sutter Memorial Hospital, Sacramento 707 2.3 Cedars-Sinai Medical Center, Los Angeles 479 2.7

These hospitals had a low mortality rate but with a higher--5% to 10% probability--that the low rates were due to chance:

HOSPITAL TOTAL PATIENTS DEATHS BY % Santa Monica Hospital Medical Center 38 0.0 Grossmont District Hospital, La Mesa 128 1.6 Sequoia Hospital, Redwood City 362 2.5 Brotman Medical Center, Culver City 108 2.8 Sharp Memorial Hospital, San Diego 574 3.0 Eisenhower Medical Center, Rancho Mirage 305 3.0 Memorial Medical Center of Long Beach 393 3.1 Mercy General Hospital, Sacramento 769 3.3 St. Vincent Medical Center, Los Angeles 472 3.6

Notes: The state computer tapes contain non-confidential case-by-case data on nearly all patients hospitalized in the state. There is a less than 5% probability that a hospital would be listed as having a high or low in-hospital mortality rate because of chance. The data is corrected for variations between hospitals in the age, sex and race of their patients, as well as variations in the number of patients with heart attacks and the number who had coronary angioplasties during the same hospital admission. Hospitals with fewer than 10 surgeries and patients who also underwent heart valve replacements or repair of heart aneurysms are excluded.

CHARGES

The median total hospital charge for bypass surgery patients was $30,920. These hospitals had median total charges of $44,000 or more. Charges for patients who died are not included.

MEDIAN HOSPITAL SURVIVORS CHARGES Hollywood Presbyterian Medical Center 25 $71,028 UC Irvine Medical Center, Orange 26 54,132 Alta Bates Hospital, Berkeley 64 50,546 Doctors Medical Center, Modesto 509 46,292 Santa Clara Valley Medical Center, San Jose 61 45,984 Mission Community Hospital, Huntington Park 24 45,328 Cedars-Sinai Medical Center, Los Angeles 466 44,878

These hospitals had median total charges of $23,000 or less:

MEDIAN HOSPITAL SURVIVORS CHARGES St. Vincent Medical Center, Los Angeles 455 $18,643 St. Bernardine Hospital, San Bernardino 357 19,438 El Camino Hospital, Mountain View 179 20,407 Sequoia Hospital, Redwood City 353 20,575 L.A. County-USC Medical Center 80 21,997 Eisenhower Medical Center, Rancho Mirage 296 22,098 St. Joseph’s Hospital, Stockton 210 22,350 Community Memorial Hospital of San Buenaventura 73 22,509 Hospital of the Good Samaritan, Los Angeles 715 22,700 Goleta Valley Community Hospital, Santa Barbara 65 22,953

FOUR YEARS OF HEART BYPASS DEATH RATES

These are the heart bypass surgery death rates between 1985 and 1988 for the 12 California hospitals with high death rates in 1987:

1985 1986 1987 TOTAL DEATHS TOTAL DEATHS TOTAL DEATHS HOSPITAL CASES BY % CASES BY % CASES BY % Santa Clara 46 13.0 53 13.2 69 11.6 UCSF 163 14.7 179 9.5 146 9.6 Dameron 0 -- 66 13.6 138 11.6 Long Beach 71 7.0 56 10.7 97 9.3 St. Joseph 165 6.7 154 11.0 122 11.5 San Jose 88 6.8 102 6.9 102 10.8 Garfield 81 6.2 81 4.9 99 9.1 Merritt 279 7.9 369 6.8 321 10.0 White 66 4.5 75 6.7 49 10.0 UC Irvine 17 0.0 22 4.5 29 10.3 St. Agnes 240 3.3 457 7.2 447 7.8 Stanford 400 5.0 378 9.0 293 9.6

Notes: Data for 1985-1987 were obtained from state computer tapes. Data for 1988 are based on hospital statistics furnished to The Times. A small number of patients who also underwent repairs of heart aneurysms are included in statistics for 1985 and 1986. Some hospitals also furnished data for part of 1989. The partial 1989 statistics are not included, because The Times’ consultants considered them too preliminary to be meaningful.

1988 1985-1988 TOTAL DEATHS TOTAL DEATHS HOSPITAL CASES BY % CASES BY % Santa Clara 59 13.6 227 12.8 UCSF 152 8.6 640 10.6 Dameron 140 7.1 344 10.2 Long Beach 101 11.9 325 9.8 St. Joseph 146 9.6 587 9.5 San Jose 119 9.2 411 8.5 Garfield 80 8.8 341 7.6 Merritt 273 5.5 1,242 7.6 White 79 8.9 269 7.4 UC Irvine 31 9.7 99 7.1 St. Agnes 468 4.9 1,852 5.3 Stanford N/A N/A

Notes: Data for 1985-1987 were obtained from state computer tapes. Data for 1988 are based on hospital statistics furnished to The Times. A small number of patients who also underwent repairs of heart aneurysms are included in statistics for 1985 and 1986. Some hospitals also furnished data for part of 1989. The partial 1989 statistics are not included, because The Times’ consultants considered them too preliminary to be meaningful.