Transplant deaths at USC a puzzle
His liver rapidly failing, William McMurrough was running out of options.
He’d been removed from the waiting list for a transplant at UCLA Medical Center for using marijuana and skipping rehab.
The 50-year-old truck dispatcher was critically ill -- with a bacterial infection and other ailments -- when he landed at USC University Hospital. He thought it was his salvation.
Surgeons there were undeterred by his deteriorating health and recent drug use. “They just took him,” his wife, Linda, recalled.
Days after joining USC’s waiting list in January 2005, McMurrough got a new liver. His family rejoiced, hoping he’d meet the grandson he’d felt kicking in his daughter’s belly.
Many hospitals would have turned McMurrough away outright, loath to risk wasting a scarce donor organ on such a risky patient. But USC was different. It took pride in giving chances to patients with few left.
After opening its liver program in 1996, the hospital just northeast of downtown Los Angeles developed a record of success.
Then, around 2003, its death rate started to climb.
Today USC’s rate is among the worst in the country. In a span of 2 1/2 years, 38 of 164 patients died within a year of their transplants, twice as many as expected, according to the most recent national data. The data largely factor in the condition of patients and donated organs.
For now, the reasons for USC’s declining success rate remain largely a mystery. Prompted by an article in The Times in July, regulators and outside experts hired by the hospital are investigating.
There are several possible explanations: It could be that the program was choosing the wrong patients for transplants or using organs of poor quality. It could be that the team mishandled surgeries or follow-up care. Or it could be a combination of reasons, including bad luck.
Officials at USC’s Keck School of Medicine, which runs the clinical side of the program, and at the hospital, owned by Tenet Healthcare Corp., declined to be interviewed for this article.
In a joint statement in September, however, both pointed to an answer: They were consciously taking high-risk patients.
It was an effort, they said, to provide extremely sick people with “a chance at life despite the risks of lowering our survival statistics.”
In some instances the program appears to have gone too far, according to top transplant experts who reviewed medical records for The Times.
“They’re pushing it as hard as they can and having the results that you’d expect to see,” said Dr. David Mulligan, chairman of transplant surgery at Mayo Clinic Hospital in Phoenix, who also sits on the board of a national oversight group.
USC’s story illustrates how an aggressive program can lose its footing, especially in a major metropolitan area where the waiting list for livers is long and competition among transplant centers is stiff.
In fact, in recent years, USC’s program has been under mounting pressure.
There were deep internal divisions over whether some patients were healthy or sober enough for a transplant, said five current and former transplant staffers who spoke on condition of anonymity for fear of jeopardizing their careers.
Beyond that, the transplant center was losing millions of dollars each year, according to its corporate owner. And staffers became enmeshed in professional and personal conflicts.
In such an environment, USC surgeons were struggling with the life-and-death medical decisions of any busy transplant center: Is the patient too sick to survive, even with a new liver? Is the donated organ good enough to save a life? Is a valuable liver going to waste?
One way that hospitals gauge whether they are making the right decisions is to keep a close eye on mortality rates. If deaths go up, doctors figure out why and make changes.
USC University Hospital apparently did not do that. Tenet said in an October statement that the hospital did not become aware of the mounting deaths until July, when national statistics were released. The statement did not address why the hospital had failed to act on data published six months earlier showing a similarly high death rate.
As for McMurrough, he died six weeks after his transplant, unable to overcome infections and other serious complications.
Linda McMurrough said she was never told why. “They kept telling us it wasn’t their fault,” she said.
Risk and nerve
Liver transplantation is immersed in risk. It takes training and practice.
It also takes nerve.
Dr. Rick Selby, USC’s chief liver surgeon, honed his skills in the late 1980s at the vaunted University of Pittsburgh, where nerve was in generous supply.
It was the cradle of liver transplantation, led by Dr. Thomas Starzl -- who performed the world’s first liver transplant and trained some of the country’s most prominent surgeons.
When Selby was training, the surgery was still largely experimental. Facing much less demand for organs and less regulation than today, “we wouldn’t think twice about transplanting a liver into a patient in critical condition, watching it fail and then trying again or even a third time,” said Dr. Maureen Martin, a former transplant surgeon who worked with Selby in Pittsburgh for seven years.
“What we did 15 years ago, we certainly wouldn’t do now,” said Martin, now chairwoman of surgery at Kern Medical Center in Bakersfield.
She described Selby then as a quiet man, inclined to stand up for the underdog. “He didn’t care about making big bucks and becoming super famous,” she said.
By the time he opened USC’s program in 1996, five liver transplant centers were vying for organs in the area. UCLA cast a long shadow, dwarfing the others in both size and prestige.
Selby “got into a very competitive neighborhood,” said Dr. John J. Fung, director of Cleveland Clinic’s transplant center, who worked with Selby in Pittsburgh. “It’s hard to compete against a 900-pound gorilla.”
Still, Selby, now 56, developed a reputation as a skilled surgeon, committed to his patients.
“If I needed a liver surgeon, I’d probably go to Rick,” Fung said.
USC steadily picked up speed. It went from four liver transplants in 1996 to 92 last year. Although it still performed fewer than half as many as UCLA, it outpaced all but 22 programs nationwide. Along the way Selby added five transplant surgeons to his staff. His brother, Brad, took over as administrator.
Within a few years of the program’s opening, patients were surviving their transplants at a greater rate than expected, according to a government-sponsored analysis.
In a field where death was common, USC seemed to be beating the odds.
Statistics take a turn
Sometime in 2003, however, the program’s fortunes turned: Patients began dying more often than they should have.
At USC, fewer than 76% of the patients who received a transplant from January 2003 to June 2005 survived at least a year, according to statistics released in July of this year. The program’s expected survival rate was 86% -- about the national average.
The difference may seem small, but in a program that performed dozens of transplants a year, the numbers added up.
Relatives of more than 10 people who died said they didn’t receive satisfactory or complete explanations.
“They just said, ‘We don’t know what happened,’ ” recalled Annette Ostoich, whose 54-year-old husband died during transplant surgery in August 2004.
Said Griselda Luna, whose 36-year-old sister, Sandra, died the same month: “After she passed, the doctors wanted her to have an autopsy.... They were puzzled.”
When asked in July about the extra deaths, Rick Selby offered technical explanations that were at odds with statistics and the views of transplant experts. “It’s clearly not because we don’t know what we’re doing,” he said.
He has since declined to comment. In their statement, USC and the hospital suggested that the national data didn’t reflect just how sick their patients were, perhaps making survival expectations artificially high.
Although the statistics are adjusted for the condition of patients and donated organs, they do not take into account every possible risk factor.
According to medical and internal records, USC was taking in patients with serious coexisting conditions -- bacterial infections, vascular disorders and extremely low blood pressure -- that experts say would have ruled out transplants at more conservative programs.
The high post-transplant death rate was not the only statistic that raised questions about the program: USC patients also had a greater chance of dying before surgery.
In 2005, USC’s was the sole liver program in California that had significantly more deaths than expected among patients awaiting livers. Fifty-eight USC liver candidates died, about 14 more than statistically expected, according to the Scientific Registry of Transplant Recipients.
Among other things, experts said, this suggests that USC may have been choosing poor candidates for liver transplantation or not managing their cases well.
Fung, director of the Cleveland Clinic’s transplant center, said programs have a responsibility to study their survival statistics long before national data are released.
“You use your own database and follow your outcomes and make mid-course adjustments,” said Fung, who added that he reviews his program’s performance monthly.
Referring to USC, he said, “I think they would want to figure out why they had all these extra deaths.”
But as its death rate crept upward, USC continued to take chances.
Fatty livers sought out
Pam Deneau recalls her giddiness in July 2003, when a liver and kidney became available for her critically ill husband, Scott.
Staffers said the organs were coming from a 20-year-old gunshot victim and were in great condition, she and another family member recalled. But according to a lab report, the donor liver was about 50% fatty -- a defect that decreased the chances it would function well.
Using marginal organs is a way to stretch the organ supply, but many doctors would have turned this one down, two experts said.
The new organs seemed to give the once-robust carpenter a new life, Pam Deneau said: “It was miraculous how he changed overnight.”
Before long, however, he seemed to develop infections everywhere, she said.
He died 39 days after surgery.
After reviewing Deneau’s records, Mulligan, the Mayo Clinic Hospital surgeon, said using a subpar liver diminished his ability to ward off infections and other complications.
“Part of it had to do with the fact that the donor wasn’t ideal and the quality of the liver wasn’t robust,” Mulligan said.
In fact, USC sought out fatty livers. The program specifically asked to be called if other hospitals turned down such organs, said Tom Mone, executive director of One Legacy, the regional agency in charge of obtaining and distributing organs.
The program’s doctors were willing to push the limits in other ways.
They made allowances for patients with drug or alcohol problems, resisting the “black and white,” “you’re in or you’re out” approach used by others, said USC surgeon Rod Mateo.
“We will give the patient the benefit of the doubt,” he said.
That made USC a good fit for William McMurrough, who was growing sicker.
Two experts who reviewed his medical records said he was a poor candidate for a transplant at the time.
In the first place, they said, McMurrough’s ongoing marijuana use should have disqualified him, because new organs ought to be reserved for people who can take good care of them and follow rules. Many transplant programs require six months of demonstrated abstinence from drugs and alcohol before they will even place a patient on their waiting list.
Once McMurrough was on the list, his infection and other complications should have ruled out the surgery, experts said --even if it meant he might die.
“You can get away with a few cases like this, but at the end of the year you’re going to have more losses than wins,” Mulligan said.
Perilous balancing act
It’s not certain whether Deneau or McMurrough would have lived longer without a transplant. Nor is it certain the organs used in their cases would have better served someone else.
Decisions about who should get an organ are seldom clear-cut.
Livers from cadaver organs obviously cannot be ordered up. As organs -- whatever their quality -- become available, they are generally offered first to the sickest patients.
If a patient is deemed too sick for surgery or the organ is not ideally suited -- both common situations -- the liver is offered to the next patient in line. Each hospital has its own waiting list, but all of these patients are part of the regional queue that determines who’s next. More than 1,300 adults are waiting for livers in the Los Angeles area.
Weighing an organ offer over can be perilous: Turn it down, and the patient may die. Accept an inferior organ, and the patient may also die. Take a perfect liver but choose the wrong patient, and a precious organ may be wasted.
“You have to wring your hands a lot and gnash your teeth and wonder if you are doing the right thing or not,” said Dr. Steven Colquhoun, a liver transplant surgeon at Cedars-Sinai Medical Center in Los Angeles.
A center can be too bold, but it also can be too timid.
UCI Medical Center in Orange, for instance, turned down the vast majority of organs offered for its patients after a spate of bad outcomes, cutting them off from potentially life-saving transplants.
At more aggressive centers, when a patient seems certain to die without a transplant, doctors sometimes go for a long shot.
A satisfied patient
USC bet that it could save Philip Arst.
After two liver programs turned the septuagenarian away, in one instance citing his age, doctors at USC took him in.
“They were willing to take a chance,” said Arst’s wife, Margareth.
Then doctors discovered that he had a cancerous growth, a complication that added to the risks posed by his age and underlying illness -- hepatitis C.
“That’s a block to any transplant,” Philip Arst said.
Undeterred, USC doctors were able to shrink the tumor. In November 2004, at age 75, he received a new liver.
“The care was all I could hope for,” said Arst, an environmental activist who maintains an active schedule. He and his wife were so pleased, in fact, that their family donated $10,000 to help pay for new transplant offices.
Earlier this year, a treatment room was named in their honor.
Worried about money
Outside the view of patients, all was not well in USC’s program. There were distractions from the core medical mission.
Director Selby was worried about money. So worried, Mateo and others said, that he wrote to USC and hospital officials last fall threatening to close the program unless it received more resources -- and eventually it got some.
In conversations with reporters in the fall of 2005, Selby blamed the financial struggles of urban liver programs, in part, on insurers and government health programs. He complained that they often paid too little for treating the very sick patients USC took in.
The average liver transplant and follow-up care in the U.S. cost nearly $400,000 last year, according to the Milliman consulting firm. Each hospital negotiates its own rate with insurers.
Other problems emerged at USC.
In the last few years, staffers haven’t been getting along. They’ve fought over assignments, perceived favoritism and one another’s competency, according to the current and former employees who spoke on condition of anonymity.
“There was such a fear of retaliation,” one said. “You just kind of feared for your job.”
Eventually, the staffers said, they simply stopped bringing up problems. Some doctors, nurses and social workers left. Selby’s brother Brad is no longer administrator.
As the program’s difficulties grew, the once-hard-charging USC dramatically scaled back.
Through the end of September, it had performed just 42 liver transplants in 2006, more than a 40% drop from last year’s pace.
In late summer, Rick Selby stopped operating. He was diagnosed with non-Hodgkin’s lymphoma, a cancer for which he has received chemotherapy.
‘Very mixed feelings’
As the regulatory and internal investigations proceed, some relatives of patients who died say they hope for explanations.
Others, including Scott Deneau’s sister, Susan, say they aren’t sure they want to know.
“I have very mixed feelings about what we may learn about Scott’s case in particular and USC’s transplant program in general,” she said in an e-mail to The Times.
But back then, USC felt like her family’s only hope.
“He was so sick at the time, we were in no position to be able to shop around.”
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The high death rate within USC University Hospital’s liver transplant program comes amid increasing concern over the performance and oversight of transplant centers across the nation. In Southern California alone, two liver transplant centers have closed as a result of scandals in the last 16 months.
St. Vincent Medical Center near downtown Los Angeles stopped performing liver transplants in September 2005 after acknowledging that its doctors had improperly given a liver to a Saudi national using an organ intended for a higher-priority patient on St. Vincent’s waiting list. Hospital staff members knew about the ethical breach but covered it up.
Two months later, UCI Medical Center in Orange closed its liver transplant program the day The Times reported that it had been turning down a disproportionately high number of organs as patients died on its waiting list. UCI did not have a full-time liver transplant surgeon for more than a year.
All told, about 200 liver patients had to find new programs when the two closed. Four adult liver centers remain in the Los Angeles area, including USC University Hospital’s.
Source: Times research