Researchers call for fewer hospitals in an organized, regionalized system
PHILADELPHIA -- The U.S. has more than double the number of congenital heart surgery centers that it needs, researchers said here.
Currently, the nation boasts more than 150 such centers: 116 participating in the Society of Thoracic Surgeons (STS) National Database as of 2018, and probably another 30-40 not reporting to it, said Carl Backer, MD, of Ann & Robert H. Lurie Children's Hospital of Chicago, and former president of the Congenital Heart Surgeons' Society (CHSS).
Among them are "problem institutions," outliers with unexpectedly high mortality rates, Backer told a standing-room-only crowd at the American Heart Association (AHA) annual meeting.
Just this year, the program at North Carolina Children's Hospital (run by UNC Healthcare) fell under scrutiny for higher-than-expected death rates, according to a New York Times investigation.
Backer recalled a scandal from the 1990s where babies died at high rates after cardiac surgery at a hospital in Bristol, England. A probe revealed that the center was poorly staffed and managed.
In response, Britain's NHS set 500 cases per year for each hospital as standard, and recommended that the number of centers in the country be reduced from 11 to seven.
Apply this 500-case minimum to the U.S. -- a country of 325 million people with roughly 32,500 congenital heart operations per year -- and the country would only need 65 centers, Backer estimated.
The idea is that higher case volume is tied to lower patient mortality in pediatric cardiac surgery, 300 cases per year being the inflection point in one study cited by Backer.
This 300-case threshold held up in a separate analysis by his group, which mined STS data and found that mortality rates adjusted for case complexity came out to 1.7% for centers doing at least 300 cases annually and 5.4% for others with 100 each year (P<0.01).
Regionalizing congenital heart surgery therefore should have the goal of keeping case volumes above 300 per hospital while minimizing travel distance. In addition, policies should allow for at least one program per state that has over 2 million inhabitants, according to Backer.
His magic number: 71 sites scattered across the country.
Currently, Florida and Texas each already have 10 pediatric heart surgery centers -- and California 11. In Backer's plan, this would be reduced to six programs in Texas, four in Florida, and nine in California.
Another researcher would cut the ideal number of programs even further.
Tara Karamlou, MD, MSc, of the Cleveland Clinic Children's and the Heart Vascular Institute, told the audience that just 57 hospitals could allow a median of 451 cases per year with median patient travel distances of 35 miles.
Optimally, centers should be sited in densely populated areas, but not too many in the same area. She noted that two-thirds of today's programs are located within 25 miles of another one. Additionally, one-quarter of patients already travel over 100 miles for surgery, while more than half bypass their nearest hospital.
"We can rationally regionalize the care of children with congenital heart disease," Backer emphasized.
All this is theoretical, however, unless someone puts regionalization into action.
It appears there's a role for surgical and cardiology societies like CHSS, STS, and AHA to work together and lobby and to set standards for heart surgery centers, Backer said, noting that quality measures from STS exist for program structure and process -- but not hospital performance.
Backer reported consulting for W.L. Gore & Associates.
Karamlou disclosed no conflicts.
American Heart Association
Source Reference: Backer CL "Are there too many congenital heart centers? The role of professional societies" AHA 2019.
American Heart Association
Source Reference: Karamlou T "Simulating regionalization: potential impact on programs, outcomes, and patient travel" AHA 2019.
Read the original article on Medpage Today: Oversupply of Congenital Heart Surgery Programs Slammed