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Hospital Death Rates for Five Surgeries Vary

March 27, 1988|ROBERT STEINBROOK | Times Medical Writer

Among The Times' most significant findings are the high death rates at 11 California hospitals for heart bypass surgery, which was associated with about 800 deaths in 1985.

In this expensive and technically complex procedure, surgeons restore an adequate blood supply to heart tissue by grafting blood vessels from elsewhere in the body around blockages in the arteries supplying blood to the heart. During the surgery, the heartbeat is stopped and the patient is kept alive on a "heart-lung machine."

The average patient undergoing bypass surgery in recent years is much sicker and older than patients operated on a decade earlier. This is due to improved medical treatments for heart disease and the increasing use of angioplasty to treat patients who previously would have required surgery. Angioplasty is a procedure performed by cardiologists 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.

Even though most surgeons have improved their skills in caring for sicker patients, some bypass patients have expected mortality rates of between 10% to 20% or more. In addition, patients who require emergency surgery because of angioplasty complications, such as ruptured heart arteries or worsened obstructions, are at particularly high risk of dying.

On the other hand, a particularly gifted surgical team, with good backup from other physicians and nurses, can save many more high-risk patients than colleagues with less talent and less organizational support.

A high percentage of very sick patients and a small number of elective cases appear to be important factors in the relatively high 9.0% bypass surgery death rate at the UCLA Medical Center in 1985.

About one-third of the 145 bypass surgery patients that year were referred from institutions that have their own cardiac surgery programs, including six of the 13 patients who died, according to Dr. Hillel Laks, UCLA'S chief cardiac surgeon. Dr. Donald Hill, the chief heart surgeon at San Francisco's Pacific Presbyterian Medical Center, has a similar referral pattern.

The 13 UCLA patients who died included four who were already in acute circulatory collapse, or "cardiogenic shock," after heart attacks. Others who died included a patient in shock after a failed angioplasty, a Jehovah's Witness who died in need of blood transfusions that she had earlier rejected and a patient having repeat bypass surgery who had been turned down by the surgeons who performed the first operation, Laks said. In 1987, three of the seven patients who died were in cardiogenic shock and two had failed angioplasties.

Cardiogenic Shock

"The mortality rate at UCLA for patients in cardiogenic shock is 30%," Laks said. "Without surgery the mortality is 90%. At the few other institutions that are willing to operate on patients in cardiogenic shock, the mortality is reported in the medical literature as being 50% or higher."

Laks said that some patients referred to him "have been given an inflated mortality figure, so they will either not have the surgery or go elsewhere." He speculated that some surgeons "may be less willing to take on high-risk patients even when surgery is indicated because of concern about the publication of their statistics."

UC San Francisco had the highest mortality rate for heart bypass cases among all California hospitals in 1985, 14.7% or 24 deaths following 163 surgeries.

For 1986 and the first nine months of 1987, surgeons performed 281 such surgeries at UCSF with 29 deaths, for a 10.3% mortality rate, according to hospital statistics. By comparison, the hospital's death rate in 1983 was 3.9%.

Dr. Stan M. Lindenfeld, chairman of UCSF's quality assurance executive committee, said that a detailed review of all bypass deaths for 1985 through 1987 had revealed no quality-of-care deficiencies.

"We feel very comfortable with the statistics," Lindenfeld said in a telephone interview. "We clearly have a (patient) population--because of referral patterns--who are very, very ill when they start."

Other Factors Blamed

But several knowledgeable sources, who requested anonymity, said high-risk patients were only partially to blame for UCSF's high mortality rates.

In particular, they pointed out that the division of cardiovascular surgery has been without a chief since June, 1986, when Dr. Paul Ebert, a world-renowned pediatric heart surgeon, left to become the director of the Chicago-based American College of Surgeons. Other university heart surgeons have also left or restricted their practices for a variety of reasons.

"It is a temporary crisis, but nobody here is going to deny it," one widely respected UCSF physician said. "We don't have as good a bypass surgery program as we had five years ago."

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