By Consumers For Quality Care, on June 10, 2019
In a recent article, The New York Times reported on physicians at North Carolina Children’s Hospital who grappled with declining outcomes for their cardiology patients. In 2016, after a number of children were faring worse than the physicians had expected them to, the doctors fought to find what was happening and questioned what care they were able to provide.
The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery.
Skylar Jones died at the hospital following complications from a low-risk surgery, which had a mortality risk of around 2 percent. Skylar died after weeks of continued complications that left her on life support for a period of time. Her parents say they wish now that they had more information or that someone had warned them about issues at the hospital. Mr. Jones says he feels as if his ability to select the best care for his daughter’s care was taken away from them.
In meetings, doctors voiced concerns about sending their own children to the hospital for surgery. One doctor said he was “increasingly morally, ethically uneasy” about referring cardiac patients to the hospital’s surgical department. The hospital’s chief pediatric cardiologist, Dr. Timothy Hoffman, admitted that the group was in “crisis” and the situation was a “nightmare.” Dr. Kevin Kelly, the head of the children’s hospital, suggested that physicians “do what [their] conscience says,” in regards of where to refer patients for surgery.
Th[ose] comment[s] and others — captured in secret audio recordings provided to The New York Times — offer a rare, unfiltered look inside a medical institution as physicians weighed their ethical obligations to patients while their bosses also worried about harming the surgical program.
All of the hospital’s cardiologists, who diagnose and treat cardiac conditions but do not perform surgery, expressed concerns. While they could not isolate what was causing the decreased outcomes in a complex-care system, they discussed possibilities ranging from inadequate resources, to issues with the chief cardiac surgeon, to the hospital taking on cases it was not equipped to handle.
While physicians across the department admitted to grave issues and concerns, Dr. Hoffman also highlighted drawbacks to sending patients elsewhere. Over time, moving patients to other hospitals for surgery could lead to fewer cardiologists and less investment in the program from administrators. Dr. Kelly warned that limiting the cardiac care could have long-term consequences for the hospital.
“I’ve been worried about this,” he said. “The implication of somebody like me declaring ‘pediatric cardiac surgery moratorium has occurred’ will spread like wildfire from North Carolina, and this will never be the same for five or 10 years.”
The cardiologists asked to review the hospital’s mortality statistics but said they could not get the data. When UNC finally released limited data, including the years in question, it showed a mortality rate higher than nearly 82 percent of the hospitals that publicly report the data nationwide. Roughly 75 percent of the hospitals that perform pediatric heart surgery in the country share these statistics publicly. Dr. Carl Backer, former president of the Congenital Heart Surgeons’ Society, questions the efficacy of hospitals, like UNC, that do not.
“You should think twice about going to a center that doesn’t publicly report,” Dr. Backer said. “People don’t buy a car without knowing what the gas mileage is.”
Following the Times report, a top UNC physician, Dr. Benny Joyner, defended its surgery program, saying there were no systematic or systemic issues that would cause the hospital to be concerned about the outcomes of its patients. Lisa Schiller, an administrator and spokeswoman for the hospital, said that there had been “a dysfunctional group” that was replaced by other physicians.
The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country.
The best outcomes for patients with complex heart problems correlate with hospitals that perform a high volume of surgeries — several hundred a year — studies show. But a proliferation of the surgery programs has made it difficult for many institutions, including UNC, to reach those numbers… Lower numbers can leave surgeons and staff at some hospitals with insufficient experience and resources to achieve better results, researchers have found.
Over the last decade, at least five pediatric heart surgery programs nationwide have been shut down or suspended over performance concerns. Others have combined systems to improve outcomes. International data, too, shows that combining systems often provides more comprehensive care and leads to decreased mortality rates.