Implications for Louisville’s Kosair Children’s Hospital and the University of Louisville.

The pediatric cardiac surgery program at the University of Kentucky has seen a steady stream of negative national publicity over the last year.  Following the death of several babies with congenital heart defects, the University suspended its pediatric cardiac surgery program in 2012.  The institution announced a desire to improve its outcomes and established an internal review process.  Its pediatric cardiac surgeon left for elsewhere. Few details were available.

CNN reported last Friday that Kentucky Children’s Hospital had resumed its pediatric heart surgery program as of the New Year.  Much of the news report centered on parents’ dissatisfaction that the internal report released last September “doesn’t explain why the babies died,” and with the hospital’s apparent reluctance to provide more specific mortality rates.  In an article  charged with emotional comments, Executive Vice President For Health Affairs at UK, Dr. Michael Karpf, was not cast in a particularly favorable light.  In responding to concerns that there seemed to be no medical governing body needed to sign off on the decision to reopen the unit, Dr. Karpf is heard saying, “The only person I need permission from is me.”  I believe this arrogant-sounding statement was unfairly taken out of context.

The Report Was Not Glowing.
Actually, the 102 page report released last September provides a considerable amount of information about the hospital’s pediatric cardiology services. The report addresses recommendations regarding the future, and was not intended to be a review of past clinical outcomes. Nonetheless, in my opinion, it supports concerns that the hospital may not have been fully prepared to offer the most complicated cardiac procedures to children.  In fact, given that the report was prepared with “extensive input and guidance from legal counsel,” the document is refreshingly and commendably frank.

Most of the issues of concern to the reviewers derive from the fact that Kentucky Children’s Hospital is not a dedicated freestanding institution.  It has to share its operating rooms, cardiac catheterization laboratories, other facilities, and personnel with the adult services of UK Hospital.  There are predictable problems with scheduling, equipment, and staffing with personnel who have extensive current experience with pediatric patients.  There was no dedicated pediatric cardiac intensive care unit.  The existing general intensive care unit was staffed overnight by residents and nurses, with attending-level physicians “available” by telephone.  It was recognized that increasing case volumes are necessary to develop a quality program that is sustainable, but this was thought to be a challenge because the institution is “surrounded by four well-established pediatric cardiovascular centers in the region.”

The review committee ultimately recommended creating a new “Pediatric Cardiac Service Line” implying that a more coordinated effort was needed.  A four bed dedicated pediatric cardiac intensive care unit was to be created and staffed 24/7 at a higher professional level.  As many as eight additional faculty with pediatric expertise were thought needed.  With these and many other specific program enhancements thought necessary, it was recommended that the hospital might reopen its surgery program as early as January 1, 2014, but then only for less complex Level I diagnoses.  The review committee contemplated a gradual increase in the difficulty of cases over time, but did not contemplate taking on the most complex Level V patients.  An aggressive statewide marketing program to increase the number of patients from Kentucky was outlined. I have no knowledge whether the specific recommended prerequisites for restarting have been met.

There is obviously much more that can be said about a 102 page analysis of multi-service capabilities.  I would however like to address the prominent focus on mortality rates as the measure of quality and outcome. There is no question that the University of Kentucky does collect data about disease severity and mortality using a national reporting system.  It has been reluctant however to release anything other than a global mortality rate of 7.1% following heart surgeries. [Pediatric heart surgery mortality rates reflect the number of patients who die within 30 days of the surgery or before they are discharged, whichever period is longer.]  There is some disagreement on how UK’s average compares to national mortality rates, but frankly, without a more detailed disclosure of mortality rates by severity of disease, the numbers disclosed up to now are meaningless to me.  By its own admission, the majority of the patients in Lexington had less severe congenital abnormalities.  What we really need to know is how Level I severity cases compared to national Level I averages, and so on up the scale of difficulty.  A 7.1% mortality rate for Level I or even Level III cases would be disastrous, but a 7.1% rate for level IV or V would be acceptable. (In fact the national mortality rate for  Level IV surgery is 7.3% and for Level V is 17.1%.)  It may be that the numbers were too painful for the University to release. This is a problem all healthcare providers face in the new world of outcome disclosure.

Why is all this relevant to our pediatric battleground in Louisville?

One of my (probably naïve) assumptions behind the University of Kentucky’s desire to associate with Norton Kosair Children’s Hospital was to facilitate a pediatric cardiac program that could provide care to the full spectrum of disease.  This is still probably partially correct.  In its review document, UK in several places recognizes that collaborations and mentorships with the larger programs that surround it would be mutually beneficial.  The committee even went so far as to specifically comment that a relationship with Norton Kosair Children’s Hospital would be desirable, “but logistically difficult.”  [I wonder why?]

It is clear however that UK is not contemplating giving up much of its pediatric cardiology program. Indeed it is ramping up to be a more formidable competitor to Norton Kosair, but might be willing to send its more difficult cases to Louisville.  [With a truly world-class pediatric Children’s Hospital just across the river in Cincinnati, our Kentucky institutions should reevaluate where the sickest of the sick could best be served.]

In truth, given the small amount of information given to the public about the justification for a presence of the University of Kentucky in Children’s Hospital and the virtual absence of any specifics, I can only speculate as to their reasons.  My instinct is that many academic and clinical benefits are possible, but for that to happen, both Vice Presidents For Health Affairs [or Presidents for that matter] would have to cooperate and interact with the full confidence of their institutions and communities behind them.  In my opinion, this will be a challenge.  I urge all our institutional leaders to rise above territorial urges and petty academic rivalries to think first about what is best for people with illness. In my mind, “What is best for Kentuckians will be best for the Universities of Kentucky and Louisville.”  Get over the rest!

Anybody think differently? Even one person?

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
January 20, 2014