Terry Boyd of Insider Louisville has reported rumors of an upcoming announcement by the University of Louisville concerning its Pediatric Heart Transplant Program. If this happens, it would not be totally unexpected. Norton Healthcare and the Department of Pediatrics have been advertising jointly for a pediatric cardiologist with experience in the medical management of these patients. (A former UofL cardiologist with those qualifications left last year to join a program in Texas.) The Division of Thoracic and Cardiovascular Surgery in UofL’s Department of Surgery still lists two cardiac surgeons with pediatric qualifications. The contact person for the advertised search is at Norton, leaving the question open of who will be hiring or paying for the new physician. Norton’s hiring away of UofL faculty has been a highly contentious issue for UofL. It is good to see that there is still some cooperation between the two competing healthcare organizations. Could this be a sign of bigger things to come?
It was noted that such a pediatric transplant program would not be completely new. Although I am told that there has been no heart transplant at Kosair during the last 12 months or so, a look at the numbers from the Organ Procurement and Transplantation Network (OPTN) confirms that Kosair Hospital has had such a program at least since 1988. The table just below shows the number of pediatric heart transplants done at Norton Kosair Hospital for Children. The numbers have never been very large and in some years there have been none. There may be accreditation issues when the volumes are low, but I do not know if that has been a problem for us.
National Data.
Nationally, in 2011, the last year for which full data is available, there were a total of 2322 adult and pediatric heart transplants. This number has not changed very much from 1990. In 2011, 373 (16%) of the transplants were for were for children 17 years old and younger. The number of heart transplants for children have been rising slowly. In the 1990s, the annual number hovered around 270.
Comments.
Places that can transplant hearts are almost certainly competent to perform a much wider variety of complicated cardiac surgery and other types of solid-organ transplantation. Transplant programs have a feather-in-the-cap nature that is often used to market their parent organizations. Certainly we have seen this in Louisville. Competition is fierce nationally. The year I worked in Washington, it was disheartening to see large and small centers fighting over organ-allocation legislation. The argument made by the larger centers was that their experience would provide a better outcomes. I do not have the facts to know if this is true, but surely there must be some minimum number of patents necessary to retain staff and enable a program to sustain itself financially.
Other Pediatric Heart Programs.
For pediatric patients, the issue of volume is even more acute: there are just not that many patients. Since 1988, Kosair/UofL transplanted 48 pediatric hearts. The University of Kentucky does not do pediatric heart transplants in children at all. In Ohio, the Children’s Hospital Medical Center of Cincinnati has transplanted 86 hearts since 1990. The Nationwide Children’s Hospital in Ohio transplanted 26 since 2003. Even the giant Cleveland Clinic with a national draw only transplanted 106 pediatric hearts since 1988, barely double our own Kosair. How best to provide such infrequent and complicated services is the kind of policy issue that health care reform should be dealing with but which gets bogged down in the hyper-competitive medical system we have inherited.
Transplantation at Jewish Hospital.
While I was rooting around in the OPTN data base, I took a look at the adult heart transplant numbers for Jewish Hospital. Take a look at the chart below. Jewish Hospital has averaged almost 16 patients a year for the past 25 years, a little more than one a month. The trend has been downward however, and in 2011 there was a dramatic dip. (The lower number for 2012 represents only a partial year.) These last few years have been turbulent ones for Jewish Hospital and may explain the variability of recent figures. The University of Kentucky Hospital is the only other hospital in Kentucky that does adult heart transplants: 243 since 1991 compared with 397 since 1988 for Jewish. For all solid organ transplants combined, UK has continued to grow, and by 2011 UK was transplanting more organs than Jewish/UofL, whose program growth has stagnated or worse. (If there is interest, I will present additional comparative data for both Kentucky adult transplant centers.)
Final Thoughts.
The people, skills, and physical resources necessary to do human transplantation are similar, yet even in Louisville we have three different and competing transplant centers. (UofL Hospital does bone-marrow transplants.) I would like to think that the Louisville medical community might have a chance to settle down and focus on providing more cooperative, efficient, and cost-effective quality care for our citizens. More than anything I would like to see that happen. In all honesty, I believe we are due for even more turmoil, out of which will come few if any winners.
Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
July 16, 2012