University Presidents speak about cooperation.

A month ago, I wrote about issues concerning the pediatric cardiac surgery program at Kentucky Children’s Hospital in Lexington. That institution, part of the University of Kentucky’s University Hospital programs, was receiving much adverse publicity about allegedly poor mortality rates for cardiac surgery for pediatric congenital heart disorders. The institution temporarily suspended that surgery program and conducted an intensive in-house review emphasizing plans for the future.

My article was seen by Elizabeth Cohen, Senior Medical Correspondent for CNN who had been following the story. She asked me to respond to several questions. Because I believe the matter is relevant to health policy in Kentucky, I present here the responses I offered with some minor edits.

Issue #1.
Does it bother me that Kentucky Children’s Hospital is restarting its pediatric cardiology surgery program without releasing its mortality rates for congenital defect surgery?

I can’t say I am “bothered” by it. Especially since they are proceeding by beginning with the least complicated procedures and carefully following their progress. They seem to have some reason, philosophically or practical, that they do not want to release many more details about their reported operative results. They do want and need to reassure their public and recapture and expand their market share. I think they want and need to get this matter behind them. I can’t blame them. However, I would be bothered if they restarted their program without addressing the facility and staffing targets that their internal review deemed necessary. I have no knowledge one way or the other that they have.

Issue #2.
Given that there are other facilities in the adjacent multi-state region, should they ever start up again?

I think it is reasonable for the hospital of Kentucky’s flagship University and its medical school to offer pediatric cardiac surgery at some level. They serve one of the most disadvantaged regions in the nation. I don’t see other institutions lining up to help them out.

I can’t give an opinion on whether the hospital should restart any program at all. I have no basis to do so. I am prepared to take Dr. Karpf at his word that he takes the interests of his institution’s patient population to heart. Professionally I expect him to do so, and practically, unless his institution is willing to do so, it will ultimately fail. I was impressed by the frankness and comprehensive scope of the Hospital’s internal review report. They recommended things that they thought they could do better. All hospitals should be doing that. (I know that all could do more.) I wish Kentucky Children’s Hospital well in its efforts.

This question raises a more global public health issue. How should we organize our health care delivery in America? My instinct is that we need vastly more cooperation among providers. For example, surely not every hospital should be doing solid-organ transplants. Should every hospital in the country be offering pediatric cardiac surgery for congenital defects? Of course not. Should every pediatric cardiology surgery service in the country be doing the most difficult and highest risk procedures such as the Norwood procedure for babies with a single ventricle? Surely not. Who should decide on who does what?

My concern is that trends in the country now (and certainly as I see them in Kentucky) is that the way healthcare is being organized by government agencies, think-tanks, and insurance companies is fostering less cooperation among competing organizations. Although individual accountable care organizations, medical homes, or hospitals hiring their own stables of physicians and primary care networks may well lead to improved coordination of care locally in a single organization, it Balkanizes, duplicates , and increases competition among regional centers. In the current social and political climate, we as a people have been conditioned to be afraid of more central coordination of medical services. We have allowed the free competitive commercial market decide how things are done but then complain about the results. In my opinion unless we find the will to ensure better cooperation and coordination among providers, we will never solve the problem of overall cost. Indeed, it will get worse.

We have a long was to go nationally in deciding how best to take care of our sick neighbors. Even within Kentucky, we are having a hard time deciding how to cooperate academically among our state’s medical schools, let alone how to share the load of our clinical obligations to our Commonwealth.

Issue #3.
The University of Kentucky presented a statement to its Board of Trustees referring to excellent standing of UK HealthCare among academic health centers. It also mentioned as several federal and state reviews of its pediatric cardiac surgery program that were said not to find any deficiencies of care and required no remedial actions. These reports were not released to the to the press. What did I think of this?

With respect to overall quality of care, I have no absolutely doubt that the University of Kentucky Hospital is an excellent one. I would not hesitate myself to go there for care.

I am not a pediatrician, let alone a pediatric cardiac surgeon. However, the issues I wrote about do not require specialty knowledge, but reflect broad trends in healthcare. The public now expects greater transparency and accountability from healthcare providers for cost, process, outcomes, and much more. Thus we now see large en-bloc releases of information from governmental agencies such as Medicare, and from a host of non-governmental accrediting and quality-rating organizations. On the whole, I very much support the intent such initiatives. On the other hand, I do not think the healthcare community knows how best to meaningfully measure even such important things like quality or safety. I have written about my disappointment with the lability of such measures over short periods of time, and the variation of individual quality scores from different organizations for the same hospital over the same interval. Certainly popularity and reputation do not quality make, but are at best carnival mirrors of performance– suggesting but not clearly reflecting. The doctor-rating sites everywhere on the internet, based largely as they are on non-objective perceptions, make me shiver.

Hence the focus on things like mortality which are both meaningful and easy to measure. But even this “bottom line” measure presents problems in interpretation and meaningful use. How does one measure mortality? Death while in the hospital? Within 30 days of discharge? One year? Death from the initial illness, or death from any cause? Does quality of life even matter? How do we adjust, as we must, for severity of illness, or for the socioeconomic and other non-medical determinants of health of the patient population being served? What is the gold standard we must use for comparison? The best in the world, or only in the region? All hospitals, or only those of similar size serving similar populations?

Thus, mortality rates by themselves are of limited use. For example, a hospital that has a low mortality rate for a given diagnosis or procedure may be doing an excellent job, or it may have patients who are less ill, or may even be admitting or operating on less sick patients unnecessarily. The mortality rate alone does not allow us to discriminate among these possibilities. Mortality rates by themselves are subject to misinterpretation and misuse. That said, I think the public has a right to know them. It will however need help in understanding what the numbers can and cannot tell us. We must also recognize that there are undesirable consequences in disclosing such information. Hospitals or doctors may avoid providing necessary services to patients at high risk for fear of a bad mark on their record, or patients may be transferred elsewhere for the wrong reason.

There is always the very real concern that such information will be used or missed by the plaintiff’s bar. The never-ending tension between the real desire to do internal quality assessment and improvement, and the fact that the results can be used against the individual or institution is a seemingly intractable fact of professional life that is not in the public interest. It is difficult enough for professionals like myself to sort meaning out of data and appearances. I believe that a jury of laypeople has an even harder task, and that the results will often be grossly unfair to one party or another. There is a reason the internal review by University of Kentucky was carefully vetted by its own lawyers.

Here endeth my earlier proffered comments!

University Presidents’ comments on cooperation.
As I write this, the struggle for control of Kosair Children’s Hospital in Louisville between Norton Healthcare and the University of Louisville continues. I have written much about it, and most likely will continue to do so. It is a complicated matter, but underlying it all lies the essential need for cooperation among the entities who provide health care to Kentuckians. Willingly or not, the University of Kentucky is a party to our dispute in Louisville.

The Presidents of the two universities recently appeared before the Editorial Panel of the Courier-Journal to make a joint case for more state funding of their institutions. When asked for examples of cooperation between the two schools, they were very hard pressed to come up with more than a feeble hand-full. President Ramsey pointed to a booklet of “more than one hundred” examples, but this could not be made available to my request for confirmation. President Ramsey responded to the panel that as the economy improved, he hoped that that opportunities for cooperation would increase, but collaborations would have to be “win-win.”

When asked specifically about the matter at Kosair Hospital and the observation that the proposed cooperation with UK had “lit the fuse” for UofL to open its current, commercial, political, and legal disputes with Norton, the issue of pediatric cardiac surgery did not arise. University of Kentucky President Capilouto expressed his interest in having faculty working together, and his “respect for what we can do together.” He hopes the matter is resolved. I suggest to both Presidents, that the only party deserving of a “win” is the citizenry of the Commonwealth. What is good for Kentuckians will be good for your institutions. It doesn’t always work the other way around. It is not always your call to make.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
February 25, 2014