By Anne Blythe
Three cardiologists from outside the state have reviewed the North Carolina Children’s Hospital pediatric heart surgery program and concluded the program can resume complex pediatric heart surgeries there.
The six-page advisory report released this week by UNC Health Care officials acknowledged that new leadership and investment in the program has helped resolve some of the thornier issues exposed several months ago in a New York Times investigative piece.
The external review panel also highlighted the program’s precarious perch as a smaller-volume pediatric cardiology program aspiring to grow in the shadow of a larger program only miles away at Duke University.
“The current pediatric cardiac surgical volume presents challenges in a number of areas,” according to the report compiled by Catherine Krawczeski, division chief of pediatric cardiology at Nationwide Children’s Hospital Heart Center, Victor Morell, surgeon-in-chief and division chief of the UPMC Children’s Hospital of Pittsburgh’s pediatric cardiothoracic surgery, and Edward Bove, chairman of the University of Michigan medical school’s cardiac surgery department.
The external panel suggests having two pediatric cardiac surgeons at a minimum, able to provide coverage 24 hours a day throughout the year.
UNC averaged slightly fewer than 120 “index pediatric surgeries” in the last year, putting it in a “medium” category in terms of volume. The panel found this “borderline for optimally supporting and maintaining” two full-time pediatric cardiac surgeons.
With smaller numbers, the panel noted, any complication or death will be magnified in percentages.
Don’t hesitate to refer
“While some smaller centers have been able to achieve excellent outcomes, in general larger programs have lower morbidity and mortality.”
With that, the panel said: “We support continued efforts to increase surgical volumes and referrals.”
In the world of surgery research, there’s an active debate over whether the number of surgeries performed by a team affects how well patients do. Some say it’s essential that surgical teams do more procedures in order to be ready to address complications more readily, while others argue that such an approach favors academic medical centers over general hospitals.
Meanwhile, the panel noted UNC “must balance” its role as a state hospital and being an important resource for patients with complex needs while also considering whether a referral to another institution might produce a better outcome.
“Complex patients with additional comorbidities that place the patient at higher risk of poor outcome (either surgically or postoperatively) should continue to be carefully evaluated by the medical and surgical teams with referral to another center if deemed appropriate,” the panel stated.
The New York Times piece that was published in May revealed concerns that physicians in the UNC pediatric cardiology program had about the pediatric heart surgery program in 2016 and 2017.
They were troubled by higher than normal death-rates there and told administrators that they were not sure they would refer their patients or their own children for surgeries there during that time.
That report, which included audio secretly recorded from meetings those cardiologists had with administrators, prompted UNC Health Care to announce changes to the program. Those changes included calling a halt to the more complex surgeries until an external advisory program had thoroughly reviewed the program.
Key staffing changes preceded the Times’ piece.
North Carolina Secretary of Health Mandy Cohen also ordered an investigation of the program. In August, state and federal regulators found the program to be in current compliance with federal rules, but also noted the staffing changes and other oversight measures put in place after the problematic period.
Additionally, the Children’s Hospital began making mortality data publicly available that they had only been using for internal reviews. Officials also settled a lawsuit brought by Ellen Gabler, the Times’ investigative reporter seeking the data.
As part of the settlement, UNC and UNC Health Care agreed to pay the news company’s $27,000 in legal fees, according to a copy of the agreement obtained by North Carolina Health News.
“We support transparency in outcomes to the public and participation of public reporting of outcomes,” the panel stated, while also recognizing “justifiable criticisms” of the current rating system.
Investments made, investments to come
“It is clear to us that significant investment in the pediatric cardiac program has been made with positive results,” the panel concluded. “UNC has an excellent foundation for continued success and ongoing improvement. To continue the move forward, this new collaborative culture should be fostered and encouraged. Open, honest, and respectful discussion of outcomes, care issues, and disagreements in care are to continue to be welcomed. We support the ongoing work to increase patient referrals and surgical volume, recognizing that the overarching goal is outstanding outcomes and not merely program growth.”
Since 2017, there have been continued efforts to recruit faculty in the pediatric cardiology division with three members added in July and a goal of increasing that number to 12, an ambition supported by the hospital.
The idea is to get faculty with more specialized interests and to move away from a generalist model. The panelists suggested a focus on more expertise in fetal cardiology and adult congenital heart disease.
Over the past six months, the health care system has created a pediatric cardiac intensive care unit that can be staffed 24 hours a day throughout the year. A search for an experienced medical director to oversee the unit is underway.
The panel suggested also considering programs that might differentiate UNC from regional competitors, suggesting perhaps a comprehensive multi-disciplinary single care unit that includes cardiac, liver, kidney and neurodevelopment specialists, or an adult congenital heart program, a pulmonary hypertension program or cardio genetics program.
“We have made significant investments over the years to improve our pediatric cardiology program, and will continue to make further enhancements because we recognize the importance of caring for very sick children with incredibly complex medical problems,” Wesley Burks, the UNC Health Care CEO, said in a statement.
Charlie Owen, chairman of the UNC Health Care board of directors, added: “We are pleased with both long term and recent improvements to the program and fully support additional enhancements to ensure that our pediatric heart surgery program is one of the best in the country.”
Sarah Ovaska-Few contributed to this report.