OF MAINTAINING SEVERAL HEART TRANSPLANT CENTERS
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Welcome to ReachMD's monthly series - focus on Public
Health Policy. This month we explore the many questions facing healthcare
The Chicago metropolitan area is home to 5 Adult Heart
Transplant Centers equal to Philadelphia for the most in one city in the United
States. Some say it's a tribute to the determination of Chicago's Hospitals to
collectively become a national leader in heart transplantation, but others
believe it's a serious strategic mistake. What are the key policy questions at
hand here. You are listening to ReachMD XM 157, The Channel for Medical
Welcome to a special segment focus on healthcare policy.
I am your host, Dr. Mark Nolan Hill, Professor of Surgery and practicing
general surgeon and our guest is Dr. Valluvan Jeevanandam, Professor of Surgery
at University of Chicago Pritzker School of Medicine and Chief of Cardiothoracic
Surgery at the University of Chicago Medical Center.
Welcome Dr. Jeevanandam.
Well, thank you very much Dr. Hill. It's my pleasure to be
here on your program.
We are discussing the potential pitfalls of maintaining
several Heart Transplant Centers in one city. Why is this a pitfall?
There have been many studies. The latest one that's come
out of Johns Hopkins that shows that with most surgical programs, volume really
does matter. You know size matters in terms of getting better results. So,
the data suggest that programs that do about 20 transplants and above have
better results than programs that do 10 transplants and less and therefore I think
programs should be only opened if they can do a certain amount of transplants
to give the best patient care.
Are there regulations that guide this?
Well, there are Medicare regulations. Now, Medicare
originally too would credential centers and to credential a center you
have to do 12 transplants over a 2-year period and have 2-year results. So, it
took 3 years to get Medicare certification. Now, that was in the past, and
after much lobbying from many other programs, those requirements decreased to
doing 10 transplants per year with 1-year results. Now, the problem is that
many programs would get Medicare certification and then let their programs
decrease in terms of volume and Medicare would never come back and audit them
and remove programs. So, once you got Medicare credentialing, you never got
de-credentialed. I think that there have been several transplant programs in
the country that have been caught with bad publicity in situations where they
were not doing transplants that they should have been doing and therefore
Medicare is now joining up forces with JCAHO, are auditing programs and going
over their results every couple of years, and if they do less than 10
transplants per year, they are now decertifying programs, and under that
threat, programs are voluntarily taking themselves off transplant certification
because they rather do that as opposed to being audited.
Let's talk about the results. In general surgery, we are
always told that if you don't do a certain number of Whipple's a year or
certain number of abdominoperineal resections a year you lose the technical
ability to get good results. When you talk about the less than optimal results
in centers that do not do a lot of transplants, are we talking about
specifically with regard to the surgical team or the overall transplant team?
I think transplant is a technical operation, but it's much
more of an intellectual operation. One needs to decide what is a good donor,
what is a good recipient, and in addition to the surgeon, there is an entire
team that needs to be passed out with transplant. That team would include
cardiologists, pathologists to read the biopsy, infectious disease experts, critical
care experts, nephrologists or renal experts. So, there need to be a large
infrastructure that is established to make a good heart transplant team or any
But how did Chicago and Philadelphia get so many heart
transplant programs to begin with?
When I was in Philadelphia, I was Director of the Temple
program. We did about 100 transplants a year. We were the largest program in
the country, and in the city of Philadelphia, the year before I left; we did
180 transplants just in the city of Philadelphia. That’s a tremendous amount
of transplants. There was a lot of enthusiasm and a lot of focus on
transplants, and after I left, you know Temple's program has decreased their
volumes significantly, and even though they have 5 programs now, they don't do
nearly the volume that we used to do many years ago.
Why do you think that is? Are we treating these patients
medically more efficiently?
Yeah, I think again since the 90s or the late 90s when I was
there, we now have beta-blockers that are being used more for patients, we have
biventricular pacing, but I also think that there are other policy decisions
that have made transplant lot less of an option. In the 90s, we did not have
ventricular assist devices, and so if the patient didn't get transplanted, you
know their only other choice was death, and so we were very aggressive by
transplanting patients. Now, you have mechanical assist devices, some of which
can actually be placed in, and for patients who are not great transplant
candidates, you can put a device in and not get them transplanted. I think the
other policy decision though is that Medicare is auditing all these programs,
and because you now get audited, unless you have a 1-year survival of greater
than 85%, you are at risk of losing your accreditation.
Well doctor, do the transplant centers in the city like
Chicago where you are or Philadelphia, do they talk to each other?
Probably more at national meetings than we do on a regular
basis within the city that we are all based in. So, we don't really talk to
each other on an ongoing basis, and honestly, it is pretty competitive.
Why would the hospitals who do not do a great number of
heart transplants want to continue their program?
Because transplant is a major draw to get patients to come
in, who in heart failure and heart failure can be potentially profitable for
institutions especially people need to have diagnostic tests performed, perhaps
a correctable lesion can be discovered and the patient will end up getting
catheterization or stent or may be even surgery, and also because there are so
many regular heart surgery programs, programs need to distinguish themselves
and take care of the heart failure patients and certainly a way to do that.
Dr. John Conte, Director of Heart Transplantation at Johns
Hopkins Chicago may have the finest group of transplant surgeons of any city in
the world. With this in mind, where is the hold up?
When I was talking to you earlier, it wasn't just the
surgeons, right, it's the whole team and it's the policies of Medicare looking
at mortality. So, let's say you have a program that does less than 10
transplants or does 10 transplants and is on the cusp. If they lose 1 patient
in the first year, that's a 90% survival and they are okay. If they lose 2
people, that's an 80% survival, but they are now going to be at the cusp of not
getting Medicare approval. So, they are going to be very, very selective on
what they do, and being selective means that you are not going to take a
patient, who may be at slightly higher risk, and I will give you an example,
let's say you have a patient, who is almost certainly going to die without
transplant, so for him the chance of death is you know 100%. Now let's say you
can operate on him and transplant him and the chance of survival is 60%, okay.
So from his point of view that's a positive 60% in terms of survival; however,
if Medicare mandates that you have..
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