Halfway through its second year, Landmark Medical Center’s open-heart surgery program is only doing three or four surgeries per week, about a third of the patient volume the state says such a program should have to ensure quality and avoid a waste of resources.
Landmark, which did its first open-heart operation in May 2005, has three more years to ramp up to the state’s 500 cases-per-year benchmark.
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The program has grown over time. In the first year, 81 surgeries were done, while this year, Chief Administrative Officer Richard Charest said, “we’re on track to do 150 to 200.”
Asked whether Landmark can still meet the target of 55, he acknowledged it could be a challenge.
Under the state’s hospital regulations, an open-heart surgery program that doesn’t meet the 500-case minimum can have its authorization suspended or revoked. But those rules may soon change.
For starters, the state’s other open-heart surgery programs, at Rhode Island Hospital and The Miriam Hospital of Rhode Island, have both fallen below that threshold, reporting 446 and 457 surgeries, respectively, in the year that ended Sept. 30.
Rhode Island Hospital also fell short in fiscal 2005, with only 491 cases. Donald C. Williams, associate director for health services regulation at the R.I. Department of Health, said his office has been working on the issue with hospital leaders for the past year.
And with open-heart surgery on the decline nationwide, Williams said that Dr. David R. Gifford, the state health director, has enlisted a group of experts – the Tertiary Care Committee – to determine whether the annual minimum should be lowered.
“There certainly are facilities across the country that have excellent outcomes with lower volumes,” Williams said, adding that some Massachusetts hospitals are in that situation.
If the standard is changed – which Williams stressed is not certain – it would be set somewhere between 300 and 500 cases, he said. But the committee has one other issue on its agenda that it must resolve first, he said, so this won’t be decided until roughly late spring.
In the meantime, Williams said, his office is going to issue variances to Rhode Island and Miriam, temporarily lifting the 500-case mandate. In the long run, of course, any changes to the rules would apply to Landmark as well, he said.
But even if the benchmark is lowered, the stakes for Landmark remain high.
To start the program, the hospital had to open two cardiac catheterization labs – the first of which alone cost $1.8 million. The second, which opened last year, and the two operating rooms used for open-heart surgery, cost a combined $4.2 million – money that Landmark borrowed.
In addition, the hospital had to improve its labs and other key services, Charest said.
Running the program is also costly, starting with the three surgeons, who are affiliated with Harvard Medical School and Beth Israel Deaconess Medical Center.
Even without red ink from the heart program, Landmark had been struggling financially, losing $1.86 million from operations in fiscal 2002 and $166,000 in 2003, and registering a $170,000 operating profit in 2004. In fiscal 2005, when the surgeries began, the hospital logged a $1.6 million operating loss; figures for fiscal 2006, which ended Sept. 30, are not yet available.
When Landmark went head to head with Blue Cross & Blue Shield of Rhode Island earlier this year, complaining about low reimbursement rates, among other things, the insurer and others suggested that the hospital’s real problem was the heart surgery program.
(Blue Cross and Landmark have since settled their differences, and neither side would comment on the role of the heart surgery program in their discussions.)
Charest wouldn’t say exactly how much the heart surgery program costs, but did say that to break even, Landmark needs to boost the case volume by another 100 surgeries per year. The cath labs are already paying for themselves, he noted, with about 1,500 procedures per year – about 1,100 of them diagnostic.
“Any program, no matter what, has a startup investment phase,” he said. “We’re not far from that program covering its cost, and we feel that we’ll be there soon. And it’s a commitment that the hospital has made … because we believe that the population we serve needs it.”
Both Charest and Dr. Divakar Mandapati, the hospital’s chief of cardiac surgery, also stressed that more than volume, Landmark’s priority has been quality. In the first year, Mandapati said, the doctors deliberately limited their activities to assure quality, sending patients with serious “co-morbidities” such as severe lung disease to Beth Israel, by default.
“We wanted to be sure that our systems were in place to execute well,” he said, and now those patients’ surgeries are also being done at Landmark.
The team has set internal quality benchmarks, Mandapati added, setting targets for how quickly patients are removed from the ventilators, how quickly they eat, how quickly they walk. “These little measures actually add up for better outcomes,” he said.
And Landmark is performing well on those measures, he added. The Society of Thoracic Surgeons, to which the hospital sends all its data, has reported back that Landmark’s program is the quickest in the nation to extubate patients, for example, reducing the risk of ventilator-related infections and allowing patients to move and eat sooner.
Landmark also has done well in the big picture. With more than 120 surgeries already completed as of last week, the program has had only one fatality, Mandapati said – an elderly woman who had an emergency operation and was found to have a ruptured coronary artery. Morbidity rates (complications not resulting in death) also have been low, he said.
“Some would ascribe it to luck,” he said, “but it would be discounting our own work to say it’s all luck.” He gave credit to the nursing staff in particular, noting that “95 percent of the innovation” in improving patient care “has come from the ground up.”
The next step for Landmark is to make the cardiac program operate 24/7. At this point, it operates about 17 or 18 hours per day, said Nancy Thomas, vice president of communications, and by January, it will be 24/7. That, in turn, is expected to boost patient volume.
The impact of larger trends, however, is hard to predict. Asked why Rhode Island Hospital’s and Miriam’s numbers had been dropping, spokeswoman Nancy Cawley said Landmark might have been a factor, but new medications and treatment options have played a bigger role.
Yet Williams, at the Department of Health, said the decline could be affected by new questions about the use of stents – one of the factors that have reduced the need for open-heart surgery. “It’s in flux,” he said of the trend.
Meanwhile, Mandapati and his colleagues, Dr. Michael A. Coady and Dr. Frank Sellke, are sticking with their vision of “total quality improvement” and gradual growth.
“Volume is very important – we want to get there,” Mandapati said. “But in doing so, you cannot lose sight of the fact that we’re doing something unique.”
