Pa. reviews infant heart deaths; N. Philly program to reopen

Twenty percent of newborns who underwent surgery for heart defects died within a month of their procedures at St. Christopher's Hospital for Children, the highest mortality rate among five hospitals analyzed in a new state of Pennsylvania report covering 2012 through 2015.

At each of the four other institutions in the report, mortality rates following the delicate surgeries were below 10 percent during that four-year period, according to the Pennsylvania Health Care Cost Containment Council.

But when statisticians took into account the level of risk inherent in each surgery and compared them with results nationwide, they determined that performance at all five, including St. Christopher's, was within an acceptable range.

St. Christopher's "outcomes are what you would expect, given how sick their patients were," said Joe Martin, executive director of the state agency, which tracks health-care costs and quality.

The North Philadelphia hospital chose not to submit its patient data for the agency's previous report on pediatric heart surgery, issued in 2015. The hospital voluntarily stopped performing all nonemergency heart procedures in late January 2016 pending an internal review.

Hospital officials said Wednesday that they were poised to resume offering the service this summer.

Soon after the stoppage last year, an Inquirer analysis found that 24 percent of newborns, defined as babies younger than 31 days, had died after heart surgery at St. Christopher's from 2009 through 2014. A month after that article was published, state investigators conducted a surprise three-day inspection of the facility, finding that the hospital failed to fully investigate why nine of its patients died after heart surgery.

Asked whether St. Christopher's was ready to ramp up its heart-surgery program after more than a year of relative inactivity, interim chief executive officer James B. Burke said yes. He was joined in that assessment by Octavio J. Diaz, chief medical officer for Tenet Healthcare, the Dallas-based corporation that owns St. Christopher's.

Two of the hospital's three heart surgeons have continued to perform surgery at other hospitals, and St. Christopher's also has sent a dozen nurses and technicians to Children's Hospital of Michigan for specialized training, Diaz and Burke said in an interview. In addition, St. Christopher's has hired cardiac intensivists — cardiologists with expertise in caring for critically ill infants with congenital heart defects.

When the program resumes full operation, surgeons will not take on the most difficult cases at first, Diaz said. Patients will receive postoperative care in a $115 million critical-care tower that was completed last year.

"We're comfortable and confident that our surgical team, our nursing team, and our clinical team have been preparing and making sure they remain up to speed in this process," Diaz said.

The new state report included surgical results from four Pennsylvania hospitals — St. Christopher's, Children's Hospital of Philadelphia, Children's Hospital of Pittsburgh of UPMC, and Penn State Children's Hospital — and one in Delaware: Nemours/Alfred I. duPont Hospital for Children, in Wilmington.

Geisinger Medical Center Children's Hospital in Danville, Pa., which also performs heart surgery on children, submitted its data but was not included in the state's analysis of mortality rates because it did not have a dedicated pediatric heart surgeon in 2014 and 2015.

The data in the state report were collected by the Society of Thoracic Surgeons, a professional medical society that gathers and analyzes similar data from more than 110 hospitals nationwide, all of which volunteer to participate.

The society calculated the hospitals' mortality rates after 10 types of heart surgery, including the one recently performed on the son of talk-show host Jimmy Kimmel, and it also determined the overall mortality rate at each facility for any heart surgeries performed on newborn patients.

In nearly every case, the mortality rates fell within the expected range during the four years in question, given the level of risk in each case. The lone exception was Children's Hospital of Pittsburgh, which had zero deaths among 30 patients who underwent an especially arduous surgery called the Norwood procedure.

Nationally, the expected death rate following the Norwood is 15.5 percent, according to the Society of Thoracic Surgeons. Pittsburgh's performance was so much better than the national average for that procedure that the difference was likely due to better quality, and not chance, the report's authors stated.

(The report did not include a Norwood mortality rate for St. Christopher's, as its surgeons performed fewer than five such operations during the four-year period.)

The report did not list the hospitals' mortality rates associated with all heart surgeries for children of all ages, including less risky procedures on older children, but the thoracic surgeons' group does so separately. By that measure, Penn State Children's Hospital achieved an overall adjusted mortality rate of just 1.3 percent, compared with the 3 percent national average.

The field as a whole has made dramatic strides from just a few decades ago, when certain heart defects were nearly always fatal, said J. Brian Clark, chief of pediatric cardiac surgery at Penn State, located in Hershey.

"Now, even with many of the worst kinds of congenital heart defects, long-term survival is expected for the vast majority," Clark said.

Jeffrey Jacobs, a professor of cardiac surgery at Johns Hopkins University and a leader of the national data-gathering effort by the thoracic surgery group, praised Pennsylvania for publishing its report.

"The state of Pennsylvania is leading the way in terms of transparency," said Jacobs, chief of cardiovascular surgery at Johns Hopkins All Children's Heart Institute in St. Petersburg, Fla.

The report did not assess whether hospitals should have declined to perform surgery on some especially fragile patients.

While hospital performance numbers were adjusted based on patient risk, the analysis also did not take into account another indicator that some experts say is correlated with outcomes: the socioeconomic status of the child's family. Three-quarters of the patients at St. Christopher's are eligible for Medicaid, and thus have fewer resources that would help in caring for a child with complex illnesses, Burke and Diaz said.

But in the Inquirer analysis of mortality rates and a separate analysis of postoperative recovery times, Medicaid status appeared to make little difference. As in the overall patient population, Medicaid patients at St. Christopher's fared worse than Medicaid patients at Children's Hospital of Philadelphia.

Yet Martin, the executive director of the agency that issued the new state report, said heart surgery outcomes at St. Christopher's had been improving before the hospital undertook the internal review.

The hospital said that in 2015, just one in 13 newborns died following heart surgery. The overall mortality rate from 2012 to 2015 was 20 percent — as 12 out of 60 children died — meaning that the deaths for the first three years stood at 11 of out 47.

"My understanding is that when you look at the number of mortalities that St. Chris has, it is skewed to the early part of this reporting period," Martin said. "If that is the case, it's fair to say they are moving in the right direction."

When the results were adjusted for how sick each patient was and the risk of each surgical procedure, St. Christopher's effective mortality rate for heart surgery on newborns was calculated at 13.4 percent.

Taken at face value, that is still higher than the comparable national mortality rate of 8.9 percent. But because of the relatively small number of newborn heart surgeries at St. Christopher's, statisticians found that the difference from the national average could be explained by chance. Generally, the larger the number of patients studied, the more confidence researchers have in the results.

Staff writer Dylan Purcell contributed to this article.