Heart surgeons at Johns Hopkins have evidence to support
further tightening rather than
easing of standards used to designate hospitals that are
best at performing heart transplants.
In a study presented Jan. 29 at the 44th annual
meeting of the Society of Thoracic Surgeons in
Fort Lauderdale, Fla., the Johns Hopkins team recommended
that the benchmark for designation as a
high-volume hospital rise from 10 heart transplants per
year to 14. High-volume centers consistently
show higher survival and fewer complication rates.
However, the standard, which is officially set by the
Centers for Medicare and Medicaid
Services and which qualifies medical centers for federal
reimbursement, was recently lowered from
12 per year to 10.
"The bar for patient safety, quality of care and
survival needs to be set pretty high," said
senior study investigator and
cardiac surgeon John Conte. "Our national health care
system has to
rethink which hospitals should do heart transplants, and,
in consultation with their physicians, patients
need to evaluate these surgical volumes to see for
themselves which hospitals have teams operating at
their peak skill level."
Conte and his team reviewed the patient records of
14,401 men and women who received a heart
transplant in the United States between 1999 and 2006.
The study is believed to be the largest and most
thorough review of survival rates after heart
transplantation in hospitals, based on volume.
"Our results clearly demonstrate that current
standards have been arbitrarily set too low," said
Conte, who is director of heart and lung transplantation at
The Johns Hopkins Hospital.
"There is a certain threshold, a minimum number of
surgeries needed to maintain the expertise
of the entire transplant team," he said, noting that a
dozen or more highly specialized professionals
are involved in each transplant case, including cardiac
surgeons, cardiologists, anesthesiologists,
transplant coordinators, intensive care nurses,
immunologists, pathologists, pulmonologists and
In the new study, researchers found that death rates
one month and one year after transplant
increased steadily at hospitals that performed fewer than
14 heart transplants per year, which was
the case for a majority of the 143 medical centers in the
United States licensed to perform them.
According to the researchers' analysis, roughly a dozen
institutions (including The Johns Hopkins
Hospital and the University of Maryland Medical Center)
perform more than 20 cases annually, and
fewer than 10 hospitals do more than 30 procedures, with no
more than five sites performing more
Study results showed that the overall average death
rate one year after surgery was 12.6
percent. However, patients had a 16 percent greater chance
of dying in a hospital that performed
fewer than five heart transplants per year and had the best
chances of surviving, with a 30-day
mortality rate of less than 1 percent, at a hospital that
performed more than 40 procedures per year.
Patients at hospitals with volumes of less than 10 had an
80 percent greater chance of dying within a
Using a graph and statistical analysis, researchers
showed that death rates flattened for the
majority of patients in hospitals with heart transplant
volumes at 14 or more per year.
Conte, an associate professor of
surgery at the Johns Hopkins School of Medicine and its
Heart Institute, says heart-failure patients on
transplant wait lists should consult with their
about hospital and surgeon volumes when making decisions
Johns Hopkins cardiologist and study co-investigator
Stuart Russell, who has cared for more
than 360 transplant patients in the past decade, says
patients should also look for consistently high
volumes over several years as well as at overall survival
rates for transplant programs.
One-year survival rates at The Johns Hopkins Hospital,
he notes, consistently average above 90
Despite the team's findings, Russell says it will take
a clear shift in public health policy to move
American medicine toward further concentration of volumes
for complex procedures such as heart
In the United Kingdom, he points out, centers
designated to performed heart transplants are
severely restricted, and volumes soar past 50 for each
"In the United States, too many low-volume hospitals
have a program that they won't let go of,
no matter how poor the results," says Russell, an associate
professor at Hopkins.
More than 2,000 people undergo heart transplants each
year in the United States. Nearly 3,000
remain on wait lists to receive a heart, and up to 20
percent of those will die while waiting. Costs for a
heart transplant often run as high as $260,000.
This study's data were supplied by the United Network
for Organ Sharing, a national network
that allocates donated organs across the country. Funding
for the study was supplied in part by The
Johns Hopkins Hospital.
Other Johns Hopkins investigators involved in this
study were lead researcher Eric Weiss,
Robert Meguid, Nishant Patel, Ashish Shah and William