Doctors Were Alarmed: ?Would I Have My Children Have Surgery Here??

Several doctors began referring more children elsewhere for surgery.[Listen to key moments from the recordings.]The heart specialists had been asking to review the institution’s mortality statistics for cardiac surgery — information that most other hospitals make public — but said they had not been able to get it for several years. “We determined,” said Dr. Benny Joyner, chief of critical care at the children’s hospital, that “there is nothing here that is systematic, or systemic that would lead us to be concerned about the performance of operations on children that are high-risk, low-risk, no-risk.”Other administrators, in a joint interview, said there was “a dysfunctional group” in 2016 that sowed mistrust, creating “team culture issues.” Lisa Schiller, a spokeswoman, said in a statement, “They were handled appropriately, and today we have new team members.” UNC cited leadership changes — most taking effect in 2017 or 2018, including the appointment of a new chief surgeon last year — to help improve the dynamics.The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country. While there is some debate about whether the data fully captures the complexity of heart surgery, many experts say it is a strong indicator of a hospital’s performance.“You should think twice about going to a center that doesn’t publicly report,” Dr. Backer said. Administrators might stop investing in the program, he said, as those at some other hospitals were considering.In a recent statement, UNC said that sending patients to other medical centers had been discussed but was determined not to “be in the best interest of UNC or its most vulnerable patients.” Separately, the five remaining cardiologists, who include Dr. Hoffman, said in a statement that they had always “selectively referred particularly complex patients to outside institutions” but sent “the large majority of patients to our internal team at UNC, because we were confident that they would receive high-quality care.”The cardiologists acknowledged in the meeting that multiple factors went into successfully managing cardiac patients, but expressed doubts about the chief heart surgeon at the time, Dr. Mill, who performed most of the operations. They did not report directly to anyone inside the children’s hospital, but to the department of surgery within UNC’s broader medical system, which includes five hospitals in a Chapel Hill complex and about a dozen other facilities around the state.A few weeks earlier, Dr. Mill had not come in on a weekend to perform a transplant on a baby when a donor heart became available, the doctors said. The surgeon’s reason wasn’t clear, but the incident could have led to a shutdown of UNC’s program if the United Network for Organ Sharing, which manages transplants throughout the country, had found out, Dr. Robinson said in the meeting.The child’s parents, who weren’t aware of what happened, soon transferred her to nearby Duke Children’s Hospital, where she would eventually receive another heart a few months later. In fact, she did leave later that summer, and for nearly two years afterward Dr. Mill was the hospital’s only cardiac surgeon.The best option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. The letter, a copy of which was shown to The Times, complained about Dr. Kelly’s “threat” to eliminate doctors’ jobs if they stopped referring patients internally, and warned of “unsafe and unethical practices” in pediatric cardiology and cardiac surgery.In a statement, UNC Health Care said the institution had conducted a “thorough internal investigation” of the concerns described in the letter, and “criticism of the program was found to be unsubstantiated.”The inquiry involved looking at specific cases and interviewing “key informants,” said Dr. Thomas Ivester, UNC’s chief medical officer. UNC said in a statement that “not each and every physician would have been involved and aware of reviews” of other personnel.At a conference last fall, Dr. Backer, the Chicago heart surgeon, urged fellow surgeons to consider “rational regionalization,” or joining forces in an effort to reduce mortalities nationwide for congenital heart defects, potentially saving hundreds of lives.Reaching adequate case volumes to keep up skills is a challenge because so many hospitals are competing for patients — surgical programs are an important driver of revenue. Children with the most complicated conditions have surgery in Charlottesville, where the hospital has a transplant team and cardiologists who specialize in pediatric heart failure.“When you get on an airplane, you want a pilot who does this every day,” Dr. Gangemi said. In fact, surgeons at other hospitals often share such data with cardiologists from competing institutions.While UNC said in a statement that it was “potentially reckless” to use the data to drive decision-making about where to refer patients, doctors across the country said it was simply one factor, among several, that should be considered.In October 2017, three babies with complex conditions died after undergoing heart surgery at UNC. Dr. Kibbe, the surgery department chairwoman, said in a recent interview that the hospital had never restricted surgeries.In December, another child died after undergoing surgery a few months earlier for a complex condition.The four deaths were confirmed by The Times, but are not among those disclosed by UNC. “It’s better than anything else that is out there, for sure, but it’s not perfect,” said Dr. John Mayer, a surgeon at Boston Children’s Hospital, who is leading an effort now.UNC has said it will publicly release its mortality data through the Society of Thoracic Surgeons once it has had at least two pediatric surgeons for several years. That information does not meet the Society of Thoracic Surgeons’ standards for public reporting, which require, among other things, four consecutive years of data to more reliably assess how a program performs over time.UNC says its recent results show that its surgical program is performing well, thanks in part to years of quality-improvement efforts including extensive reviews of each death; specialized training for nurses; and protocols to decrease infections, standardize preoperative care and manage post-surgical patients with irregular heart rhythms.By 2018, four of the nine pediatric cardiologists had left the hospital. Although UNC maintains that its surgery program had adequate resources in 2016, it is now taking steps the cardiologists discussed back then, like hiring more cardiac intensive care doctors and opening a cardiac intensive care unit.“The program today is not the program from 2016, and the program in 2016 was not the program from 2012,” said Dr. Ivester, the chief medical officer. The child’s condition, hypoplastic left heart syndrome, requires a series of three surgeries to reconstruct the heart and blood vessels.He had the first two operations at UNC — including the riskiest, which has a mortality rate of 15 percent — but given the complexity of his condition, his parents, Quanasia Dean and Sean Moore, said they considered taking him to a Philadelphia hospital that specializes in the third procedure.They’d gotten the idea a year earlier, when Jeremiah’s cardiologist, Dr. Whitham, had said she would send referrals for second opinions to the Charlotte medical center and Children’s Hospital of Philadelphia. After Dr. Frantz discussed Jeremiah’s case with other physicians at the hospital, a plan was made for the almost 2-year-old to have his third surgery there that spring, according to his medical records.When the hospital called Jeremiah’s mother to schedule the operation, she was surprised, she said, because of the earlier recommendation about the Philadelphia hospital. It reports a mortality rate of less than 1 percent for the surgery, known as the Fontan procedure; the national rate is 1.1 percent.When Ms. Dean called Dr. Frantz to ask about taking Jeremiah to Philadelphia, he assured her the surgery could be done at UNC, she said in an interview.Nearly two years earlier, Dr. Frantz had said in the meeting with Dr. Kelly that the cardiologists had come to feel that UNC wasn’t “where we need to be for complex cases,” according to a recording. “We all sort of have our own take on the results and it’s not favorable, and we’ve sort of lost confidence in the program,” he said.Jeremiah was on Medicaid, which can make it harder to go out of state, but his mother said Dr. Frantz never mentioned that as a reason to keep him at UNC.It is unclear whether the cardiologist considered Jeremiah’s case to be complex, but Dr. Mill, the surgeon, noted that the little boy was a “high-risk candidate” last May, shortly before his operation, according to his medical records.The surgery took twice as long as expected, his mother said, but after about 11 hours, he was wheeled into the pediatric intensive care unit.Over the next two weeks, he struggled.