Letters

Posted: June 08, 2003

What really drives our health care system?

Two seemingly unrelated articles in The Inquirer presented data that lead me to conclude again that the Philadelphia regional health care system is driven by competition and dollars and not by patient care.

First, Josh Goldstein accurately reported that this region already has more heart transplant centers than the entire state of New Jersey ("Rivalry for heart patients growing," May 30). With Thomas Jefferson University Hospital and Lankenau Hospital planning to add new and untested programs, we will have more than the entire Los Angeles region. Are these additional programs needed? What is driving their entrance into this marketplace? Is it ego and dollars or is it patient care? How can quality of care possibly be preserved with the patient base being spread over so many institutions?

Last Sunday, reporters Stacey Burling and Susan FitzGerald compellingly reported yet another example of problems with transplants. ("A mystery at Jefferson: 52 surgeries, 9 deaths"). Nine sick patients died during or immediately following liver transplants. This is a complications/death rate far in excess of what can and should be expected.

Jefferson is a first-tier hospital and one where I have personally had surgery. However, one must ask: Did the surgeons tell the patients how many liver transplants they had performed in the past five years and what their complication rates were? Did they tell them that the liver transplant program at Jefferson was undergoing its own transition? Did they give the patients, and their families, enough data to make informed choices? After the first few unexplained deaths, were patients informed of these tragedies?

In this region, we have four excellent medical schools with superb teaching hospitals. Is it necessary that each provide every service? I think not. They should share expertise and training programs.

Patients, and their families, should be confident that the doctors and hospitals have the systems in place to assure that every patient receives high-quality care. Our doctors and hospitals should be motivated to provide Philadelphians the best quality health care in this country and not be driven by competition, egos or dollars. If the hospitals and doctors cannot quickly prove that they can self-regulate in order to protect patients, state and local government should take action.

Stuart Shapiro, M.D.

Bala Cynwyd

shapirostu@aol.com

The writer was Philadelphia's health commissioner from 1981-1986.

Outstanding physicians

I would like to address misconceptions I feel could arise from the article on the deaths related to liver transplantation at Thomas Jefferson University Hospital ("A mystery at Jefferson: 52 surgeries, 9 deaths," June 1).

I recently retired after 16 years as chairman of the department of radiology at Jefferson. Although I no longer have any official affiliation with the hospital, I am familiar with the work of most of the surgeons and other specialists mentioned in the article. All are outstanding physicians who are dedicated and highly competent.

It is important that readers (and the many thousands of patients who receive care at Jefferson every year) understand that deaths and other complications of surgical procedures sometimes occur in clusters that may simply be statistical aberrations, particularly when dealing with only 52 cases. It is also important to remember, as pointed out in the article, that outside monitoring organizations looked at Jefferson's program and found no evidence of deficiencies.

I have a pretty good idea of what quality medical care is. Jefferson's medical care is top-notch. I and my family have received all our care there since coming to Philadelphia and we will continue to do so without hesitation.

David C. Levin, M.D.

Bryn Mawr

david.levin@mail.tju.edu

Wider review process

Re: "A mystery at Jefferson: 52 surgeries, 9 deaths," June 1:

One would think that Jefferson would have been more vigilant to realize that there was indeed a problem needing a timely and effective solution. Alas, it appears that it neither recognized that a problem existed nor believes that its transplant program should be scrutinized.

As a former board member of the Health Systems Agency of Southeastern Pennsylvania and a consultant to the Maryland Health Services Cost Review Commission and the New Jersey Department of Health during my career, I believe that what the Inquirer reporters have brought into the sunlight should be applauded.

There are many challenges facing the health care industry today, but the public should not be placed at increased risk. Meanwhile, as hospitals struggle with their financial structure, physicians struggle with their compensation, plaintiff and defense attorneys struggle with their compensation amount related to malpractice litigation settlements, insurers struggle to reward their investors by increasing premiums while reducing payouts, and government seeks ways to assure citizens that health care can be accessible and affordable, patients are held hostage by the system.

Several questions come to mind: Should the "peer review" process for surgery-related deaths be revised to include not only disinterested health care professionals but also others from non-health-care professional backgrounds such as systems or industrial engineering, business process management or similar disciplines? When human life is concerned, even NASA includes these professionals to assist with problem resolution. Are the standards of disclosure of relevant experience of each member of a surgical team directly related to the planned procedures? What oversight is incumbent on an institution in which the procedures are performed to continuously monitor the performance of the team members, some of whom are not employees but are granted "privileges" to ply their skills?

While "informed consent" is a way of business in health care, more information must be provided to the public and patients about the successes as well as the failures that occur when human life is involved.

Alan C. Verbit

Liver transplant story caused undue alarm

The Inquirer's June 1 article regarding Jefferson's liver transplant program caused undue alarm among some of our patients, their families and the public at-large. We feel that the headline, "A mystery at Jefferson: 52 surgeries, 9 deaths," was especially misleading. We want to ensure that our Philadelphia community fully appreciates the fine health-care resource that the liver program in particular - and Jefferson in general - represents.

The article states that Thomas Jefferson University Hospital is "an academic medical center with a good reputation and long experience in transplants." Some of your readers might recall that we were, in fact, the first to perform a liver transplant in the Delaware Valley, in 1984. (That same patient just came in for his regular checkup.)

The Inquirer is also correct in reporting that "liver transplant surgery is exceptionally difficult," that it is "as tough as surgery gets," ". . . a long, complex operation done on people who will certainly die without it."

Yet the article suggests that it is a "mystery" when a liver transplant patient - among the sickest people doctors ever see - dies on the operating table.

The mystery to us is why The Inquirer would see fit to target a solid program like Jefferson's, which has continuously demonstrated long-term success rates comparable to quality institutions across the nation. The article itself notes that no less an authority than UNOS, the national United Network for Organ Sharing, confirmed that Jefferson has never been identified as a "low performer." In fact, according to UNOS, "Thomas Jefferson is an approved program in good standing."

It was also confusing to us (and perhaps to your readers) how, after acknowledging in some detail Jefferson's roster of experienced transplant surgeons - Drs. Ignazio Marino, Cataldo Doria, Donald Dafoe, Lloyd Ratner and Liise Kayler - the reporters could second-guess their decision-making in the operating room.

Teams of physicians, nurses and other health-care professionals exhaustively evaluated the cases in question. Review after review found no common thread, no connection other than that each patient was extremely ill and in dire need of a new liver.

Thomas Jefferson University and Jefferson Hospital are immensely proud of the liver transplant program. We continue to strengthen and expand it with innovative techniques and talented individuals. We've earned the trust and confidence of our patients by constantly exploring ways to be even better.

So while we expect scrutiny, we think it's important not to frighten our patients and their families. For well over a century now, they've come to rely on Jefferson for the highest level of care.

This past year, we did more than 40,000 surgical procedures at Jefferson. While the article focused on a handful of cases in which very sick patients died, it might also have reported on the many lives we're saving every day.

Paul C. Brucker, M.D.

President

Thomas Jefferson University

Thomas J. Lewis

President & CEO

Thomas Jefferson University Hospital

Thomas J. Nasca, M.D.

Dean

Jefferson Medical College of Thomas Jefferson University

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