In the past few years, an unprecedented growth in heart transplant centers and their activities has marked the progression of heart transplantation from an experimental to an accepted therapeutic technology of proven value in end-stage heart disease.
Both the Washington Hospital Center and Fairfax Hospital have recently applied to their local health planning authorities to become the first providers of heart transplants in the metropolitan area. Their action forces local health planners to decide whether the dramatic technology, already recognized as life-saving but expensive and resource-intensive, should be introduced and by which hospital.
Prior to a decision, it is critical that a thorough assessment be made to include the needs of the community, the minimal requirements to justify the establishment of a heart transplant center, the availability of donor hearts, the impact on organ availability for neighboring transplant institutions, the center's qualifications to ensure expert and comprehensive patient management and the effect that the new program will exert on the other services of the hospital.
A successful heart transplant center must marshal a staggering array of expertise, resources and logistics. Heart transplantation requires an enormous institutional commitment involving many of its major departments, including medicine, surgery, cardiology, cardiovascular surgery, anesthesiology, blood bank, pathology, immunology, infectious disease, neurology and neurosurgery, psychiatry, social service and occupational therapy.
It requires exquisite teamwork, intensive organ procurement efforts and adherance to legal and ethical requirements.
The benefits to potential transplant candidates in the region also must be considered. If a major heart transplant center is established in the metropolitan area, residents would not have to travel to transplant centers in Richmond, Baltimore or elsewhere.
The medical center performing heart transplants would gain prestige, recognition and a competitive advantage in attracting patients and physicians.
Technological advances have led to significant gains in the quality of life and in life expectancy.
On the other hand, a transplant recipient still faces major risks: rejection of the donor heart, infections and other complications from immunosuppressant therapy, and organ rejection. Nevertheless, since 1980, the one-year survival rate has been reported to be 80 percent or better with the five-year survival rate at 50 to 60 percent. As many as 80 to 90 percent of recipients can return to previous activities.
In 1984, 407 heart transplants were performed in about 60 centers across the nation, compared with 172 transplants in 14 centers in 1983 and only 62 transplants in 1981, according to the National Heart Transplantation Study.
The number of transplant procedures each year is determined by three major factors: availability of donor organs, selection of recipients and the number of transplant centers. Given the strict criteria required for acceptable heart donors and the general shortage of donor organs, the supply of donor hearts is the limiting factor in heart transplantation.
Estimates of who might benefit from heart transplants vary widely up to perhaps 50,000, but more likely it is in the range of a few thousand. The National Heart Transplantation Study concluded that of 14,000 patients dying from end-stage cardiac disease in 1980, about 1,900 would have been acceptable candidates for transplantation.
The number of centers performing transplants has increased considerably, prompting concerns over the qualification of these programs and the impact of resource demands of transplant programs on the hospitals other services. The success rates cited previously have been achieved because of research, dedication and extensive clinical experience at major transplant centers. The results can be duplicated only if new programs are patterned similarly.
Logically, the number of transplant centers across the nation should be determined by the level of need and the availability of donor organs. Based on such considerations, the National Heart Transplantation Study has estimated that only 19 to 48 centers are required. Nevertheless, several U.S. cities have two or three competing transplant programs.
In order to limit the number of transplant centers, policy makers have proposed linking Medicare reimbursement to the program's quality, establishing criteria to determine a program's quality, and proposals for regional transplant centers.
As with many of the major new technologies, heart transplantation is expensive, costing in the first year $100,000 to $200,000 per patient. Thus, the 407 heart transplant procedures performed in 1984 cost the nation $40 million to $80 million.
Given the expense, sophistication and resource-intensity of this technology, and the shortage of donor organs, regionalization could prevent costly, wasteful and inefficient duplication of efforts.
Ideally, in any given geographic area in which there are competing institutions, health planning, including the provision for and adoption of major expensive and beneficial technologies, should be coordinated to conserve and use scarce resources most effectively. Granted that a heart transplant center is warranted in the Washington area, every effort should be made to achieve that ideal.