Most Washington area hospitals that perform heart surgery are doing too little for safety and efficiency, and some have high surgical death rates, a study by a task force of regional health planners and doctors shows.
Only three area hospitals -- the Washington Hospital Center, Fairfax Hospital and Children's Hospital -- are doing enough heart surgery to assure their patents skilled care, the group said in a report completed yesterday.
Other area hospitals, including Georgetown, George Washington and Howard University Hospitals as well as the Veterans Hospital in Washington, Walter Reed Army Medical Center and the National Naval Medical Center in Bethesda, are doing many fewer operations than experts believe necessary for the best care.
All but the last two military hospitals had heart surgery death rates of 10 percent or more in 1977 -- meaning at least one patient in ten died during the last year for which the group collected full figures. These rates were well above the rates of major medical centers in other cities, the task force figures reveal.
Still, the study said, "it is misleading to draw conclusions" about patient safety at any individual hospital "because of the small number" of heart operations performed at almost all area hospitals.
The data "suggest that most openheart surgical programs, especially those with higher caseloads, have provided quality care," the task force concluded.
At the same time, the group said the mortality rate in the 30 days following a heart operation "should not exceed 5 percent for coronary bypass surgery and 10 percent for all other types of cardiac surgery." Most of the heart surgery being done in area hospitals is coronary bypass surgery -- surgery to relieve heart attack pain -- so some hospitals evidently did not meet these goals.
The task force accepted guidelines set six years ago by a national Intersociety Commission for Heart Disease Resources. "The smallest practical unit" to "qualify as a cardiac center," that commission said, should do at least four to six operations a week -- or at least 200 a year -- for "quality performance."
On the basis of its findings, the task force -- a joint body created by the health planning agencies of the District, suburban Maryland and Northern Virginia -- recommended that no new cardiac surgery and catheterization (diagnosis) units be created in the near future.
It said there is already vast excess and unused heart surgery and catheterization capacity at area hospitals. It recommended that health planning agencies, doctors and hospitals -- and the federal government for its hospitals -- find ways to consolidate and even close down some services to improve heart care.
It said that only Children's Hospital here should do pediatric heart surgery. Some children's operations are also being done at Georgetown and Howard Universities and at the Naval and Walter Reed Army Medical Centers.
The hospital with the highest 1977 adult heart surgery death rate was Georgetown University Hospital with 14 deaths -- or a 17.5 percent mortality rate -- in 80 open-heart operations.
Open-heart operations are those in which almost all the patient's blood is temporarily shunted through artificial heart-lung machinery -- machinery to pump it and feed it fresh oxygen -- so the surgeons can work on a bare, blood-free heart. Almost all current heart surgery is in this class.
The report said: "The relatively high mortality rates at Georgetown University may be attributed to the type of surgery done (there). More valvular surgery is done at Georgetown."
Surgery to replace diseased or worn valves -- the valves between the heart's chambers -- is indeed among the most difficult and dangerous heart surgery.
Georgetown's reported mortality rate for all heart surgery,including valve surgery, was 11 percent in 1975, 5 percent in 1976, 17.5 percent in 1977 and an estimated 10 percent in 1978.
Except for the 5 percent figure, some medical centers report better statistics for valve surgery alone. A leading surgeon at one of the nation's leading medical centers -- one performing 1,200 heart operations a year -- said yesterday that mortality in valve surgery alone is 6 to 7 percent there.
He said his center's mortality in coronary bypass operations -- where the Washington task force said an acceptable ceptable figure is 5 percent -- is "currently about 3 percent," and "many institutions around the country have reduced their coronary bypass surgery mortality to 1 to 2 percent."
Among other area hospitals, George Washington University Hospital did 19 open heart operations in 1977 with 10 percent mortality; Howard, 19 operations with 11 per cent mortality; Washington Hospital Center, 364 operations with 5 percent mortality; Washington Adventist Hospital, 51 with 2 percent mortality; and Fairfax Hospital, 53 with 6 percent mortality.
In 1978, however, Fairfax did 220 operations with an estimated 5 percent mortality.
Among federal hospitals, the VA Hospital did 47 operations in 1977 with 13 percent mortality, the Naval Medical Center 133 with 4 percent mortality, and Walter Reed, 153 with 6 percent mortality.
Children's Hospital did 84 operations in 1977 with an 18 percent mortality. Georgetown did two operations on children, and Howard did four, with no deaths.
The task force nonetheless urged that children's surgery be concentrated at Children's.It said such operations, commonly done on very sick children, are necessarily risky.
The Metropolitan Tertiary Care Task Force, the group that prepared the heart surgery report, was chaired by Edward Kelly, a board member of the Northern Virginia Health Systems Agency. The task force was assisted by a technical advisory panel headed by Dr. James Estes.
The task force will hold a public hearing on its report at 8 p.m., March 7, at D.C. Red Cross headquarters, 2025 E Street NW.
"This effort is a first in the area in the way of substantial metropolitan health planning," Kelly said yesterday. "Now we have to discuss how we can transfer or move or close facilities to improve our care."
Mark Epstein, task force coordinator, said that the group's main findings are clear, but the conclusions "may not be statistically valid" for any one hospital. "To some extent too," he said, "an institution may be able to determine its mortality by the type of cases it accepts."
"We're a high-risk, advanced care center in all types of care," commented Dr. Jack Stapleton of Georgetown University Hospital, where heart surgery mortality was high. "We get some patients turned away by other centers."
Dr. Ross Fletcher of the VA Hospital's "often older, often higher risk patient," perhaps "at the end of the road, but someone we try to help."
"If certain institutions are not within the guidelines," said Dr. Estes, "we will have to sit down with them. But every institution deserves a chance to discus its own circumstances. Together we'll find some way to make better services in the metroplitan area."