PROFILE ON OPEN-HEART SURGICAL FACILITIES IN THE NEW YORK CITY AREA
After the brief interlude into patients’ rights and representatives, CCHAS resumed its profiling of hospitals; at least those with designs of developing or maintaining open-heart surgical programs. In the 1970’s the medical model turned to increasingly invasive and potentially dangerous methods to address the high incidence of and death rates due to diseases of the heart. At the moment of that dramatic shift all opportunity for consideration of wellness and life style prevention were lost.
As the shift occurred hospitals competed for the relatively few people who might benefit from the newer surgical techniques, procedures and equipment. The costs to the hospitals to be able to provide open-heart surgery were even for its day extreme. At many hospitals new construction for stabilizing emergency rooms, expanded surgical suites to accommodate the new array of heart-pump and related equipment, specially trained surgery room staff, addition of new drugs to prevent normal body immune system responses, specially trained surgeons and anesthesiologists, more intensive recovery rooms, isolation and special surgical intensive care units, specially trained unit staff, etc. As the costs increased to the hospitals, the expenses to the patient and their insurance companies also increased. The economic opportunity costs of using limited resources for a small percentage of patients were enormous.
More importantly, based on the researched data, again available to the public but kept in a dark corner of the state agencies was the literal killing fields in the midst of aggressive hospitals. These hospitals saw potential public relations, patient flow, prestige and income streams flowing to them if they could just get it right. Until they did many people filled with hope, desperation and uncertainty would be directed to them; with little chance of recovery and greater chances of dying. Open-heart surgical operating suites in its relative infancy were graveyards waiting to be filled. A simple open and closed case of burying your mistakes as you learned. Medical and surgical care was often premised on this hit and miss process in the past. But with open-heart surgery it was not hit or miss. Odds were at a few hospitals with adequate equipment and staff and what turns out to be the critical factor, enough open-heart surgical procedures each week, the chances of surviving the pre-, actual, and post-operation care improved dramatically. Of course hospital representatives raised the chicken and the egg argument that every hospital started with just one open-heart operation and that if several institutions did not start open-heart surgery programs there would have fewer options for people and fewer experiences to learn what would eventually work. In the late 1960’s through the 1970’s, few parties spoke about the issues of cost and expense with the possible exception of the non-profit Blue Cross plans and CCAHS. Fewer spoke about the quality and need for follow up of people who had open-heart surgery to determine the efficacy and safety of the procedure at each hospital and by surgeon. And even fewer spoke about primary prevention through healthy life styles.
New York State had the data to create safe, efficient and positive outcome hospital programs, yet let it lie as people died. The CCAHS publication disclosed the relationship of death rates and volume of procedures. Most studies then showed an inverse relationship between the number of people who had open-heart surgery and the numbers of procedures, (i.e. coronary arteriography) which were always done prior to open-heart surgery, and the mortality rates. Fewer procedures equaled more deaths. The exposure in the New York Times and other respected newspapers was the death knell for dangerous action by hospitals without successful track records and inaction by a lethargic health department. The publications tables and charts simply brought together a compelling argument for change.
Once in place in the public’s mind open-heart surgery took hold and raised expectations where those expectations were unjustified. Coronary artery bypass surgery has value when a person is having a heart attack. Studies are not conclusive about its value as opposed to that of medical care for patients with stable angina; surgery can provide temporary alleviation of chest pain but not extended longevity. As with other medical and surgical intervention there were significant adverse side effects most notably declines in mental acuity. Safer, less costly and more effective measures related to wellness and life style changes would be more lasting and effective to reduce the need for expensive dependence on surgical intervention followed by a life time of dependence on regular monitoring, tests, treatment and drugs.
Unfortunately, the publication did not address two issues: primary prevention of what are now known to be completely avoidable diseases and the actual success and adverse effects of open-heart surgery.