State officials review heart program at Beth Israel

Emergency catheters had high mortality rate in ’09

By Liz Kowalczyk
Globe Staff / March 3, 2011

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Massachusetts public health officials are monitoring the heart program at Beth Israel Deaconess Medical Center after discovering the hospital had a high death rate in 2009 for a small group of patients who had emergency cardiac catheterization.

An analysis of mortality data for the fiscal year ending Sept. 30, 2009, showed that 13 of 93 patients who underwent the procedure died, the hospital said. Beth Israel Deaconess’s mortality rate — after adjusting for how ill the patients were — was 5.82 percent, compared with 5.12 percent for hospitals statewide, according to state public health officials.

The hospital’s mortality rate for the 1,039 nonemergency cardiac catheterization patients in 2009 was average.

Beth Israel Deaconess doctors said their internal investigation, as well as an outside review by a top cardiologist from Brigham and Women’s Hospital, found that no patients died from complications of the emergency procedure, or from post-surgical care.

And since 2009, hospital executives and doctors said, the death rate has fallen among patients who undergo emergency catheterization to remove blockages from their coronary arteries.

Dr. Donald Cutlip, Beth Israel’s chief of interventional cardiology, said the state’s adjustment model did not fully account for how sick the emergency patients were, including a patient who was in shock and three who had cardiac arrests.

The state has since changed its adjustment model to weigh more heavily the mortality risk of cardiac arrest patients, officials said.

Elizabeth Daake, interim director of health care safety and quality at the Massachusetts Department of Public Health, said the Brigham reviewer, Dr. David Williams, found that in some cases patients may have been too sick to have the procedure.

She said a second outside review by the Philadelphia-based American Medical Foundation, scheduled to begin this week, will examine that issue among other potential causes for the higher-than-average death rate in 2009.

Cutlip said that in emergency cases, “you have to make a decision within minutes’’ about whether someone should have a catheterization, and that sometimes it is difficult to know whether a patient will benefit from the procedure. Often families urge that doctors do everything possible.

Even so, he said, the hospital now has a second attending physician review cardiac arrest cases before the procedure when possible, to make sure the patients are appropriate for catheterization.

Two years ago, public health officials monitored heart programs at Massachusetts General Hospital and St. Vincent Hospital in Worcester after discovering that they had high death rates in 2007 among patients who underwent cardiac catheterization procedures. Doctors at both hospitals said that they did not find any quality problems, but that many of the patients were extremely ill and therefore more likely to die.

At the time, public health officials said that performing procedures too aggressively on extremely ill patients can be a problem, because it wastes resources and raises family expectations.

But many cardiologists are concerned that hospitals nationwide generally are becoming less aggressive with high-risk patients because public reporting of mortality rates, or the possibility of it, has made physicians more cautious.

Daake said she does not recommend patients avoid hospitals with higher-than-expected mortality rates on the state report. She said the state’s public reporting system for cardiac surgery and catheterization is intended to be a tool to spur improvement at hospitals and “keep them focused on quality and safety.’’

Liz Kowalczyk can be reached at