Scandal Rocks UNC Health Care's Pediatric Heart Surgery Program

A recent New York Times investigation revealed shocking rates of mortality in children who underwent pediatric heart surgery at North Carolina Children’s Hospital, which is part of the University of North Carolina (UNC) health system.

The exposé (1), written by Ellen Gabler and published on May 31st, 2019, details how UNC higher-ups repeatedly dismissed cardiologists’ concerns about patient safety. Although the Times was unable to obtain complete data on mortality rates for this initial investigation, an anonymous staff member provided secret audio recordings of doctors’ meetings in 2016 and 2017. The Times also reviewed emails, medical records, and state death data.

They found that all nine cardiologists on staff had expressed concerns about the pediatric heart surgery program; these concerns centered around patient deaths that could have been prevented, especially those involving children whose surgeries were considered low risk. Gabler explains:

“The cardiologists — who diagnose and treat heart conditions but don’t perform surgeries — could not pinpoint what might be going wrong in an intertwined system involving surgeons, anesthesiologists, intensive care doctors and support staff. But they discussed everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it wasn’t equipped to handle.”

The case of Jeremiah Moore

Jeremiah Moore was just under two years old when he came to the North Carolina Children’s Hospital for what was meant to be the last of three heart surgeries to correct hypoplastic left heart syndrome (1), a birth defect that affects the normal flow of blood through the heart (2).

Dr. Jennifer Whitham, Jeremiah’s cardiologist, had recommended seeking a second opinion from the Children’s Hospital of Philadelphia, which specializes in the operation he needed (called the Fontan procedure). However, Dr. Whitham then left UNC, and Jeremiah was seen by a different cardiologist, Dr. Elman Frantz, who assured his parents that he could have the surgery at UNC. This was despite having previously stated in a meeting that “We’ve [the UNC cardiologists] sort of lost confidence in the program.”

Although Jeremiah did survive the surgery, he developed complications over the next two weeks and died. His grandmother, Inez Holmes, told the Times that, “They said Jeremiah was strong. We trusted them” (1).

Complaints about chief heart surgeon

Although the UNC cardiologists cited multiple factors that likely contributed to the poor quality of care, some of their concerns centered around Dr. Michael Mill. Dr. Mill was the chief heart surgeon at the time, and performed the majority of the surgeries.

Several of the cardiologists were alarmed when a donor heart became available for a baby who required a transplant, and Dr. Mill failed to come in on a weekend to perform the operation. The child’s parents were unaware that this happened, but soon transferred their daughter to Duke Children’s Hospital. Thankfully, she eventually received another heart. However, multiple UNC cardiologists were horrified by the missed opportunity, noting that Dr. Mill’s absence could have cost the patient her life.

“As the mother of three children, oh my God…It’s inexcusable,” said Dr. Whitham in an audio recording. “As a physician, I mean, we all took the oath. We are supposed to do what’s right for our patients…This is what you signed up for. And who is he to play God with some kid’s life?”

Complaints about head of children’s hospital

Dr. Kevin Kelly was the head of the North Carolina Children’s hospital up until last year, when he retired. In 2016, he met with concerned cardiologists. At the time, he told them to “Do what your conscious says” in making decisions about where to refer patients. However, he also stated that, “If it [external referrals] reduces the volume of things…I’ll just — we’ll just reduce the number of people that we have.”

Following this conversation, someone sent an anonymous letter to the UNC chancellor and hospital leaders, stating that Dr. Kelly had essentially threatened to fire doctors if they stopped referring patients to the North Carolina Children’s Hospital (1).

Government review

After the Times article came out, the North Carolina secretary of health (Dr. Mandy Cohen) began an investigation of North Carolina Children’s Hospital. In a statement, Dr. Cohen said that “Patient safety, particularly for the most vulnerable children, is paramount” (3).

State regulators have also contacted former UNC clinicians, requesting to interview them about their experiences and concerns (4).

What do the statistics say?

UNC finally released mortality statistics for their pediatric heart surgery program on Monday, June 15th, well after the Times initiated a lawsuit for this information.

From the audio recordings and various documents, we know that cardiologists had been telling administrators the hospital was ill-equipped to handle complex heart surgeries back in 2016 and 2017. The data show that even after these warnings, mortality rates continued to rise.

Initially, UNC emphasized the importance of risk-adjusted data. In other words, hospitals that care for patients with serious conditions/important risk factors may have higher mortality rates, even if they are providing excellent care. However, the data (from January 2015-December 2018) show that UNC’s overall mortality rate for pediatric heart surgery was 5.4% (compared to a national average of 2.8%), while their risk-adjusted rate was even worse: 5.6%.

For the most complex cases, the rate of mortality was especially shocking: 58.3%, with a risk-adjusted rate of 47.4%. Nationwide, the rate is 14%.

UNC denies wrongdoing

Pending state and federal investigations, UNC has suspended surgeries for the most complicated pediatric cardiovascular conditions. They have also introduced new initiatives to improve safety, such as creating an external advisory board, agreeing to release mortality data to the public, and investing $10 million dollars into the program over a three-year period.

Despite these changes, they continue to deny accusations of medical malpractice. They have emphasized recent improvements (over the past 11 months, the rate of mortality has been just 3%), saying that today the program is “very strong” (4).

As for previous years, they have cited “team culture issues,” and say that leadership changes have helped with group dynamics. Dr. Benny Joyner, chief of critical care, told the Times that, “there is nothing here that is systematic, or systemic that would lead us to be concerned about the performance of operations on children that are high-risk, low-risk, no-risk.”

Despite these dismissals, the audio recordings make it clear that individual staff members thought the issues were more profound. Dr. Blair Robinson, a cardiologist, could be heard saying,

“I ask myself, ‘Would I have my children have surgery here?’…if I can’t say it for my kids — and that should be our group discussion — if we can’t all look ourselves in the mirror and think we’re doing the right thing, then we need to change what we’re doing.”

Chief of pediatric cardiology, Dr. Timothy Hoffman, had similar sentiments. “We are in crisis,” he said, “and everyone is aware of that” (1).

Consolidation of programs?

Research has shown that the best patient outcomes for complex heart surgeries occur in hospitals that perform high volumes of such surgeries (1, 5).

U.S. News & World Report found that centers that treated 250 or more congenital heart surgery patients a year had much better outcomes than lower-volume treatment centers. Moreover, their data suggest that over 26% of deaths could have been prevented if surgeries for the most severe heart defects were only performed at high-volume centers (5).

This suggestion isn’t just theoretical. Data from Sweden and the United Kingdom has shown that, after surgery programs from different hospitals consolidated, mortality rates dropped dramatically. Some U.S. hospitals have also begun to join forces in order to improve their surgery programs.

Many have suggested that UNC and nearby Duke Health’s Children’s Hospital could combine their pediatric heart surgery programs. Currently, they are competitors; and as Dr. Kelly put it, they are “basically destroying each other’s capacity to be great” (1).

In an opinion piece for The News & Observer (6), Kevin Keister also pressed for a combined program. He wrote that UNC Children’s low volume of surgeries means that their surgeons don’t have much opportunity to develop their skills over time. It also means the hospital has a more difficult time recruiting and retaining surgeons, as well as other staff members.

He goes on to quote a statement from UNC Children’s Hospital, saying there are “no plans to combine our programs.”

Keister’s response doesn’t beat around the bush:

“UNC Children’s would prefer to run its own pediatric heart surgery program as a matter of institutional pride and money — the most complex operations can cost a half-million dollars. But pride and money aren’t — or shouldn’t be — the primary concerns. What matters most is how to get the best care for children in this highly specialized and high-stakes area of medicine.”

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