Wednesday, January 31, 2007

Transplantation Darts and Laurels

The Columbia Journalism Review has a section called "Darts and Laurels", in which the editors offer short commentary on recent events in journalism, either negative or positive. With full credit and due respect to the CJR, I want to borrow their nomenclature and apply it to two recent items in the field of liver transplantation here in New England.

I understand fully that offering this kind of commentary about other hospitals is dangerous business, violating unspoken protocols in the health care field. But if we can't be open and forthright on matters relating to cost and quality, how can we expect the public to trust us? In the interest of full disclosure, I freely admit that my comments also can be viewed as an attempt to enhance BIDMC's competitive position in the region. But that does not necessarily mean that they do not have validity. You be the judge. The power of a blog like this is that anyone can offer comments in rebuttal -- or even set up their own blog.

First, a "laurel" to Dartmouth-Hitchcock Medical Center in Hanover, NH, for reportedly cancelling their plans to establish a liver transplantation program. As discussed on this blog on October 13, 2006, and as supported by commentors at that time, it is difficult to rationalize the establishment of this highly technical and expensive program for the very few patients who would be treated. We recently received word that these plans had been scuttled. If so, congratulations.

Next, a small "dart" to UMass Memorial Medial Center and Lahey Clinic for something that could otherwise be a big "laurel". In December, the two institutions announced a joint program in liver transplantation. This is a fine idea and shows the power of collaboration between two great places. But here's where we award a "dart":

UMass Memorial and Lahey Clinic will continue to function as independent transplant centers, caring for their own patients from intake to surgery, through continuing care. Surgeons and medical staff will have access to and privileges at each center and will perform operations, consult with patients, and provide post-operative care at both sites.

For the volume of liver transplants to be done in Worcester, and the relative number of faculty based at the two places, it probably makes more sense to move those patients to Lahey for surgery. Otherwise, Lahey doctors will have to travel an hour to go 50 miles to Worcester to perform surgeries and otherwise be on-call for patients there. This seems to be one of those examples where a slightly less convenient approach for those few patients would help maintain a greater critical mass for a program in one setting.

I hope to be proven wrong on this point, but I cannot imagine how asking Lahey doctors to commute to Worcester for a relatively small liver transplantation program will be a good use of their time or will optimize patient care and control costs overall.


Emily DeVoto, Ph.D., said...

For some surgical procedures, hospital volume predicts better outcomes than surgeon volume. It may be a team effect. I don't know what the data are for liver transplants, but I imagine moving the surgeons around - as individuals - to populate a small program would not, as you say, produce the critical mass you need for quality.

Anonymous said...

The concept of rewarding the highest quality, most cost-effective providers with more patients that Porter and Teisberg wrote about in their book, Redefining Healthcare, is especially relevant to organ transplants which are, by their nature, complex and expensive procedures. The more complete information, at least about outcomes data, that can be made available to both patients and doctors, the better. To the extent that the team and the hospital may be as important as the surgeon in determining overall outcomes, surgeons should, presumably, have a vested interest in practicing in the best possible environment.

Anonymous said...

The Globe's White Coat Notes blogs describes what I just said in this blog, as follows:

"Levy pans joint liver transplant program -- Paul Levy has harsh words for the new joint program for liver transplantation between Lahey Clinic and UMass Memorial Medical Center. Both transplant centers will continue to function independently, with surgeons operating in Burlington and Worcester, undermining the promise of collaboration, he writes in his blog today."

I just have to say that I don't think I "panned" this program, although I clearly stated a disagreement with one of its features. I termed this a "small dart" for something that could otherwise be a "big laurel." Also, I don't think I used harsh words.

What do you think?

I end up feeling I should apologize to Lahey and UMass Memorial for this characterization of my posting, but, then again, I didn't write it! I stand by what I said, and I chose the words I used quite carefully.

I am not complaining - just observing. Really. The virtue of this medium is that it gives everyone the ability to make his or her judgments, and then post them.

Manu Varma said...

While attempting to duplicate patient care activities across two hospitals may not be a great plan, combining the expertise between transplant programs may be an excellent opportunity. It should allow the centers to collaborate on research projects, share clinical insights from their differing strengths, and expose fellows in transplantation to a greater breadth of practice. A similar collaboration exists in the Washington DC area between Georgetown, Washington Hospital Center, and the NIH. I'd be curious to see more clearly what the Lahey and UMass programs' intentions are, and how the DC collaboration has worked out.

As for volume and outcome, a transplant surgeon at Dartmouth gave a talk on this topic about a year ago. Overall, the research on this question in transplantation is mixed (some shows an effect, some doesn't). But it seems positive that Dartmouth is active in researching this question on a large scale as they consider the implications for their own program.

For more "darts and laurels" or general thoughts and issues on transplantation, I've started a blog recently: Transplant Headquarters.

Anonymous said...

Your comments about what other hospitals should or should not be doing would carry greater weight for me if you can give some examples where BIDMC decided to not pursue, or drop, a service line because the service was adequately provided at other locations. I'm sure there are some examples, aren't there?

Anonymous said...

I'm quite surprised at the Globe blog's words. Fundamental journalism skills including carefully choosing one's wording to be accurate about what did and didn't happen. The blog did a poor job of that.... it's more like advocacy journalism, a tabloid, or a gossip column. Somebody deserves reproach, gentle or otherwise.

Is the Globe affiliated with (or a fan of) any particular health care provider in the Boston area?

Another possibility, which I shudder to think about, is the reality that some bloggers writing mildly flaming things as "linkbait," i.e. hoping to get others to link to their article, which supposedly means you're a cool blogger. That may be appropriate for things like the Drudge Report, but it ought to be out of bounds (as a matter of policy) for an operation like the Globe.

Anonymous said...


We did not pursue heart or lung transplants.