Surgeries down at Holtz Children’s Heart Center

Lower birth rates, increased competition from regional hospitals, and the departure of a pediatric cardiac surgeon have contributed to a drop in the number of heart surgeries performed during the past year at the Children’s Heart Center at Holtz Children’s Hospital, threatening the program’s status as an approved healthcare provider for the most severely ill children in the state and the hospital’s reputation as one of the most prestigious speciality medical institutions in South Florida.

In April, administrators for Holtz’s pediatric cardiovascular program, which is staffed by University of Miami Miller School of Medicine physicians, voluntarily accepted probation from the Florida Department of Health’s Division of Children’s Medical Services, which coordinates healthcare for children with intense medical needs, including congenital heart disease and arrhythmia.

Probation will not affect day-to-day operations at the Children’s Heart Center, including physicians’ ability to treat patients, said Dr. William Harmon, a UM physician and the center’s chief of pediatric cardiology.

But the designation indicates that state regulators are concerned about the declining volume of heart surgeries, and unless the number increases to required levels over the next two years the center could be disapproved as a CMS facility.

Like each of the eight approved CMS cardiac facilities in Florida — including Miami Children’s Hospital, and Joe DiMaggio Children’s Hospital in Hollywood — Holtz’s pediatric cardiovascular program is required to perform at least 150 heart surgeries each year, according to state standards, in order to ensure that surgeons remain proficient.

But last year, the Children’s Heart Center fell “just shy” of the requirement, Harmon said.

Physicians must have performed at least 100 heart surgeries in the past year, though, or else state regulators would have been required under CMS standards to provide a notice of intent to disapprove the facility.

Instead, state regulators placed the center on probation, which means the annual number of surgeries fell below the required 150 but above 100. Probation may be extended one more year if the center shows a “positive trend” in meeting the required volume, according to state standards. Failure to meet the standard at the end of a second year of probation, though, would lead to formal disapproval, a process that requires a notice of intent from the state and a 90-day transition period.

Harmon, who noted that UM physicians helped write the CMS standards for pediatric cardiovascular programs, said the state standards help justify the expense of such programs.

“You want to make sure there’s an expertise in the institution, and you want to make sure that there’s an adequate volume to support that expertise,’’ he said. “It would be inappropriate to have a program that did 15 cases a year. That would be inordinately expensive. If you have extreme changes [in surgical volumes], you could have quality concerns.’’

Steven Burghart, chief administrative officer for Holtz, said there are many reasons for the drop in children’s heart surgeries at Holtz. But he singled out lower birth rates as “the most important driver.”

The birth rate in Miami-Dade has dropped each year since 2007, according to the Florida Department of Health’s Bureau of Vital Statistics, from 34,286 births in 2007 to 30,479 births in 2012.

Another reason for the reduced number of heart surgeries, Harmon said, is the advent of medical technologies such as stents and balloon angioplasties that can be applied in an interventional catheterization laboratory at the center.

For instance, Harmon said, to repair a hole in the upper chambers of the heart, surgeons can now perform the great majority of those procedures — 90 percent — in a cath lab.

“Those used to be open heart procedures,’’ Harmon said.

Harmon estimated the center performs 30 to 50 interventional catheterizations per year that a decade ago would have required open heart surgery.

“This is where the field has gone,’’ he said. “It’s not unique to us. It’s the science of pediatric cardiology.’’

The pediatric cardiovascular program at Holtz is one of the oldest in Florida. It’s been approved as a CMS facility since the 1970s.

State regulators last visited the center in April 2012, and approved the facility for one year. A follow up visit was scheduled for June 4 for a three-year approval, but Burghart canceled the visit and voluntarily accepted probation in a letter to CMS dated April 25.

Matt Pinzur, a spokesman for Jackson Health System, which includes Holtz Children’s Hospital, wouldn’t talk about any strategy the hospital might have to increase the number of pediatric heart surgeries “because we are competing with local hospitals.”

Pinzur said that over the next year Jackson administrators plan to renovate labor and delivery rooms, postpartum rooms and other amenities in the hospital system’s obstetrics ward.

Burghart dismissed the significance of local competition from regional hospitals.

“We get patients from all across the state and internationally,’’ Burghart said. “It would be hard to say any one program has impacted us in any meaningful way.’’

But Holtz did lose a “young superstar” heart surgeon last year, Harman noted, a loss that might affect the volume of surgeries.

Hospital administrators feel strongly that probation in no way indicates a decline in the quality of care at the heart center.

“There’s been absolutely no impact on quality of care in the program,’’ Burghart said, noting that a committee of state regulators who visited the center in April 2012 gave the pediatric cardiology program high marks for the quality, teaching and research.

“This is one of the oldest programs in Florida, one of the original programs, and we have one of the largest training programs, if not the largest cardiac training program,’’ he said. “There’s an awful lot to be proud of, and we really don’t consider this a material issue.’’

Burghart said the Children’s Heart Center will meet the state required number of surgeries within 12 months.

“We evaluate thousands of children a year with all sorts of cardiac issues, from a child that had chest pain all the way through to the most complex of transplantations,’’ Harmon said. “The total program is evaluated with glowing results. The only issue was the volume of surgery.’’

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