Protest signs sprouted on lawns and 134 000 Ottawans signed a petition when the province announced it would eliminate the pediatric cardiac surgery program at the Children's Hospital of Eastern Ontario (CHEO). At press time a review of that plan, headed by Senator Wilbert Keon, was under way. But is the well-intentioned opposition just denial of the inevitable? The answer appears to be yes, as the country's premiers prepare to establish regional sites of excellence for low-volume, highly specialized surgery. And this consolidation is bad news for low-volume sites like Ottawa.
In January 2002, all premiers except Quebec's approved the move toward consolidation, and an implementation plan is due in August. The premiers say consolidated sites would “lead to better care for patients and more efficient use of health care dollars.” However, the Ontario government avoided any mention of savings in announcing the Ottawa closure. Health Minister Tony Clement simply says the province is “doing what's best for the children” by trying to reduce morbidity and mortality rates and providing more “timely access to care.”
A member of the Ontario expert committee that recommended closing the Ottawa program by April 2003 argues that the writing is on the wall for low-volume programs across Canada. Eventually, says Dr. Hugh O'Brodovich, chief of staff at Toronto's Hospital for Sick Children (HSC), there will only be “2 or 3 centres in Canada doing [pediatric cardiac surgery].” There are now 8.
O'Brodovich says consolidation leads to more cases for each surgeon, which in turn leads to improved expertise and better outcomes. “There is no magic number,” he adds, although one recent study (Pediatrics 2002;109[2]:173-81) determined that the optimum caseload is 170 patients per year. O'Brodovich does say that a surgeon in this field needs to perform at least 100 operations a year, and each program needs at least 2 surgeons.
Program closures like the one in Ottawa are in accord with inquest findings following the highly publicized deaths of 12 children treated through Manitoba's pediatric cardiac program. The inquest found that program, which was responsible for about 100 operations annually, didn't have the patient volume needed to support a pediatric cardiac team's clinical skills. This was one reason why the mortality rate among high-risk patients in 1994 was 29%, compared with a norm of 11% (CMAJ 1998;159 [10]: 1285-7). Manitoba children are now sent to Edmonton for this surgery, along with children from British Columbia, Saskatchewan and Alberta.
In England, an inquiry into the care of pediatric cardiac patients at the Bristol Royal Infirmary also found a relationship between low volumes and higher morbidity and mortality rates (CMAJ 2001; 165 [5]:628) and called for standards stipulating minimum caseloads.
Ontario's expert committee cited data from the Winnipeg inquest to justify the elimination of programs in Ottawa and London, which reported handling about 140 and 120 cases per year, respectively. London's sole pediatric cardiac surgeon, John Lee, quit last November because he was discouraged by a lack of support for his program, which closed when he left. Patients are now sent to the HSC, which handled 441 pediatric cardiac surgery cases in 2000/01.
Closure of CHEO's program would leave only 7 such programs — and 15 pediatric cardiac surgeons — across Canada. Meanwhile, CHEO says the mortality rate for its pediatric cardiac surgery program is about the same as the HSC's. CHEO already sends its most difficult cases to HSC — last year, 25 patients were sent. The hospital also argues that closing the program will mean added stress for families that will have to travel, and will lead to a loss of staff and training opportunities. CHEO officials are also upset that no pediatric cardiac surgeon sat on the expert committee that recommended closure of its program. That's where Keon, a cardiac surgeon, comes in, and Clement says he will abide by his recommendation. — Barbara Sibbald, CMAJ