Health Care and Diseases and Clarian and Hospitals and Health Care & Life Sciences

Clarian blazes trail with transplants, but some question its zeal

May 19, 2008

It's Tuesday morning, and Dr. Jonathan Fridell has no transplants scheduled. But this day, like most, the surgeon at Clarian Health's Indiana University Hospital won't wait long for things to pick up.

By 9:45 a.m., the blue-scrub-clad Fridell is stamping up and down a hallway of offices on the hospital's fourth floor, conferring with his fellow surgeons about a doubleheader, kidney-pancreas transplant that's about to happen.

Clarian Health this decade has transformed its transplant program into one of the busiest in the country. Its team of surgeons takes calls around the clock if a viable organ becomes available. They will hop on a charter plane to check out an organ other doctors don't want.

"I'm listening to my phone at night for a call to come in," said Dr. Joe Tector, the director of Clarian Transplant. Tector is also a professor at the IU School of Medicine.

Clarian's rapid growth in transplants has drawn interest and even mimicry from other surgeons around the country. But some surgeons also have criticized Clarian and its methods--particularly the practice of accepting livers from sicker donors for patients not in critical need of a transplant.

Transplants are a big health issue--and big business--for academic medical centers like Clarian. A shortage of organs has left 99,000 people on a national waiting list. Hospitals would love to provide those needy patients--and willing customers--an organ, not least because they charge hundreds of thousands of dollars for every transplant they do.

The typical hospital bill for a liver transplant approaches $270,000, according to a 2005 study by Milliman Research. For intestinal transplants, the average charges are $695,000.

Those high charges also come with high costs for the hospital, said Ed Abel, a hospital accountant at Indianapolis-based Blue & Co. But for Clarian, which already had built up the equipment and staff to handle transplants, increasing the number of procedures can only add to profits.

"There's got to be X amount of fixed costs," Abel said, adding, "If you're doubling the number [of transplants], it becomes more profitable."

Transplant powerhouse

At 10:45 a.m., Fridell bends over a bowl of ice, holding a pancreas, in an operating room in the basement of the hospital. His gloved hands deftly tie sutures to close up openings in the organ.

An iPod connected to speakers blasts The Turtles' song "Happy Together." Fridell sings along.

At 11:15, the pancreas is sewn up and lying in a cooler, while another surgeon cuts open the patient's abdomen. Fridell steps outside, but he's not taking a break.

While he was preparing the pancreas, a nurse in the operating room took phone calls from the University of Michigan, whose transplant staff was offering another pancreas for transplant. Fridell now punches a number into his BlackBerry and, as he heads down the hall, says, "I think I just got a pancreas for a lady to move this afternoon."

By juggling surgery and tracking down organs, doctors at Clarian performed 526 transplant surgeries last year, ranking the center No. 6 in the country. It topped all other hospitals for pancreas transplants. In 2005, Clarian ranked No. 3 in the nation, with 604 surgeries.

The number of transplants Clarian has done has more than tripled since 2001, the year Tector arrived from the University of Miami School of Medicine. His team handles all abdominal transplants, which include the liver, pancreas, kidneys and intestines. Other surgeons handle heart and lung transplants.

Tector has hired most of the other surgeons on Clarian's abdominal team and helped train a dedicated staff of 100 nurses and other assistants.

"The real growth of the program started when he came," said Dr. Tim Taber, director of kidney transplant patients at Clarian. Taber said the 42-year-old Tector is a virtuoso in the operating room. "He is Mozart."

At the same time Fridell was working on the pancreas, Tector leaned over a liver patient in an operating room down the hall. A faint burning smell filled the room as his electric cauterizing tool methodically cut loose the patient's liver.

Techno music thumped off the blue and white tile of the operating room from speakers connected to an iPod. Without a word exchanged, a nurse handed Tector whatever tool he needed exactly when he needed it.

"It's really teamwork," Tector said. "The group that we've set up works really well together."

Tector's team takes about two hours for each liver transplant, while other surgeons take as much as six hours. Fridell does pancreas transplants in about three hours.

In 2007, officials from the transplant division of the U.S. Department of Health and Human Services visited Clarian to see how its surgeons had raised their volumes so dramatically. In a publication last year, the agency recommended some of Clarian's practices, along with those of seven other transplant programs around the country.

One key reason Clarian does more procedures is it accepts organs others reject. Doctors turn down donated organs for various reasons. Perhaps the organ offered doesn't fit their patient or comes from an older donor when the doctor's recipient is young.

But they also reject organs because of concerns about the donor's health. For example, many transplant surgeons would reject the liver of an alcoholic. But Tector's team will go take a look at the liver to see for themselves.

"So the patient drank a lot. That could make a liver bad, but it doesn't have to," Tector said. "A lot of times you go look and--Holy Toledo!--this thing's a great organ."

Tector defends his method by noting Clarian's transplant survival rates, which exceed national averages.

His approach also has cut down on waiting times. Since Tector arrived to do liver transplants, Clarian's average wait time for a new liver has dropped from 27 months to one month, he said.

Just over half of Clarian's transplant candidates have been waiting more than a year. Nationally, nearly two-thirds of transplant candidates have been waiting that long.

By doing a higher number of transplants, Tector and Fridell said, Clarian's transplant surgeons and nurses get better at the procedures, make fewer mistakes, and handle complications more easily.

Some doctors uneasy

But other doctors say the real question is whether a patient, particularly one not in critical need of a new organ, would have survived just as well without a transplant.

Researchers at the University of Michigan published a study in February showing that patients with less severe needs for a liver transplant actually have a greater chance of dying if they get a new liver transplant than if they don't.

Patients' need for livers is measured by something called a MELD score, which stands for Model for End-stage Liver Disease. Scores can range from 6 to 40, with higher numbers indicating a greater need for a new liver. In general, doctors consider patients with scores of more than 15 as having a critical need. Patients with scores less than 15 are considered in less need.

Since 2005, one-third of Clarian's liver transplant procedures were done in patients with MELD scores below 15, according to data from the United Network of Organ Sharing.

"Pairing of [high-risk] livers with lower-MELD candidates fails to maximize survival benefit and may deny lifesaving organs to high-MELD candidates who are at high risk of death without transplantation," wrote Dr. Robert Merion and four of his colleagues at Michigan's Department of Biostatistics, in an article published by the American Journal of Transplantation.

Tector and Fridell face two state complaints from the families of patients who died after receiving a liver transplant at Clarian. Steven Nelson was 46. Gail E. Biggs was 59. Their surviving family members filed complaints with the Indiana Patient's Compensation Fund in 2005, and both cases are still pending.

"They're both really nice people. And they didn't live. And that hurts," Tector said. The attorney for the Nelson family declined to comment. The attorney for the Biggs family could not be reached for comment.

Still, Tector is skeptical of the Michigan researchers' findings. In any case, he said, they don't really apply to Clarian's program. Since wait times are so short at Clarian, he said, he's not skipping over higher-need patients in order to do a transplant for a lower-need patient.

But the incentive to do just that is there, according to a 2005 Northwestern University study, because it's less profitable to do a transplant for a sicker patient. The MELD system, implemented in 2002, has led hospitals to do even more transplants in the sickest patients. That caused profit margins to decline 114 percent from 2000 to 2003.

Tector acknowledged that his team's aggressive approach "doesn't hurt" the surgeons' and hospital's incomes. But he and Fridell said their focus is on making sure no one dies waiting for a transplant.

"If you're going to get everybody transplanted, you have to use every organ out there," said Fridell, the day after doing the pancreas transplant. The donation from the University of Michigan hadn't worked out. But in another hour, he said, he'd be on a plane to Evansville to look at another pancreas.

"The lifestyle of a transplant surgeon is unpredictable," he said.

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