Sunday, April 22, 2018

Need for more HCA trauma centers not clear-cut

Officials at one of the nation's largest hospital chains have made a powerful argument to defend their unprecedented expansion of Florida's trauma system:
Hospital Corporation of America is saving lives.

For months, HCA has handed out reports portraying improved survival rates. HCA supporters have suggested that people will die if state courts force the company to close its new trauma centers.

Judging by positive votes the company has received in the Legislature, it appears lawmakers are accepting the claims, which HCA paints as settled fact.

"I feel like I am fighting for something that has already proven itself," Dr. Darwin Ang told the Senate Health Policy Committee late last month. Ang is a trauma surgeon who serves as medical director of the trauma center at HCA's Ocala Regional Medical Center. He's also the director of research for the new trauma network.

But the reality is far less clear.

The evidence that HCA trauma centers are lowering mortality rates comes exclusively from Ang's research on the impact of the company's trauma expansion.

Statewide death rates from traumatic injury were declining long before HCA got into the trauma business, experts say. The company may be claiming credit for that trend.

In addition, HCA's trauma centers are flooded with injuries that in the past were not considered serious enough for trauma centers. In effect, the state's trauma numbers are being inflated by patients least likely to die, who could have been treated less expensively at their nearby emergency room. But inflating the overall numbers treated appears to help the company claim that it is lowering death rates.

Patients and paramedics in some of the counties where it has opened new trauma centers have been traveling to Tallahassee to endorse HCA. In Ocala, home to the newest HCA trauma center, it used to take paramedics more than a half hour to take critically injured patients to the nearest trauma center. Now the average trip takes 16 minutes.

HCA and its supporters say that is saving lives.

But opponents say that since the research methods, particularly the statistical models, have not been published, it's impossible to independently verify HCA's claims.

"This is all insulting, nonsensical public relations," said Dr. J. J. Tepas, a surgeon and trauma researcher, who recently published his own research in the Journal of Trauma and Acute Care Surgery indicating that HCA's expansion raised costs at a time when there was no evidence of need.

The hospital where Tepas works, UF Health Jacksonville, is among several existing trauma centers that have sued to stop HCA's trauma expansion.

"They can sit there and do all the bragging they want," he added, "but who knows?"

Scientific research methods are complicated.

The Tampa Bay Times did a simple review of state hospital records. It shows that after HCA's expansion virtually the same number of people died in Florida trauma centers as the year before the expansion. In 2010, 1,690 people died compared with 1,689 in 2012.

In the Tampa Bay region, 340 trauma patients died at the area's three trauma centers in 2010. Late the following year, HCA opened trauma centers in Pasco and Manatee counties.

In 2012, 368 patients died at the area's five trauma centers.

Though deaths increased, the mortality rate for the region's trauma centers actually improved, from 4.7 percent to 3.9 percent — thanks to the 2,100 additional patients treated, mostly at the new HCA centers. Many of these patients faced little risk of dying from their injuries.

"The number of trauma patients who ultimately died did not change, but they were distributed over more trauma centers," said Barbara Langland Orban, a University of South Florida College of Public Health professor and trauma researcher who reviewed the Times analysis.

• • •

No one is quite sure why deaths from traumatic injury had been declining even before HCA launched its network in partnership with USF's Morsani College of Medicine.

It could, for instance, be because of safer cars, greater use of seat belts or advances in life-saving technology.

"HCA is trying to claim credit for a fall in 2012 that started back in 2006 at least," said Etienne Pracht, a USF health care economist who is one of the state's leading experts in analyzing injury severity and trauma trends using the state's data.

What is clear is that after years of little growth, the number of Floridians treated at trauma hospitals boomed as HCA got into the business. It now operates five of the state's 25 trauma centers treating adults.

Between 2010 and 2012, an additional 6,000 injured patients flooded the state's trauma centers, a Times analysis of state-reported hospital data found. These specialized units are staffed around the clock to treat the worst injuries from car accidents, debilitating falls and gunshot wounds.

A recent investigation by the Times found that trauma centers across the state are exploiting a little-known fee that is meant to offset some expenses of high-priced care. But HCA's average $28,000 trauma response fee is by far the highest in the state. The company hopes to open even more trauma centers.

HCA's own records explain how it created the demand for its trauma centers at a time when researchers say Florida was not seeing an increase in serious injuries:

As many as 40 percent of HCA's trauma patients had the kinds of injuries previously treated in routine emergency room visits. All HCA had to do was open trauma centers in its hospitals to reclassify the injuries as traumatic.

The numbers are laid out in a report that HCA filed with the state in February 2013 to justify a new trauma center in Ocala. The company had a consultant conduct a count of injured people by region. The analysis assumed the Ocala center — like the other HCA trauma centers — would get some business from its own conventional emergency room.

Then they would draw other patients who otherwise would have been taken to existing trauma centers located farther away.

Ang said in a statement Friday that the patients going to HCA trauma centers "are now appropriately receiving care at a trauma center and now have access to all the resources including specialists and technology available which lead to better outcomes."

Another for-profit hospital chain took a similar look at the numbers and concluded the community would not benefit if it added trauma centers to its hospitals.

"All I was doing was adding cost," said Alan Levine, then the senior vice president overseeing Health Management Associates' Florida facilities.

"My gain would have come at the expense of another trauma center, or by just converting patients that I was already taking care of very successfully in my own hospital," he added.

HMA would later buy Bayfront Medical Center in St. Petersburg, which is among the trauma centers suing to stop HCA's trauma expansion. Levine now works for a nonprofit hospital chain in Tennessee.

• • •

Ang says several of his studies on the HCA trauma network have been presented at national conferences. He said one of his papers, coauthored with surgeons from USF, will be published in July in the Journal of Trauma and Acute Care Surgery. He said he is barred from sharing details until that happens.

Until a scientific paper is published, other experts say they cannot fully evaluate the methodology used.

Even so, HCA officials have cited this work to lobby the public and state lawmakers.

In legislative hearings and in documents shared with the media, HCA says mortality rates have declined everywhere it has opened trauma centers.

"We have made Florida trauma better," Ang said at a Senate hearing.

Experts point out that noting a trend is different than proving why it happened.

Using his methodology, Ang said he found that some regions of the state without a new HCA center did not experience mortality rate improvements. He said "it is logical to attribute the improvement in patient mortality to improved access to trauma care."

HCA officials told the Times that they stand by Ang's findings.

Scientific findings generally gain validity if they can be independently verified and stand up over time. The HCA centers have been open only for a relatively brief period.

Even studies published after rigorous, independent review frequently turn out to be wrong, according to Dr. Jerome Hoffman, a University of California, Los Angeles professor and expert in the pitfalls of scientific research.

"It's a little bit of a dirty secret of medical science," he said. "Even if it gets published it doesn't mean it's true."

Passing laws based on research that hasn't been independently scrutinized "would be really silly," he added.

Times computer-assisted reporting specialist Connie Humburg and staff writer Alexandra Zayas contributed to this report. Zayas can be reached at (727) 893-8413 and [email protected]

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