Progress Report – the Pittsburgh-Palermo Connection [back]

This July, the Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IsMeTT – or UPMC Palermo) celebrates its third anniversary of clinical activity in Sicily, Italy. Thanks to the dedicated work and expertise of UPMC professionals, many from our own Department, in this brief time, not only has the Istituto established much-needed services in an area that was lacking, but it has also distinguished itself internationally as a model of private-public partnership in health care. Victor L. Scott, MD, director of Anesthesiology & Critical Care Medicine, and medical director of Operating Room Services at IsMeTT, was there to assist with the birth of the project and has worked tirelessly to help the Istituto reach its current phenomenal level of success.

UPMC Palermo traces its history to 1996, when senior UPMC administration – including Dr. Thomas Detre, Jeffrey Romoff, and Michelle McKenney – began exploring the possibility of an overseas venture. They were looking for an opportunity to export what the UPMC does best, specifically, solid organ transplantation. The group surveyed the health care environment in Europe and identified southern Italy as a location where the UPMC could make a significant difference. According to Dr. Scott, Rome had a small transplantation program, but there were no such services south of the Eternal City, and Sicily was sending its transplant patients elsewhere – at great expense. The UPMC team offered Italian officials the proposition that they could save money if Sicily had its own transplantation program. The Italians agreed to give UPMC an opportunity to try.

That’s when Dr. Ignazio Marino approached Dr. Scott, who was then a member of the Hepatic Transplantation Anesthesia team at UPMC Presbyterian. Dr. Marino, of the Thomas E. Starzl Transplantation Institute, had been entrusted with oversight of the Istituto, which is a joint venture between the UPMC Health System and two public institutions: Civico and Cervello hospitals in Palermo, Sicily. UPMC has a nine-year agreement with the Italian government, and an option to renew.

IsMeTT, the first US-style freestanding medical center of its kind in Europe is dedicated to all types of solid-organ transplantation and advanced specialty medical services, including specialized interventional radiology. The potential reach of IsMeTT’s services extends beyond the outline of Sicily, or even Italy itself. Patients from the entire Mediterranean Basin, who previously might have had to travel to the United States for these procedures, can now look to a resource thousands of miles closer to home.

“This is an experimental venture in private-public health care,” Dr. Scott explains. “Part of what we’re trying to do is determine whether we can operate more efficiently and more cost-effectively than the government can.”

UPMC Palermo’s success to date has been extraordinary.

“Clearly, we’ve already shown results,” says Dr. Scott. “We’ve demonstrated, first of all, that we can manage a public-private venture. The University of Pittsburgh was the first university to successfully start up such a program, to get it to the break-even point, and, indeed, even beyond. We’ve shown that we can do it more efficiently and at reduced cost. Most important is the fact that we successfully initiated several programs not previously available in Sicily.”

During the first year of clinical activities (1999-2000), the Anesthesiology & Critical Care Medicine Service at IsMeTT supported performance of 20 solid-organ transplantations without intraoperative mortality, an unusual feat for a newly initiated organ-transplantation program. Liver transplantations and liver resections are now routinely successful at IsMeTT, with the lowest mortality of any start-up program in all of Europe. IsMeTT’s transplant group is ranked the best in Italy – quite an accomplishment for such a young program. The Istituto has performed more living-related kidney transplants than all other transplantation centers in Italy, and a living-related liver-transplantation program was initiated last year.

State-of-the-art invasive radiology services for the treatment of hepatic tumors and portal hypertension are performed by interventional radiologists from IsMeTT, using facilities at nearby Villa Sofia Hospital. These interventions are facilitated by IsMeTT’s Anesthesiology & Critical Care Medicine services. In addition, a cardiovascular program will open in the near future. This service will encompass heart and heart/lung transplantation, artificial heart programs, and interventions for valvular heart disease.
The Department of Anesthesiology plays a central role in the administrative, operational, and clinical activity of the Istituto. Personnel include Americans, who remain in Italy for months or years before returning, and Sicilians. UPMC provides physicians, support staff, and senior administrators – who work to develop a management style that is adaptable to business administration in Sicily.

Dr. Ernesto Pretto was the first anesthesiologist to join Dr. Scott in Palermo (1999-2000) and has returned home. Dr. Jan Smith joined Dr. Scott in Palermo two years ago. In addition to working in critical care and anesthesiology, Dr. Smith is the education coordinator for Anesthesiology, and the director of continuing medical education for the Istituto. The Division of Hepatic Transplantation Anesthesiology at Presby has an intensive training program designed to create a base of experts who will be able to care for patients with liver disease at IsMeTT, and rotate as faculty members in Pittsburgh. Dr. Howard Doyle (now of the new Department of Critical Care Medicine) has returned to Pittsburgh after serving at IsMeTT. Two non-UPMC faculty members, Drs. Michael Chandler and Michael Moellenhoff, were recruited to assist in developing a cardiovascular program at IsMeTT and have returned to the US.

The Department of Anesthesiology provides staffing for OR anesthesiology, radiology, the outpatient clinic, gastroenterology special procedures, and the Intensive Care Unit. The ICU mortality was 7.8% in the past year (2000-01; see Table.) The first nurse anesthetist to join the team, Elda Silla, was instrumental in facilitating the operational and organizational management of anesthesiology services, both at the Istituto and in the off-site facilities, and the development of the ambulance services. Other Department staff members who have worked at IsMeTT are nurse anesthetists Daniel Mikuta and Mary Lou Tucker.

“We have introduced a different style in the management of critical care cases,” says Dr. Scott. “We have demonstrated that a system with expertise in liver transplantation is effective. Our liver transplant program has the highest survival rate in Italy. Ventures in other areas of Europe have taken notice and are looking closely at IsMeTT to see how it’s done.”

IsMeTT uses an integrated electronic medical record throughout the institution. Data entry occurs in real time, and authorized staff members can extract data on the patient immediately. Dr. Dan Martich (Department of CCM) hired the information technology specialists who developed the system.

The Istituto also instituted telemedicine programs and trans-Atlantic telepathology consults, which allow a real-time link to the laboratories at UPMC in Pittsburgh. The US Armed Forces Institute of Pathology, interested in starting a similar system, is examining IsMeTT’s telepathology program.

Already, international recognition has created a significant demand for clinical rotations at IsMeTT by students outside of Sicily. During Academic Year 2001, the Division of Anesthesiology & Critical Care Medicine hosted two students from Pitt and one each from the University of Buenos Aires, the University of Hamburg, and the University of Vienna. All were pleased with the expert level of training, and several expressed a desire to pursue a residency at IsMeTT. In 2001, IsMeTT inaugurated an extramural elective rotation program for fourth-year students at the University of Pittsburgh School of Medicine. This program was made possible by funds raised by Dr. Marino for this specific purpose. So far, five students have traveled from Pittsburgh to Palermo, each spending eight weeks working side by side with IsMeTT staff members. In the past 12 months, the program has attracted several U.S. students who have chosen to travel to Sicily to learn more about transplant medicine. Among these are a Fulbright Scholar from Princeton University, a first-year medical student from Ann Arbor, and a second-year medical student from Johns Hopkins University.

Dr. Scott says that technological advances have been slow in arriving to this part of the world. Italy is still waiting for many of the services that we regularly see offered in Pittsburgh. Members of the Anesthesiology & Critical Care team at IsMeTT have been closely involved in the design of a new hospital building for the Istituto; the new building is scheduled to open next summer. The new facility will allow IsMeTT to expand its services.

“We hope to introduce more programs that don’t yet exist in Italy,” says Dr. Scott, “such as the complex and esoteric neurosurgical and orthopedic procedure s performed at UPMC Presbyterian.”

Dr. Scott and the rest of the team first arrived in Palermo in 1997, living out of their hotel rooms at first, but they were too busy at the time to be concerned about accommodations. There was so much to be done.

“There have been many challenges,” Dr. Scott says. “When we got here, they did not have some of the most basic drugs (e.g., there was no fentanyl at all when we arrived). It’s amazing how much we have in Pittsburgh and how much we take for granted – speaking of availability.

“In Italy, everybody is covered by insurance, but they could wait forever to receive services. The laws and regulations in the EU force everything to be done by public bids. There is no way around it.”

“It was an enormous amount of work – more than I ever imagined. But I don’t regret it. What else could I do that could so quickly have this kind of impact on more than 5 million people? Our most important contribution, I think, is that we conveyed a different idea of how to deliver health care, and we’ve provided the tools to make the changes. I hope that this experimental partnership will offer a nidus of change for health care.”

Dr. Scott will be back at UPMC Presbyterian this summer, where, as he says, “I’ll just be a ‘regular Joe’ on the Liver Transplant Team. I’ve been happy here in Sicily, but it will be nice to come back to Pittsburgh, where I can go to K-Mart in the middle of the night if I want to.”

The Department looks forward to Dr. Scott’s return to Pittsburgh and congratulates him for his stellar performance with the team at UPMC Palermo.