Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

The overwhelming evidence in favour of centralisation

Since 1979, the year of the first publication on the subject, what dictated intuition has been amply demonstrated. In other words, the volume of complex surgical procedures treasured by a single team is related to the survival of the operated patients. Subsequent studies have refined the analysis and have concluded that the centres with the best results know, in the first place, how to adjust the indications. Still, above all, they are prepared to rescue incidents, through the preventive detection of complications and the subsequent performance of well-trained teams trained to give critical post-operative service of the highest level. Surprisingly, 40 years later, according to the review's authors, centralisation plans are having a hard time everywhere.

Disruption in regulations

Experts believe that centralising concepts are generally well established for transplants, paediatric surgery, and neurosurgery, while in all other specialities, the criteria are quite different. An example is the wide variations in the minimum number of interventions required by various governments. For oesophageal cancer, the figures show a range that goes from 6 annual cases in Spain to 80 in Denmark. For pancreatic resections, the range of minimal interventions is also very wide: from 10 in Switzerland, Norway or Germany at 80-100 in the United Kingdom and Denmark, ranges that reappear in all the complex processes reviewed by the authors. It is curious that, in all of them, Spain is used to being in a very permissive position.

Expert proposals

The European Surgical Association promoted a Delphi study whose purpose was to agree on proposals that would help overcome difficulties in centralising complex surgery, of which I would like to highlight the following:

1. Centralisation projects should be based on diseases or systems, for example, pancreatic cancer or complex diseases of the liver-biliary-pancreatic system, rather than on specific surgical processes such as pancreatectomy.
2. The minimum number of cases should be attributed to a team or centre and not to a surgeon.
3. We should attempt to balance the territorial question (if possible) to avoid excessive concentration at one point (usually a large city).
4. Centralisation must have legal force and must equally bind the public and private sectors.
5. The government must guarantee the accessibility of all citizens who require it.

According to the study, hospitals with a centralised sophisticated surgery program should commit to:

1. Provide the appropriate and updated infrastructure.
2. Have sufficient and well-trained professionals to cover all the needs of the clinical process.
3. Promote multidisciplinary teamwork.
4. Network with other centres in the territory to decentralise the services that require proximity.
5. Have advanced professional training programs.
6. Guarantee the quality of the processes and the safety of the patients.
7. Promote evaluative research and clinical trials.
8. Facilitate external audits and share data with other homologous programs for benchmarking.

Patients must be involved

The surgeons who participated in the Delphi forgot the patients. For this reason, I believe that the recommendations would need an approach such as: introducing shared decision methodology; rethinking outcomes taking into account the perception of patients (PROM) and incorporating patients in the rethinking of processes and circuits, with elements of design thinking and scales of evaluation of perceived experience (PREM).

Sometimes, very few, the evidence says that a way of organising is valuable for patients, as has happened with transplants and the codes for heart attack and stroke. Now it is time to rigorously centralise complex surgery, an inescapable moral duty for planners, managers, and physicians.


Jordi Varela
Editor