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June 29, 2020

Centralization of High-risk Surgery in the US: Feasible Solution or More Trouble Than It Is Worth?

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
  • 3Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
  • 4Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
JAMA. Published online June 29, 2020. doi:10.1001/jama.2020.2953

Centralization, or shifting patients to hospitals with the most experience (or best outcomes), through the implementation of volume standards continues to be discussed as a means of improving the safety of high-risk surgical care. High-risk surgery involves operations in which postoperative complications are common or the risk of perioperative death is approximately 1% or greater.1 High-risk operations, such pancreatectomy, lung resection, or complex procedures for colorectal cancer, are performed on hundreds of thousands of patients annually in the US.2 Despite considerable enthusiasm for centralizing high-risk operations at designated centers, it remains unclear whether this delivery model is feasible in the US. Recent work suggests that a very small proportion of US hospitals currently meet established volume standards for high-risk operations set forth by initiatives like “Take the Volume Pledge” and the Leapfrog Group’s evidence-based hospital referral.2,3 Moreover, these standards may not consistently or reliably differentiate hospitals based on commonly measured perioperative quality outcomes.

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