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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.
Centralization policies have been successfully implemented in other countries, but these programs have had variable results.4,5 For example, centralizing pancreatic cancer surgery in the Netherlands was associated with improvement in perioperative safety, whereas a policy to centralize lung cancer surgery in Canada was not associated with improvement in perioperative mortality. Furthermore, the successes (or failures) from health care systems in other economically developed countries may not generalize to the US because of fundamental differences in populations and geography. The presence of a large private-payer market in the US makes implementation of any singular policy more challenging. A more nuanced discussion that acknowledges the potential trade-offs associated with centralization may aid in the design of better strategies to improve the safety and effectiveness of surgical care.
Problems With the Current Model of Centralization
There are several problems with the current model of centralization of high-risk surgery in the US. First, centralization of all high-risk procedures is impractical. For some procedures targeted by these initiatives, there are too few high-volume hospitals. In 2016, less than 25% of hospitals that performed pancreatic, lung, rectal, and esophageal cancer surgery met even modest volume standards put forth by the Leapfrog Group.2 This raises the question of how implementing annual volume thresholds might affect patient access to surgical care for certain conditions, especially for people living in rural health care markets that do not include a high-volume center. Prior studies have suggested that for nearly half of patients needing an esophagectomy or pancreatectomy, hospital volume thresholds similar to currently recommended benchmarks (19 per year for esophagectomy, 16 per year for pancreatectomy) would impose at least 2 additional hours of travel for care.6 Other studies have shown the adverse effects of travel on health outcomes. Patients who lived a greater distance from Veterans Affairs transplant centers had lower chances of being listed or receiving a transplant and a higher risk of death.7 These issues are particularly relevant for socioeconomically disadvantaged patients who may not have the means or desire to travel farther for care.8 Ultimately these trade-offs (ie, better outcomes vs travel burden) should be explained to patients so that they can decide where to have surgery.
Second, there is uncertainty about what drives better outcomes at high-volume hospitals. Although many studies have demonstrated an association between higher surgical volume and better perioperative outcomes, the underlying mechanisms remain unclear. High procedure volume alone is not sufficient. There is significant variation in surgical quality among high-volume hospitals, and some low-volume hospitals have very good outcomes. An understanding of how health care infrastructure, surgeons’ experience, care processes, or combinations of these factors influence outcomes could better inform the designation of high-quality centers in a centralized care model.
Third, current volume standards are not dynamic. Surgical care has gotten safer over time. As a result, volume standards used to differentiate hospitals 10 years ago may no longer be relevant. While applying uniform volume standards may be efficient, it may also be imprecise and ineffective to promote uniform standards across various health care markets because each has unique needs, risk tolerance, geographic barriers, and resource availability.
Potential Approaches for Ensuring Quality Surgical Care
Several strategies may help to promote quality surgical care. One involves helping to move patients to the most experienced hospitals or to those with the best outcomes. This conventional centralization model may be most feasible within narrow geographic areas or health care markets where at least 1 experienced or high-quality center already exists. Insurance networks aside, there is no reason for patients in large metropolitan areas with 1 or more tertiary referral hospitals to undergo elective, high-risk surgery at a center with limited experience.
Several factors would need to be addressed for this approach to be successful. What constitutes adequate experience or outcomes will need to be defined with feedback from patients, clinicians, and clinical societies with expertise in the care being provided. Volume or quality thresholds should remain flexible and reflect the needs of the local health care environment. Centers with suboptimal outcomes should be incentivized to refer patients to possible competitors within the local health care market. In markets without a high-volume or high-quality hospital, insurers would need to agree to cover care provided by out-of-network facilities.
Creative strategies are needed to address the burden and costs of travel, even locally, for patients and their families. In some employer-based insurance programs, patients are given the option of subsidized travel to preselected, high-quality hospitals across the nation. This approach not only addresses financial issues patients identify as barriers but could also make economic sense for insurers.8 While there is some debate over the effectiveness of travel programs, facilitating patients getting care at the best hospitals by subsidizing travel appears credible and may save costs in aggregate by reducing complications.9 However, this needs to be balanced against a potential disruption to the patient’s support system when physically separated from their family while receiving care at a distant facility.
Another strategy, which today concerns a much larger group of hospitals and health care markets, involves facilitating sharing knowledge and expertise. Telemedicine technology continues to expand across many domains in health care. As an alternative to travel, local hospitals can leverage technology to access clinical input from experienced centers to aid in evaluating preoperative imaging, receiving multidisciplinary input for care planning, or providing advice for management of postoperative complications. This strategy could minimize the travel burden imposed on patients while also acknowledging that many patients have strong preferences for local care or may not have the means to travel farther.8 It requires a willingness on the part of hospitals and health systems to invest in the technological infrastructure to facilitate distant consultation and sharing of expertise. For cases in which a health system may not include an in-network high-volume center or surgeon, collaboration with a potential market competitor would need to be emphasized in the interest of what is best for the individual patients.
Ensuring that patients receive quality surgical care remains an important goal, but uniform centralization of high-risk surgery could decrease access and disenfranchise patients who may be unable or unwilling to travel for care. Tailoring strategies to the local health care market would not only align resources with practical needs but also empower clinicians to engage in the development of standards and best practices for high-risk surgical care. Identifying, acknowledging, and learning from the trade-offs inherent to implementing a conventional centralization model within the US health care system may actually be the most useful path forward.
Corresponding Author: Kyle H. Sheetz, MD, MSc, Center for Healthcare Outcomes & Policy, University of Michigan School of Medicine, 2800 Plymouth Rd, NCRC B016, Room 100N-11, Ann Arbor, MI 48109 (firstname.lastname@example.org).
Published Online: June 29, 2020. doi:10.1001/jama.2020.2953
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the US Department of Veterans Affairs (VA) Health Services Research & Development Service of the VA Office of Research and Development Merit Review (award I01 HX002447 [Dr Massarweh]) and Center for Innovations in Quality, Effectiveness and Safety (award CIN 13-413 [Dr Massarweh]).
Role of the Funder/Sponsor: The VA had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.
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Sheetz KH, Massarweh NN. Centralization of High-risk Surgery in the US: Feasible Solution or More Trouble Than It Is Worth? JAMA. Published online June 29, 2020. doi:10.1001/jama.2020.2953
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