National centralization of Hirschsprung's disease in Sweden: a comparison of postoperative outcome.

BACKGROUND: In Sweden, surgical treatment of Hirschsprung's disease (HSCR) was centralized from four to two pediatric surgery centers 1st of July 2018. In adults, centralization of surgical care for complex or rare diseases seems to improve quality of care. There is little evidence supporting centralization of pediatric surgical care. The aim of this study was to assess surgical management and postoperative outcome in HSCR patients following centralization of care. METHODS: This study retrospectively analyzed data of patients with HSCR that had undergone pull-through at a pediatric surgery center in Sweden from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 (before centralization) were compared with patients managed from 1st of July 2018 to 30th of June 2023 (after centralization) regarding surgical treatment, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through as well as complications classified according to Clavien-Madadi up to 30 days after pull-through. RESULTS: In the 5-year period prior to centralization, 114 individuals from 4 treating centers were included and compared to 83 patients from 2 treating centers in the second period. There was no difference regarding age at pull-through or proportion of patients with a stoma prior to pull-through. An increase of laparoscopically assisted endorectal pull-through (8.8% to 39.8%) was observed (p < 0.001). No significant differences were seen in postoperative hospital stay, unplanned procedures under general anesthesia, or readmissions up to 90 days after pull-through. There was no difference in severe complications (Clavien-Madadi ≥ 3); however, HAEC treated with antibiotics increased following centralization (10.5-24.1%; p = 0.018). CONCLUSION: Centralization of care for HSCR does not seem to delay time to pull-through nor reduce severe complications, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through. The increased HAEC rate may be due to increased awareness of mild HAEC. LEVEL OF EVIDENCE:  Level III.

Is centralization for rectal cancer surgery necessary?

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guidelines. However, there are barriers to implementation at a professional, political, governance and resource allocation level. Centralization may increase inequalities to accessing healthcare, particularly impacting socioeconomically disadvantaged and rural populations with difficulties to commuting longer distances to "centres of excellence". Furthermore, it is unclear if centralization actually improves outcomes. Recent studies demonstrate that individual surgeon volume rather than hospital volume may be more important in achieving optimal outcomes. In this review, we examine the literature to assess the value of centralization for rectal cancer surgery.

National Centralization of Hirschsprung's Disease in Sweden:A Comparison of Preoperative Management and Outcomes.

BACKGROUND: Surgical treatment of Hirschsprung's disease (HSCR) in Sweden was centralized to two tertiary pediatric surgery centers 1st of July 2018. Although complex surgical care in adults seems to benefit from centralization there is little evidence to support centralization of pediatric surgical care. The aim of this study was to assess centralization of HSCR in Sweden, with special consideration to preoperative management and outcomes in this group of patients. METHODS: This study retrospectively analyzed data of patients with HSCR that had undergone or were planned to undergo pull-through at our center, from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 were compared with patients managed from 1st of July 2018 to 30th of June 2023 regarding diagnostic procedures, preoperative treatment, complications and time to definitive surgery. RESULTS: Thirty-six patients were managed during the first five-year period compared to 57 during the second period. There was an increased number of patients referred from other Swedish regions to our center following the centralization. Time from diagnosis to pull-through increased from 33 to 55 days after centralization. There were no significant differences in pre-operative management or complications, general or related to stoma. CONCLUSIONS: Despite increasing patient volumes and longer time from diagnosis to pull through, centralization of care for HSCR does not seem to change the preoperative management and risk of complications. With access to support from the specialist center, transanal irrigations remain a safe mode of at home management until surgery, regardless of distance to index hospital. LEVEL OF EVIDENCE: Level III.

Cystectomy for bladder cancer in Sweden - short-term outcomes after centralization.

OBJECTIVE: Radical cystectomy (RC) for bladder cancer is associated with an inherent risk of complications and even postoperative mortality. The number of hospitals performing RC has decreased in Sweden over time, and since a formal regional centralization in 2017 cystectomy care is currently provided by nine hospitals. MATERIAL AND METHODS: In the Swedish National Urinary Bladder Cancer Register (SNRUBC) 90-day complications after RC have been registered with high coverage since 2012. Descriptive data and short-term outcomes were compared in relation to centralization of the cystectomy care by stratifying data before (2012-2016) and after (2017-2023). RESULTS: Out of all 4,638 cystectomies, 2,738 (59%) were performed after the centralization in 2017 and onwards. The median age at RC increased from 71 (Inter Quartile Range [IQR] 65-76) to 73 (IQR 67-77) years, and the proportion of patients with comorbidity (American Society of Anesthesiologists [ASA] 3 or 4) increased from 32% to 37% after the centralization (p < 0.001). The number of patients suffering from high-grade complications within 90 days of surgery corresponding to Clavien grade three were 345 (18%) and 407 (15%), and corresponding to Clavien grade four 61 (3%) and 64 (2%) before and after centralization, respectively. Reoperations within 90 days of RC decreased from 234/1,900 (12%) to 208/2,738 (8%) (p < 0.001), and 90-day mortality decreased from 84/1,900 (4%) to 85/2,738 (3%) (p = 0.023) before and after centralization, respectively. CONCLUSION: After the centralization of the cystectomy-care in Sweden, older patients and individuals with more extensive comorbidity were offered RC whereas 90-day mortality and the proportion of patients subjected to reoperations within 90 days of surgery decreased without increasing waiting times.

Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service.

OBJECTIVE: Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND: The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS: Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS: Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS: There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.

Centralization of pediatric surgical care in the Netherlands: Lessons learned.

Centralization of care is a difficult process, as there are several stakeholders that are involved and should be heard. What can be the best option for a small group of patients may be detrimental to a larger group of patients that cannot be adequately treated close to home. The weighing of these factors is different in every environment. One universal rule however is: if you don't do it yourselves, others will do it for you. In the Netherlands, pediatric oncology, including surgery, is centralized in one center (Utrecht) with the help of several shared care centers scattered throughout the country for things that can be managed close to home.

Effect of thoracic surgery regionalization on long-term survival after lung cancer resection.

OBJECTIVE: Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit. METHODS: We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ2 or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors. RESULTS: Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality. CONCLUSIONS: We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.

Estimates of the effects of centralization policy for surgery in Japan: does centralization affect the quality of healthcare for esophagectomies?

PURPOSE: This study compared the quality of healthcare before and after implementation of a policy restructuring the healthcare delivery system and estimated the impact of centralization. METHODS: We used the National Clinical Database to study patients undergoing esophagectomies from 2011 to 2016. We compared the effect of centralization based on the patient background, surgical mortality, and year of surgery. Difference-in-difference methods based on the generalized estimating equation logistic regression model were used for before-and-after comparisons after adjusting for patient-level expected surgical mortality. RESULTS: In total, 34,640 cases were identified. More cases with risk factors were noted in ultra-low-volume hospitals, where 38.4% of cases in underpopulated areas were treated, than in higher volume facilities, and the operative mortality, readmission within 30 days and length of stay were worse among patients treated in these hospitals. In centralized prefectures, the number of cases per hospital increased over time (7.2 in 2011 to 9.5 in 2016) while the crude operative mortality tended to decrease (3.4% in 2011 to 1.8% in 2016). The difference-in-difference estimator was 0.856 (95% confidence interval: 0.639-1.147, p = 0.298). CONCLUSION: The centralization of ultra-low-volume hospitals did not lead to a deterioration in the quality of care but rather an improving trend.

Modelling centralization of pancreatic surgery in a nationwide analysis.

BACKGROUND: The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort. METHODS: Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds. RESULTS: A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively). CONCLUSION: The best performance model for centralization involved a threshold for volume combined with a mortality threshold.

ANTECEDENTES: Los beneficios de la centralización de la cirugía pancreática están bien documentados, pero la política de actuación difiere entre los países. Este estudio tuvo como objetivo desarrollar modelos de centralización basados en varios criterios y analizar su aplicación en una cohorte nacional. MÉTODOS: Los datos de todas las resecciones pancreáticas realizadas entre 2014 y 2016 se obtuvieron del Ministerio de Salud italiano. La mortalidad se evaluó para diferentes categorías del volumen hospitalario y para cada centro individualmente. Se calculó la mortalidad observada y la tasa estandarizada de riesgo de mortalidad (risk standardized mortality rate, RSMR). Se analizaron varios modelos de centralización aplicando criterios de volumen solos o en combinación con umbrales de mortalidad. RESULTADOS: Un total de 395 hospitales realizaron 12.662 resecciones; 305 de ellos pertenecían a la categoría de muy bajo volumen (media de 2,6 resecciones/año). La mortalidad nacional fue del 6,2%, aumentando progresivamente del 3,1% en los hospitales de muy alto volumen al 10,6% en los hospitales de muy bajo volumen. Para fines de centralización, al aplicar un umbral de volumen mínimo ≥ 10 resecciones/año, se seleccionarían 92 centros, con una mortalidad global del 5,3%. Sin embargo, la mortalidad sería > 5% en 48 hospitales y > 10% en 17 hospitales. Si el volumen mínimo fuera de 25 resecciones/año, la mortalidad global sería del 4,7% en 38 hospitales, pero aún > 5% en 17 centros y > 10% en seis centros. La combinación de un volumen necesario (≥ 10 resecciones/año) con un umbral de mortalidad (RSMR ≤ 5% o ≤ 10%) permitiría excluir hospitales con resultados inaceptables, determinando una mortalidad global más baja (2,7% en 45 hospitales o 4,2% en 76 hospitales, respectivamente). CONCLUSIÓN: El mejor modelo para la centralización de resecciones pancreáticas incluyó un umbral para el volumen hospitalario combinado con un umbral de mortalidad.

Simulating the impact of centralization of prostate cancer surgery services on travel burden and equity in the English National Health Service: A national population based model for health service re-design.

INTRODUCTION: There is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment. Using prostate cancer surgery as an example, this national study analysis aims to simulate the effect of different centralization scenarios on the number of center closures, patient travel times, and equity in access. METHODS: We used patient-level data on all men (n = 19,256) undergoing radical prostatectomy in the English National Health Service between January 1, 2010 and December 31, 2014, and considered three scenarios for centralization of prostate cancer surgery services A: procedure volume, B: availability of specialized services, and C: optimization of capacity. The probability of patients travelling to each of the remaining centers in the choice set was predicted using a conditional logit model, based on preferences revealed through actual hospital selections. Multivariable linear regression analysed the impact on travel time according to patient characteristics. RESULTS: Scenarios A, B, and C resulted in the closure of 28, 24, and 37 of the 65 radical prostatectomy centers, respectively, affecting 3993 (21%), 5763 (30%), and 7896 (41%) of the men in the study. Despite similar numbers of center closures the expected average increase on travel time was very different for scenario B (+15 minutes) and A (+28 minutes). A distance minimization approach, assigning patients to their next nearest center, with patient preferences not considered, estimated a lower impact on travel burden in all scenarios. The additional travel burden on older, sicker, less affluent patients was evident, but where significant, the absolute difference was very small. CONCLUSION: The study provides an innovative simulation approach using national patient-level datasets, patient preferences based on actual hospital selections, and personal characteristics to inform health service planning. With this approach, we demonstrated for prostate cancer surgery that three different centralization scenarios would lead to similar number of center closures but to different increases in patient travel time, whilst all having a minimal impact on equity.

Impact of Centralisation on Abdominal Aortic Aneurysm Repair Outcomes: Early Experience in Catalonia.

OBJECTIVE: Several studies have revealed high volume centres have better outcomes in the treatment of abdominal aortic aneurysms (AAAs), thus supporting centralisation of this procedure into selected centres based on volume. To date however, the real benefit of centralisation of this pathology has not been well demonstrated. The aim of this study was to analyse the impact of centralisation in to high volume centres (defined as those performing more than 30 cases per year) on AAA treatment outcomes carried out in Catalonia (Spain). METHODS: Data were collected from official national registries (HDMBD) for AAA treated by endovascular aneurysm repair (EVAR) or open repair (OR) over a nine year period. Two time periods were selected for comparison: before centralisation (2009-2014) and after complete centralisation (2015-2017). The primary objective was to determine short term mortality (in hospital and 30 day mortality) and length of stay (LOS) after intact AAA (iAAA) and ruptured AAA (rAAA) repair, before and after centralisation. Uni- and multivariable analyses were performed in order to identify independent outcomes predictors. RESULTS: A total of 3 501 iAAAs, including 1 124 (32.1%) OR and 2377 (67.9%) EVAR, and 409 rAAAs, including 218 (53.3%) OR and 191 (46.7%) EVAR, were identified. After centralisation, there was a significant decrease in overall mortality in iAAA repair (4.7% vs. 2.0%, p < .001) and rAAA repair (53.1% vs. 41.9%, p = .028). Mortality reduction in iAAAs was significant for OR (8.7% vs. 3.6%, p = .005), but not for EVAR (2.2% vs. 1.5%, p = .25). Overall LOS decreased as well, mainly in iAAAs (9.49 ± 10.84 vs. 7.44 ± 12.23 days, p < .001), and in particular in elective EVAR (7.32 ± 7.73 vs. 6.00 ± 8.97 days, p < .001). Multivariable analysis was identified before the centralisation period as an independent predictor for both mortality (odds ratio 1.484, 95% CI 1.098-2.005, p = .010) and LOS (B coefficient 1.146, 95% CI 0.218-2.073, p = .016). CONCLUSION: The implementation of a country based centralisation programme for AAA treatment led to a significant reduction in short term mortality, for both iAAA and rAAA, and mainly for elective OR. LOS also significantly decreased, mainly for elective EVAR. These results support the benefit of centralisation of AAA repair procedures.

Regionalization of Congenital Heart Surgery in the United States.

The objective of this study is to simulate regionalization of congenital heart surgery (CHS) in the United States and assess the impact of such a system on travel distance and mortality. Patients ≤18 years of age who underwent CHS were identified in 2012 State Inpatient Databases. Operations were stratified by the Risk Adjustment for Congenital Heart Surgery, version 1 (RACHS-1) method, with high risk defined as RACHS-1 levels 4-6. Regionalization was simulated by progressive closure of hospitals, beginning with the lowest volume hospital. Patients were moved to the next closest hospital. Analyses were conducted (1) maintaining original hospital mortality rates and (2) estimating mortality rates based on predicted surgical volumes after absorbing moved patients. One hundred fifty-three hospitals from 36 states performed 1 or more operation (19,064 operations). With regionalization wherein, all hospitals performed >310 operations, 37 hospitals remained, from 12.5% to 17.4% fewer deaths occurred (83-116/666), and median patient travel distance increased from 38.5 to 69.6 miles (P < 0.01). When only high-risk operations were regionalized, 3.9-5.9% fewer deaths occurred (26-39/666), and the overall mortality rate did not change significantly. Regionalization of CHS in the United States to higher volume centers may reduce mortality with minimal increase in patient travel distance. Much of the mortality reduction may be missed if solely high-risk patients are regionalized.

Making surgery safer by centralization of care: impact of case load in penile cancer.

PURPOSE: Penile cancer is a rare but aggressive disease, often requiring a rapid and extensive surgical treatment of the primary tumor and staging or treatment of the inguinal lymph node basins. Current management and guidelines of the disease are mainly based on retrospective data, as there is a lack of controlled trials or large series. The purpose of this work is to review contemporary data on the impact of centralization and formation of rare disease networks on penile cancer care and outcomes. METHODS: This narrative, non-systematic review is based on publications retrieved by a PubMed and EMBASE search and on the current guidelines of the European Association of Urology, the National Institute for Health and Care Excellence, and the National Comprehensive Cancer network. RESULTS: The low case load, particularly in non-specialized centres, combined with limited evidence regularly results in a disparity between the treatment strategy and the guidelines. The suboptimal guideline adherence is specifically the case for organ-sparing surgery and surgical staging of the groin areas in selected cases. Treatment of the disease in high-volume referral centres has been shown to improve the use of organ-sparing surgery, the utilization of invasive lymph node staging in high-risk patients, and finally has resulted in increased survival rates. CONCLUSIONS: The management of penile cancer in disease networks and in countries where centralized healthcare is offered positively influences functional and oncological outcomes. We propose that governments and health care providers should be encouraged to centralize healthcare for rare tumors such as penile cancer.

State-wide outcomes in elective rectal cancer resection: is there a case for centralization in Victoria?

BACKGROUND: The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes. METHODS: The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups. RESULTS: There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed. CONCLUSION: Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.

[Extremely preterm birth in Sweden - clear progress but remaining challenges]. / Extremt förtidig födelse ­ svåra utmaningar trots stora framsteg - Överlevnaden till 1 års ålder är hög, men allvarlig neonatal sjuklighet är en utmaning.

The recently documented high survival of extremely preterm infants in Sweden is related to a high degree of centralization of pre- and postnatal care and to recently issued national consensus guidelines providing recommendations for perinatal care at 22-24 gestational weeks. The prevalence of major neonatal morbidity remains high and exceeded 60 % in a recent study of extremely preterm infants born at < 27 gestational weeks delivered in Sweden in 2014-2016 and surviving to 1 year of age. Damage to immature organ systems inflicted during the neonatal period causes varying degrees of functional impairment with lasting effects in the growing child. There is an urgent need for evidence-based novel interventions aiming to prevent neonatal morbidity with a subsequent improvement of long-term outcome.