Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees.

OBJECTIVE: The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. METHODS: A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. RESULTS: During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). CONCLUSIONS: In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma.

BACKGROUND: A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS). METHODS: Using the National Cancer Database (NCDB) 2004-2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS. RESULTS: Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%-44%, p < 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%-15%, p < 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88-0.97, p < 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83-0.91, p < 0.001) were independently associated with improved OS. CONCLUSIONS: Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival.

Rates, Characteristics, and Outcomes of Patients Transferred to Specialized Stroke Centers for Advanced Care.

Background While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers' front door versus Transfer-Ins from another hospital. Methods and Results We analyzed 970 390 AIS cases in the Get With The Guidelines-Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale. Conclusions There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.

Toward a Consensus on Centralization in Surgery.

OBJECTIVES: To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations. BACKGROUND/METHODS: Most countries are increasingly forced to maintain quality medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents. RESULTS: Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education. CONCLUSION/RECOMMENDATIONS: There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.

Effects of centralizing acute stroke services: A prospective cohort study.

OBJECTIVE: To investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR). METHODS: The CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective "before-and-after" cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014. RESULTS: Centralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38-0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark. CONCLUSIONS: Centralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

Comparison of patients with multivessel disease treated at centers with and without on-site cardiac surgery.

BACKGROUND: The regional needs and consolidation of cardiac surgery services (CSS) result in an increased number of stand-alone interventional cardiology units. We aimed to explore the impact of a heart team on the decision making and outcomes of patients with multivessel coronary artery disease referred for coronary revascularization in stand-alone interventional cardiology units. METHODS: This prospective study included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention (PCI), with or without on-site CSS. RESULTS: Of the 1063 patients, 487 (46%) underwent coronary artery bypass grafting (CABG) and 576 (54%) underwent PCI. A higher proportion of patients underwent PCI in hospitals without on-site CSS compared with those with on-site CSS (65% vs 46%; P < .001). Furthermore, patients referred to CABG from hospitals without on-site CSS had a significantly higher mean SYNTAX score compared with those who underwent CABG in centers with on-site CSS (29 vs 26; P = .018). Multivariate logistic regression analysis consistently showed that the absence of on-site cardiac surgery and a heart team was independently associated with a 2.5-fold increased likelihood for predicting the referral of PCI rather than CABG (odds ratio, 2.54; 95% confidence interval, 1.8-3.6). CONCLUSIONS: Patients with multivessel coronary artery disease treated in centers without on-site cardiac surgery services receive a lower rate of appropriate guideline-based intervention with CABG. These findings suggest that a heart team approach should be mandatory even in centers with stand-alone interventional cardiology units.

Beyond Volume Indicators and Centralization: Toward a Broad Perspective on Policy for Improving Quality of Emergency Care.

STUDY OBJECTIVE: Policymakers increasingly regard centralization of emergency care as a useful measure to improve quality. However, the clinical studies that are used to justify centralization, arguing that volume indicators are a good proxy for quality of care ("practice makes perfect"), have significant shortcomings. In light of the introduction of a new centralization policy in the Netherlands, we show that the use of volume indicators in emergency care is problematic and does not do justice to the daily care provided in emergency departments (EDs). METHODS: We conducted an ethnographic study in 3 EDs, a primary care facility, and an ambulance call center in the Netherlands, including 109 hours of observation, more than 30 ethnographic interviews with professionals and managers, and 5 semistructured follow-up interviews. RESULTS: We argue that emergency care is a complex, multilayered practice and distinguish 4 different repertoires: acute and complex care, uncertain diagnostics, basic care, and physical, social, and mental care. A "repertoire" entails a definition of what good care is, what professional skills are needed, and how emergency care should be organized. CONCLUSION: The first repertoire of acute and complex care might benefit from centralization. The other 3 repertoires, however, equally deserve attention but are made invisible in policies that focus on the first repertoire and extrapolate the idea of centralization to emergency care as a whole. Emergency care research and policies should take all repertoires into account and pay more attention to alternative measures and indicators beyond volume, eg, patient satisfaction, professional expertise, and collaboration between EDs and other facilities.

The Centralization of Total Joint Arthroplasty in New York State An Analysis of 168,247 Cases.

We identified 168,247 total hip and total knee arthroplasties performed in New York State between 2010 and 2012 to examine the evidence for increased geographical and institutional centralization of these procedures. We measured the increased growth of high volume institutions as compared to lower volume hospitals in New York State. We found a high proportion of total arthroplasties already performed in the dozen biggest hospitals in New York back in 2010 and a significant higher growth of these high volume, "centers of excellence," hospitals when compared to low volume hospitals.

The Regionalization of Lumbar Spine Procedures in New York State: A 10-Year Analysis.

STUDY DESIGN: A retrospective review of an administrative database. OBJECTIVE: The purpose of this study is to determine the current extent of regionalization by mapping lumbar spine procedures according to hospital and patient zip code, as well as examine the rate of growth of lumbar spine procedures performed at high-, medium-, and low-volume institutions in New York State. SUMMARY OF BACKGROUND DATA: The association between hospital and spine surgeon volume and improved patient outcomes is well established. There is no study investigating the actual process of patient migration to high-volume hospitals. METHODS: New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 228,695 lumbar spine surgery patients from 2005 to 2014. The data included the patients' zip code, hospital of operation, and year of discharge. The volume of lumbar spine surgery in New York State was mapped according to patient and hospital 3-digit zip code. New York State hospitals were categorized as low, medium, and high volume and descriptive statistics were used to determine trends in changes in hospital volume. RESULTS: Lumbar spine surgery recipients are widely distributed throughout the state. Procedures are regionalized on a select few metropolitan centers. The total number of procedures grew 2.5% over the entire 10-year-period. High-volume hospital caseload increased 50%, from 7253 procedures in 2005 to 10,915 procedures in 2014. The number of procedures at medium and low-volume hospitals decreased 30% and 13%, respectively. CONCLUSIONS: Despite any concerted effort aimed at moving orthopedic patients to high-volume hospitals, migration to high-volume centers occurred. Public interest in quality outcomes and cost, as well as financial incentives among medical centers to increase market share, potentially influence the migration of patients to high-volume centers. Further regionalization has the potential to exacerbate the current level of disparities among patient populations at low and high-volume hospitals. LEVEL OF EVIDENCE: 3.

Trends in Abdominal Aortic and Iliac Aneurysm Repairs in Norway from 2001 to 2013.

OBJECTIVE/BACKGROUND: The objective was to examine trends in abdominal aortic and iliac aneurysm repairs in Norway from 2001 to 2013, and study regional variations and organizational developments in this type of vascular surgery. METHODS: This was a retrospective study on aortic and iliac aneurysm repairs using data from the Norwegian Patient Register. The vascular centers were categorized by yearly volume of repairs into small (<18), medium (18-49) and large (≥50). Incidence rates were assessed per 100,000 ≥ 60 years. The percentage of endovascular aneurysm repairs (EVAR) was calculated among the conducted repairs at the three categories of centers and the South-Eastern, Western, Central, and Northern Norway Regional Health Authority (NRHA). RESULTS: The national incidence rates of intact repairs per 100,000 ≥ 60 years increased from 57.4 to 65.7 (p < .01). Ruptured repairs decreased from 19.7 to 9.2 (p < .01). The rate of EVAR increased from 6.0 to 29.9 (p < .01) in intact and from 0.4 to 2.5 (p < .01) in ruptured repairs. The vascular centers were reduced from 25 to 16. The rate of EVAR was 27.1% (p < .01) higher at large centers and 7.9% (p < .03) higher at medium centers compared with small centers, and from 11.1% to 15.7% higher (p < .01) at the Central, Western, and Northern NRHA compared with the South-Eastern NRHA, which had the most centers (also in the large category). The national increase in intact EVAR from 10.6% to 43.3% was less compared with many other Western countries. CONCLUSION: During the study period the rates of intact repairs increased while the ruptured repairs decreased. EVAR was associated with centers performing high volumes of abdominal aortic and iliac aneurysm repairs and regional authorities organized with few centers.

Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England.

BACKGROUND AND PURPOSE: In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients' homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London's stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. METHODS: Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. RESULTS: Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3-66.2); London=72.1% (71.4-72.8); comparator=55.5% (54.8-56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. CONCLUSIONS: Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models.

[The importance of centralized treatment: research and development]. / Betydning af centraliseret behandling: forskning og udvikling.

Biomedical research in Denmark enjoys a strong position at present but will be challenged by a new organization for all hospitals in Denmark beginning in 2007. It will be very important to recognize the importance of medical research as the cornerstone of optimal patient treatment in the new hospital organizations. Centralization with a focus on efficiency and low cost, as well as decentralization combined with the loss of university hospital functions, will further challenge the conditions of clinical research already seen worldwide and also experienced in Denmark.

[Centralization versus decentralization. Hematology]. / Centralisering versus decentralisering. Haematologi.

Clinical haematology is the result of teamwork among dedicated specialists in pathology, molecular diagnostics, imaging, radiotherapy and the haematologist, who in turn can focus on only a limited fraction of the various and highly complex diseases that together constitute clinical haematology. The treatment of patients should be centralized in departments large enough to permit internal subspecialization and to provide expert service focused on haematology. No more than three such hematology centers are needed in Denmark.