Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland.
HPB and Transplant Unit, St. James's University Hospital, Leeds, UK.
Ann Surg. 2018 Nov;268(5):712-724. doi: 10.1097/SLA.0000000000002965.
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.
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.
批判性地评估欧洲和北美的高度专业化手术集中化政策，并提出建议。
背景/方法：大多数国家越来越被迫以合理的成本维持高质量的医疗服务。全面的观点，包括医疗服务提供者、支付者、整个社会和患者，在不同的环境中都以不同的理由普遍失败了。这篇特别文章遵循了 3 个目标：首先，分析不同国家集中化政策的医疗保健政策；其次，分析集中化策略如何影响患者的预后和其他方面，如医学教育和成本；最后，提出集中化建议，这些建议可能适用于各大洲。
利益冲突导致许多国家为基于超越最佳以患者为中心的护理因素的医疗保健系统做出妥协。集中化一直是一种常见的策略，但各国的模式差异很大，对于每个中心或外科医生所需的最低手术数量没有共识。大多数国家政策要么部分实施，要么完全没有实施。数据压倒性地表明，将复杂护理或手术集中在专门中心可以提高护理质量和降低成本。然而，对于那些要求集中化的门槛较低的国家，可能会导致适应症的不当扩大，因为医院为了达到标准而苦苦挣扎。集中化需要调整普通和专业外科医生的培训和认证，并对患者进行教育。
结论/建议：在大多数领域，都明显需要有效的集中化。不受限制的、纯粹的“市场驱动”方法对患者和社会都是有害的。集中化不应仅仅基于最低手术数量，而应基于包括受过良好训练的专家在内的复杂疾病的多学科治疗，这些专家可以随时提供服务。强制性使用经审核的前瞻性数据库来监测护理质量和成本。
