Background: Experts and researches have looked into factors improving the outcomes of highly complex and supramajor surgeries. Centralization of the complex and very major surgeries has also been one of the important factors analyzed. In today’s era, the concept of centralization has not remained new as many centers in some of the developed nations have already adopted this concept. Having said this, there are yet many centers even in the developed world that do not believe in the concept of centralization and thus have not accepted it. In Nepal too, we haven’t yet accepted the concept of centralizations. Except the major organ transplants like liver and kidneys, there are no restrictions or any standard guidelines in use and thus any centers are allowed to perform surgeries of any extent of complexities and related to any specialty. The decision is solely left on treating surgeon and the centers. Thus, worldwide there is still ongoing debate on the adoption of the concept of centralization.
Since long time centralization has been proposed as a strategy to improve the outcomes of certain heath care services regarded as high risk and requiring high-level multispecialty care. Centralization is also defined as a strategy for improving outcomes of major and complex surgeries by reducing treatment related adverse events. Despite many limitations, many centers around the world have accepted strategy of centralizations of major and complex surgeries. Many population-based studies have already shown improved outcomes at high volume medical centers.
Furthermore, there has already been many reports published on the relationship of hospital volumes and decreasing mortality, especially for cancer related surgeries. It is very much observed fact that the hospital performing these complex surgeries are more likely to possess the necessary ancillary services so as to provide a better cares for these patients. Around the world, some of the hospital and big academic centers have already restricted the complex surgeries to the hospital and surgeons meeting at least predetermined volume thresholds.
Based on the level of expertise required and the necessity of the multispecialty care, surgical procedures of any specialties are considered major and complex. It is a well-known fact that in every stream of surgical specialties the procedures are commonly classified into minor, intermediate, major and supramajor surgeries. There might be many other classification systems in use for classifying the surgical complexities and almost all of these consider both the level of expertise and the specialty care required. It is very obvious that the complexities of the surgical procedures define the possible postoperative outcomes and long-term survivals. As the complexities increase the morbidity and mortality are also expected to increase but many still have an opinion that it may not always hold true due to major improvement in overall evaluation process and perioperative care supported by the most advanced technologies. Due to the availability of the most advanced care, highly trained and experienced caregivers, there has been some difference in defining the complexities of surgeries from center to centers. Thus, the procedure or a surgery that could be a supramajor for one center might not be of same level of complexity for the other center that have much experienced surgeons and support from different specialties.
Around the globe: Greatest examples of successfully implemented policies on the concept of centralizations come from European countries like France and Netherlands who have adopted centralization policies for gastrointestinal cancer surgeries. They have been able to demonstrate the significant improvement in short and long term survival. Study done by Kyle H, published in Journal of Clinical Oncology, June 2019 and study based on US centers revealed that greater centralization was associated with lower rates of postoperative complications and deaths for lung, esophageal and pancreatic resection surgeries. Postoperative mortality for pancreatic cancer surgery was two times higher in the least centralized system than in the most centralized system (8.9%v 3.7%). In Netherlands 90-day mortality following gastric cancer surgery decreased from 11% to 7%, whereas 2-year survival increased from 55% to 59% after centralizing these procedures to selected centers in 2012 as published in the study in British Journal of Surgery in 2018 by van Putten M et al.
Disadvantages: The health care delivery systems around the world vary in many important ways. Before adopting the system of centralization the policy makers should take into consideration about the structures around which the surgical cares are planned for centralizations. Centralizations could be based on established volume load criteria or it could be based on the geographic or organizational structures. Around the world, Criteria-based centralization is becoming increasingly common. A recent initiative by the Commission on Cancer and the American College of Surgeons has established the National Accreditation Program for Rectal Cancer surgery. This initiative is based on the evidence-based standards to accredit centers with the clinical, research, and outcomes reporting infrastructure to care for patients with rectal cancer. There has been growing concern by the clinicians and the policy makers on the models of centralizations. There is always a worry that centralizations might bring increase disparities, possibly exacerbate the issues of access to the care and also it could potentially affect on the training of future surgeons and physicians. Similarly, centralization is likely to add burden to the big centers as well. Access to the care for the patients would certainly be a big burden to them in terms of time and the cost of health care. There is also a possible risk that the centralization could divert away all the major procedures from the rural and regional centers and thus minimizing their chances of improving and upgrading to become a higher facility in future.
Conclusion : The debate about the concept of centralization will continue to float in future specially in resource strained countries like ours and where access to the care and the cost of care is a major deciding factors for patients seeking the healthcare services. Having said this, there are certainly few procedures in every specialty, which if performed in high volume centers could have best possible outcomes. The most important issue for the policy makers is to come up with the centralization policies in the most rationale way considering the important negative aspects of centralizations as described above. There has been a very important report published in Annals of surgery 2018 with the title “Toward a Consensus on Centralization in Surgery. This publication was made to critically assess centralization policies for highly specialized surgeries in Europe and North America. It has come up with conclusions and recommendations that there is an obvious need of effective centralization in most areas. However, it reinforces that the unrestrained and purely market driven approaches are deleterious to patients and the society. It recommends that the centralizations should not be based solely on minimum number of procedures but rather on the multidisciplinary treatment of complex diseases including well-trained specialist round the clock. Audits based on prospective database, monitoring of quality of care and the cost of procedure should be the mandatory component of the centralized centers. Similar concept has to be adopted even in countries like ours when we will be planning to adopt the concept of centralizations.
