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Background: Centralized surgery care improves curative resection outcomes in rare malignancies. Less is known about the secondary effects of such centralization on all patients, including patients receiving palliative treatment or no tumor treatment. This population-based cohort study aimed to evaluate the effects of centralization on survival and treatment decision in all patients with gastric cancer in Sweden between 2006 and 2016., Methods: All patients diagnosed with gastric cancer, including cardia cancer Siewert III, were identified using the National Registry for Esophageal and Gastric Cancer in Sweden. Patients diagnosed at a local hospital performing low-volume curative gastric cancer surgery before centralization were compared with patients in the same communities after curative cases were referred elsewhere. Survival differences were determined using multivariate Cox regression models, and the probability of curative care was determined using multivariate logistical regression., Results: A total of 4547 patients diagnosed at 49 hospitals were included, among which 28 hospitals stopped performing curative gastric cancer surgery during the study period. After centralization, 8 hospitals performed curative gastric cancer surgery, and the median overall survival (OS) increased from 7.9 to 9.1 months. The resection rates decreased from 36% to 30%. Treatment recommendations performed at multidisciplinary cancer conferences increased from 23% to 80%, and any active tumor treatment (curative and palliative) recommendation increased from 68% to 73%. No significant difference in treatment strategy or time to surgery was observed among the groups. No difference in OS was observed among the groups., Conclusion: During the centralization of gastric cancer surgery, survival, multidisciplinary treatment decisions, and active treatment increased, with no detrimental effects on populations outside the major centers' primary uptake areas., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

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.

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., (© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Objective: Evidence favours centralisation of emergency care for specific conditions, but it remains unclear whether broader implementation improves outcomes and efficiency. Routine healthcare data examined consolidation of three district general hospitals with mixed medical admission units (MAU) into a single high-volume site directing patients from the ED to specialty wards with consultant presence from 08:00 to 20:00., Methods: Consecutive unscheduled adult index admissions from matching postcode areas were identified retrospectively in Hospital Episode Statistics over a 3-year period: precentralisation baseline (from 16 June 2014 to 15 June 2015; n=18 586), year 1 postcentralisation (from 16 June 2015 to 15 June 2016; n=16 126) and year 2 postcentralisation (from 16 June 2016 to 15 June 2017; n=17 727). Logistic regression including key demographic covariates compared baseline with year 1 and year 2 probabilities of mortality and daily discharge until day 60 after admission and readmission within 60 days of discharge., Results: Relative to baseline, admission postcentralisation was associated with favourable OR (95% CI) for day 60 mortality (year 1: 0.95 (0.88 to 1.02), p=0.18; year 2: 0.94 (0.91 to 0.97), p<0.01), mainly among patients aged 80+ years (year 1: 0.88 (0.79 to 0.97); year 2: 0.91 (0.87 to 0.96)). The probability of being discharged alive on any day since admission increased (year 1: 1.07 (1.04 to 1.10), p<0.01; year 2: 1.04 (1.02 to 1.05), p<0.01) and the risk of readmission decreased (year 1: 0.90 (0.87 to 0.94), p<0.01; year 2: 0.92 (0.90 to 0.94), p<0.01)., Conclusion: A centralised site providing early specialist care was associated with improved short-term outcomes and efficiency relative to lower volume ED admitting to MAU, particularly for older patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high-risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high-risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co-ordinating centre ('hub'), for having surgery by the presence of surgical services on-site, and for receiving high dose-rate brachytherapy (HDR-BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91-1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10-1.40), and more likely to receive additional HDR-BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94-12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities., (© 2018 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Perinatal epidemiology examines the variation and determinants of pregnancy outcomes from a maternal and neonatal perspective. However, improving public and population health also requires the translation of this evidence base into substantive public policies. Assessing the impact of such public policies requires sufficient data to include potential confounding factors in the analysis, such as coexisting medical conditions and socioeconomic status, and appropriate statistical and epidemiological techniques. This review will explore policies addressing three areas of perinatal medicine-elective deliveries prior to 39 weeks' gestation; perinatal regionalization; and mandatory paid maternity leave policies-to illustrate the challenges when assessing the impact of specific policies at the patient and population level. Data support the use of these policies to improve perinatal health, but with weaker and less certain effect sizes when compared to the initial patient-level studies. Improved data collection and epidemiological techniques will allow for improved assessment of these policies and the identification of potential areas of improvement when translating patient-level studies into public policies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Emphasis on improving healthcare quality has led to centralization of services for patients suspected of ovarian cancer. As centralization of services may induce treatment delays, we aimed to assess compliance with health system interval guidelines in patients suspected of ovarian cancer., Design: Evaluation of health system intervals, comparison between direct and indirect referrals and between 2013 and 2014., Setting: A managed clinical network (MCN) comprising 11 hospitals in the Netherlands., Participants: Patients that were treated for ovarian cancer within the University Medical Center Groningen in 2013 and 2014., Intervention: Introduction of an MCN to centralize services for patients suspected of ovarian cancer., Main Outcome Measure: Compliance with national guidelines regarding health system intervals., Results: Between 2013 and 2014 a clinically relevant improvement in compliance with guidelines was demonstrated. Within this period, median treatment intervals decreased from 34 to 29 days, and the percentage of patients in which treatment interval guidelines were met increased from 63.5 to 72.2%. New regulations and increased awareness of health system intervals inspired changes in local practice leading to improved compliance with guidelines. Compliance was highest in patients that were directly referred to our academic hospital., Conclusion: Evaluation of health system intervals in patients suspected of ovarian cancer was feasible and may be applicable to other MCNs. Though compliance with guidelines improved within the study period, there is potential for improvement. To facilitate real-time evaluation of compliance with national guidelines establishing uniformity of electronic patient files in the MCN is deemed essential., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: The aim was to compare resource utilization across the four health trusts within the Western Norway Regional Health Authority since the establishment of positron emission tomography (PET) at Haukeland University Hospital in Bergen in 2009., Methods: Metadata from all PET examinations from 2009 to 2014 were automatically imported from the PET centre's central production database into a custom-developed database system, MDCake. A PET examination was defined as a procedure based on a single injection of radioactive tracer. The patients' place of residence and tentative diagnosis were coded based on the available clinical information., Results: The total number of PET examinations increased from 293 in 2009 to 1616 in 2014. The number of PET examinations per year increased across all diagnostic groups, but plateaued for lung cancer, gastrointestinal cancer and malignant melanoma since 2013. The number of examinations per capita was evenly distributed between the three northern health trusts with an average of 1260 PET studies per million inhabitants in 2014. However, patients residing in the most southerly health trust received between 44% (2010) and 27% (2014; P<0·001, repeated measures ANOVA) fewer examinations per capita per year., Conclusion: Centralized PET in the Western Norwegian health region meets the current clinical demand for patients residing in the three northern health trusts while patients from the most southern health trust receive approximately 30% fewer PET examinations. Access to specialized health care should be monitored routinely in order to identify inequalities in referral patterns and resource utilization., (© 2015 The Authors. Clinical Physiology and Functional Imaging published by John Wiley & Sons Ltd on behalf of Scandinavian Society of Clinical Physiology and Nuclear Medicine.)

The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

Background: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective., Methods: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts., Results: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level., Conclusion: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy., (© The Author 2016. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: In 2006, the Centers for Medicare and Medicaid Services restricted coverage for bariatric procedures to designated high-volume Centers of Excellence. The effect of centralization of elective surgical procedures on the ability of patients to access surgery has not been studied previously., Study Design: Inpatient claims data from 2008 to 2011 from 2 high-volume surgical states were used. All patients older than 18 years undergoing a bariatric surgical procedure were included. The number of bariatric procedures and characteristics of patients undergoing bariatric surgery were examined in each year. Nonparametric tests for trend were performed to analyze time trends. Difference-in-difference analyses were performed to assess the rate of bariatric surgery in underserved Medicare patients compared with underserved patients with other payers., Results: The percentage of procedures performed at Centers of Excellence increased from 60.5% in 2008 to 73.1% in 2011 (p < 0.01). The proportion of Medicare patients receiving surgery at a Center of Excellence increased from 77.7% in 2008 to 88.1% in 2011 (p < 0.01). The proportion of bariatric surgery patients from underserved groups increased over time except among those residing in rural areas, for whom there was no change. Among patients from underserved populations, only black Medicare patients experienced an increase in bariatric surgery use when compared with non-Medicare patients. The travel distance for Medicare patients consistently exceeded travel distance for non-Medicare patients. However, travel distance for Medicare patients decreased slightly during the study period., Conclusions: Despite the longer travel distance required for Medicare patients, centralization of bariatric surgery to Centers of Excellence did not result in impaired access to care. In fact, in this study, an improvement in access to bariatric surgery was seen and persisted among some underserved populations., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: In 2009 the Vascular Society of Great Britain and Ireland reported its recommendations for The Provision of Vascular Services for Patients with Vascular Disease. The objective is to halve the UK elective surgery mortality rate for Abdominal Aortic Aneurysm to 3.5% by 2013. From 16th March 2012, statutory approval has been given by Parliament to recognise Vascular Surgery as a Specialty in the UK. This study assesses the provision of vascular surgery in acute trusts across England., Method: From the Department of Health, 169 acute trusts were identified in England and each acute trust was emailed under the Freedom of Information Act., Results: There was a 98.8% response rate. There are currently 80 trusts in England providing acute and elective arterial and aortic surgery, with 48 vascular hubs and 32 trusts which either provide a local on call network or are currently under review. Within the 48 vascular hubs there are a mean of 4.8 consultants and 3.75 middle grades. The on call rota was on average a 1 in 6., Conclusion: This study has shown that currently 80 trusts in England provide acute and elective arterial and aortic surgery with 48 centralised complex and arterial vascular services. An integrated vascular service will provide the best quality of care, develop the latest techniques and improve clinical standards., (Copyright © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are largely unknown. We determined the extent of regionalization of care for adrenal surgery and the extent to which this centralization has evolved with time., Materials and Methods: Using 1996 to 2009 hospital discharge data from New York, New Jersey and Pennsylvania we identified all patients 18 years old or older treated with adrenalectomy. Hospital volume quintiles were created using 1996 hospital volumes. These cutoffs were then applied to subsequent years. Outcome variables were examined by hospital volume status with time using logistic regression models., Results: A total of 8,381 patients underwent adrenalectomy from 1996 to 2009 with a significant 17% to 42% shift toward regionalization to very high volume hospitals, defined as 15 or greater procedures per year (p <0.001). For each successive year the odds of having surgery performed at a very low volume hospital decreased by 13% (OR 0.87, 95% CI 0.84-0.89). There were significant differences in patient age, race and payer group for very low volume hospitals, defined as less than 1 procedure per year, compared to very high volume hospitals (p <0.0001). Patients at very high volume hospitals were less likely to be 55 years old or older (OR 0.73, 95% CI 0.61-0.88), insured through Medicaid (OR 0.60, 95% CI 0.45-0.79) or uninsured (OR 0.34, 95% CI 0.17-0.70). When controlling for year treated, patients were less likely to die in the hospital if treated at a very high volume hospital (OR 0.38, 95% CI 0.19-0.75)., Conclusions: These data reveal the increasing centralization of adrenalectomy to very high volume hospitals since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Gynaecological cancers are the second most common cancers among women. It has been suggested that centralised care improves outcomes but consensus is lacking. This systematic review assesses the effectiveness of centralisation of care for patients with gynaecological cancer, in particular, survival advantage., Methods: A comprehensive search of the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL (The Cochrane Library, Issue 4, 2010), MEDLINE, and EMBASE up to November 2010 was conducted. Registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies were also searched. Randomised controlled trials (RCTs), quasi-RCTs, controlled before-and-after studies, interrupted time series studies, and observational studies were included and multivariable analysis to adjust for baseline case mix were used., Results: Five retrospective observational studies met the inclusion criteria. Meta-analysis of three studies assessing over 9000 women suggested that institutions with gynaecologic oncologists on site may prolong survival in women with ovarian cancer, compared to community or general hospitals: hazard ratio (HR) of death was 0.90 (95% confidence interval (CI) 0.82 to 0.99). Similarly, another meta-analysis of three studies assessing over 50,000 women, found that teaching centres or regional cancer centres may prolong survival in women with any gynaecological cancer compared to community or general hospitals (HR 0.91; 95% CI 0.84 to 0.99). The largest of these studies included all gynaecological malignancies and assessed 48,981 women, so the findings extend beyond ovarian cancer. One study compared community hospitals with semi-specialised gynaecologists versus general hospitals and reported non-significantly better disease-specific survival in women with ovarian cancer (HR 0.89; 95% CI 0.78 to 1.01). The findings of included studies were highly consistent., Conclusions: The meta-analysis provides evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere., (Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Background: Gynaecological cancers are the second most common cancers among women. It has been suggested that centralised care improves outcomes but consensus is lacking., Objectives: To assess the effectiveness of centralisation of care for patients with gynaecological cancer., Search Methods: We searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL (The Cochrane Library, Issue 4, 2010), MEDLINE, and EMBASE up to November 2010. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies., Selection Criteria: We included randomised controlled trials (RCTs), quasi-RCTs, controlled before-and-after studies, interrupted time series studies, and observational studies that examined centralisation of services for gynaecological cancer, and used multivariable analysis to adjust for baseline case mix., Data Collection and Analysis: Three review authors independently extracted data, and two assessed risk of bias. Where possible, we synthesised the data on survival in a meta-analysis., Main Results: Five studies met our inclusion criteria; all were retrospective observational studies and therefore at high risk of bias.Meta-analysis of three studies assessing over 9000 women suggested that institutions with gynaecologic oncologists on site may prolong survival in women with ovarian cancer, compared to community or general hospitals: hazard ratio (HR) of death was 0.90 (95% confidence interval (CI) 0.82 to 0.99). Similarly, another meta-analysis of three studies assessing over 50,000 women, found that teaching centres or regional cancer centres may prolong survival in women with any gynaecological cancer compared to community or general hospitals (HR 0.91; 95% CI 0.84 to 0.99). The largest of these studies included all gynaecological malignancies and assessed 48,981 women, so the findings extend beyond ovarian cancer. One study compared community hospitals with semi-specialised gynaecologists versus general hospitals and reported non-significantly better disease-specific survival in women with ovarian cancer (HR 0.89; 95% CI 0.78 to 1.01). The findings of included studies were highly consistent. Adverse event data were not reported in any of the studies., Authors' Conclusions: We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.

Background: The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in-hospital mortality after PD in the Netherlands between 2004 and 2009., Methods: Nationwide data on International Classification of Diseases, ninth revision (ICD-9) code 5-526 (PD, including Whipple), patient age, sex and mortality were retrieved from the independent nationwide KiwaPrismant registry. Based on established cut-off points of annually performed PDs, hospitals were categorized as very low (fewer than 5), low (5-10), medium (11-19) or high (at least 20) volume. A subgroup analysis based on a cut-off age of 70 years was also performed., Results: Some 2155 PDs were included. The number of hospitals performing PD decreased from 48 in 2004 to 30 in 2009 (P = 0·011). In these specific years, the proportion of patients undergoing PD in a medium- or high-volume centre increased from 52·9 to 91·2 per cent (P < 0·001). Nationwide mortality rates after PD decreased from 9·8 to 5·1 per cent (P = 0·044). The mortality rate during the 6-year period was 14·7, 9·8, 6·3 and 3·3 per cent in very low-, low-, medium- and high-volume hospitals respectively (P < 0·001). The difference in mortality between medium- and high-volume centres was statistically significant (P = 0·004). The volume-outcome relationship was not influenced by age (P = 0·467). The mortality rate after PD in patients aged at least 70 years was 10·4 per cent compared with 4·4 per cent in younger patients (P < 0·001)., Conclusion: With nationwide centralization of PD, the in-hospital mortality rate after this procedure decreased. Further centralization of PD is likely to decrease mortality further, especially in the elderly., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: In the year 2009 the Federal Joint Committee (G-BA) obliged neonatal units in Germany to publish yearly data on the number of preterm infants treated and their outcome in the internet. At the same time annual minimum volumes were introduced for each level of perinatal care. The exact numbers of compulsory minimum volumes are heavily discussed both scientifically and politically., Methods: 28 perinatal centres (PNC) in the state of Baden-Württemberg published data on mortality and short-term morbidity of preterm infants with a birth weight (BW) <1,500 g admitted in the year 2008 (n=1,141). These data were analysed on the background of quality assessments of structures and processes in all hospitals performed by the Medical Service of Statutory Health Insurance (MDK)., Results: By the end of 2008, 8 PNC had fulfilled the quality criteria of the G-BA nearly completely and reached a numerical benchmarking value of more than 300 of 465 maximally achievable points. Introducing annual minimum volumes of 36 preterm infants with a BW <1,250 g would lead to a concentration of perinatal care in 7 PNC and minimum volumes of 50 preterm infants with a BW <1,500 g per year in 8 such centres., Conclusion: Further centralisation of clinical care for low birth-weight preterm infants in a limited number of PNC in the state of Baden-Württemberg would be economically reasonable and could be achieved either by the introduction of higher minimum volume standards or a stringent interpretation of quality criteria of the G-BA. Based on self-reported data of the PNC currently available in the Internet it is not possible to predict the effect of such a centralisation process on patient outcome., (© Georg Thieme Verlag KG Stuttgart · New York.)

There has been great interest in the setting of threshold operative volumes for safety to guide centralisation of vascular surgical services by healthcare commissioners. This editorial examines the evidence for designing services around a numeric safety threshold in the relationship between volume and outcome in vascular surgery. Thresholds should be aimed at the best outcomes and equity of care. Equity means access to the most up-to-date technology and all the relevant support services for elective and emergency cases. The relationship of volume and outcome with quality is complex, and demands a shift in focus to infrastructural and procedural improvements that drive high-quality services rather than the concentration of planning exclusively around an operative volume threshold.

Background: Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals., Objectives: This review assessed the efficacy of centralization for knee arthroplasty by examining the relationship between hospital and surgeon volume and patient outcomes., Data Sources and Review Methods: The systematic review identified studies using multiple databases, including Medline and Embase. Two independent researchers ensured studies met the inclusion criteria. Morbidity, mortality, length of stay, financial outcomes and statistical rigour were examined. Correlations between volume and outcome were reported., Results: Twelve primary knee arthroplasty studies examined hospital volume, which was significantly associated with decreased morbidity (five of seven studies), mortality (two of five studies) and length of stay (two of three studies). Three primary knee arthroplasty studies examined surgeon volume, which was significantly associated with decreased morbidity (two of three studies), mortality (zero of two studies) and length of stay (one of one study). Two revision knee arthroplasty studies examined hospital volume. One study examined but did not test for significance between hospital volume and patient morbidity; both studies examined volume and patient mortality reporting inconclusive results; and one study reported no significant association between volume and length of stay. None of the revision knee arthroplasty studies examined surgeon volume., Conclusions: Significant associations between increased hospital and surgeon volume and improved patient outcomes were reported. However, when these results were separated by arthroplasty type, the association appeared tenuous. Judgements regarding centralization of knee arthroplasty should be made with caution until further evidence is published.

Esophagectomy needs experienced surgical techniques and a well-trained perioperative care team. There are now many reports that the mortality rate after esophagectomy is higher in those hospitals with a low volume of esophagectomy and/or low surgeon's volume. The purpose of this study is to decide the respective numbers of esophagectomy operations per year to define low-volume and high-volume hospitals in Japan. If medical policy aims to further reduce mortality and morbidity associated with esophagectomy, then esophagectomy operations should be further centralized, away from low-volume hospitals, into high-volume hospitals. The Japanese Association for Thoracic Surgery has accumulated the surgical outcomes from 31 380 esophagectomy operations, registered from 709 institutes during the period from 2001 to 2006. These institutes are here classified into six groups according to the number of esophagectomy operations per year as 4 or less, 5-9, 10-19, 20-39, 40-79, and 80 or more. Using a statistical model-selection procedure by information criteria, these six groups are then classified into three categories as low-volume, medium-volume, and as high-volume hospitals. Among the 31 380 patients registered, overall, 390 patients (1.2%) died within 30 days, and 1187 patients (3.8%) died during the primary hospital stay. The odds ratio of the greatest volume group to the minimum volume group was 0.307 for the 30-day mortality rate, and 0.288 for the in-hospital mortality rate. For both the 30-day mortality rate and the in-hospital mortality rate, a hospital with less than five esophagectomy operations per year was classified as a low-volume hospital. A hospital with 40 or more esophagectomy operations per year was classified as a high-volume hospital. Concerning the number of esophagectomy operations performed per year in Japan, low-volume hospitals are defined as those where esophagectomy is performed less than five times per year, and high-volume hospitals are defined as those where esophagectomy is performed 40 or more times per year. If medical policy in Japan aims to further decrease the mortality after esophagectomy, then esophagectomy operations should be limited in these identified low-volume hospitals.

Purpose: The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly centralized and that this centralization has resulted in increased travel burden for patients., Patients and Methods: Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled., Results: Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization., Conclusion: There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.

Introduction: International studies indicate that decentralised vascular surgical activity could have a positive influence on the organisation of vascular services in Denmark., Materials and Methods: Numbers of vascular operations in 1994-2004 in the various Danish counties were collected from the Danish National Vascular Registry (www.karbase.dk). Incidences were compared by z-test. P-values were corrected by the Bonferroni method., Results: The incidence of operations for carotid stenosis, critical lower limb ischaemia, and acute lower limb ischaemia 68% (P<0.01), 26% (P < 0.01), and 16% (p < 0.01) higher in counties with own vascular surgical services compared to counties without own vascular service. The incidence of operations for carotid stenosis was 22% higher in counties offering such operations compared to counties offering most other vascular surgical except carotid thrombendarterectomies (P < 0.001)., Conclusion: Own vascular surgical services in Denmark are associated with a higher incidence of operations, thus preventing stroke and amputation.

Introduction: Previous studies have shown an association between surgical volume and a decreased mortality rate for departments as a whole as well as for individual surgeons. The background for this study was to investigate whether it would be beneficial to centralize gastric surgery, not only in fewer departments but also in fewer hands in the department., Materials and Methods: The study was based on the patient records of the 93 patients operated between 1 January 2000 and 1 September 2005. The surgeons were divided into two groups based on whether they had performed more than 15 or less than 5 operations during the period., Results: Of the 93 operations, 3 surgeons performed 80 and 7 surgeons performed the remaining 13 operations. The mortality was significantly increased in patients operated by surgeons with a low operation volume, p = 0.0004. The 12 acute operations were performed as often by a surgeon with low operation volume as by a surgeon with high operation volume. Again, mortality increased when the operation was performed by a surgeon with low operation volume, p = 0.015., Conclusion: The results argue for a centralization of gastric resections on a few surgeons and for an organisation of acute surgery so that these procedures are performed by only a few experienced surgeons.

Background: The objective of this study was to evaluate the cost-effectiveness of centralized referral of patients with advanced-stage epithelial ovarian cancer who underwent primary cytoreductive surgery and adjuvant chemotherapy., Methods: A decision-analysis model was used to compare 2 referral strategies for patients with advanced-stage ovarian cancer: 1) referral to an expert center, with a rate of optimal primary cytoreduction of 75% and utilization of combined intraperitoneal and intravenous adjuvant chemotherapy, and 2) referral to a less experienced center, with a rate of optimal primary cytoreduction of 25% and adjuvant treatment that consisted predominantly of intravenous chemotherapy alone. The cost-effectiveness of each strategy was evaluated from the perspective of society., Results: A cost-effectiveness analysis revealed that the strategy of expert center referral had an overall cost per patient of $50,652 and had an effectiveness of 5.12 quality-adjusted life years (QALYs). The strategy of referral to a less experienced center carried an overall cost of $39,957 and had an effectiveness of 2.33 QALYs. The expert center strategy was associated with an additional 2.78 QALYs at an incremental cost of $10,695 but was more cost-effective, with a cost-effective ratio of $9893 per QALY compared with $17,149 per QALY for the less experienced center referral strategy. Sensitivity analyses and a Monte Carlo simulation confirmed the robustness of the model., Conclusions: According to results from the decision-analysis model, centralized referral of patients with ovarian cancer to an expert center was a cost-effective healthcare strategy and represents a paradigm for quality cancer care, delivering superior patient outcomes at an economically affordable cost. Increased efforts to align current patterns of care with a universal strategy of centralized expert referral are warranted.

In 2001, the oral and maxillofacial surgical (OMFS) services for adults in Birmingham were centralised at the Selly Oak site of the University Hospital and the OMFS department was given access to the emergency operating theatre every day. We examined the effects of this on the emergency workload during the 6 months after centralisation and compared it with the emergency workload at the University Hospital during the 6 months before centralisation. The number of adult patients who attended the University Hospital as emergencies increased from 242 in the 6 months before centralisation to 545 in the subsequent 6 months (an increase of 127%). Of the latter 164 (30%) were admitted and operated on, 138 (84%) within 24h of admission. Despite the large increase in the number of patients, 102 (74%) were operated on during normal working hours. After centralisation, all operations were done on multidisciplinary emergency lists compared with only 55% before centralisation. Centralisation did not reduce the access of patients to the emergency service and conformed with the guidelines of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

Substantial evidence is established showing that centralising treatment and rehabilitation of stroke victims in stroke units reduces mortality and disability. Numbers needed to treat are 33 in order to avoid death of at least one patient and treat 20 to avoid disability of at least one patient. A Danish medical technology assessment indicates that stroke units are cost-beneficial. This knowledge has been available in Denmark for more than 15 years, but there is still not sufficient capacity to treat all stroke patients in stroke units. Hopefully, this problem will be resolved in the near future.

Today there are 19 paediatric departments in Denmark. Most of the children's departments are placed in obsolete buildings. Centralisation in children's hospital provides a child-oriented environment with staff, who are knowledgeable about the needs of children, have the competence in both basic and highly specialised medical care, there will be greater opportunities to conduct research in children's diseases and be at the cutting-edge of both national and international excellence in the paediatric area of specialisation, accomplishing this ambition through research and medical improvements.

Diagnosis of and care for people with rare diseases are a challenge. Most rare diseases are inherited with clinical presentation in early childhood, complex with involvement of several organ systems and progressive with ever changing phenotype. Physical and neurological disability makes many families dependent on social security. In Denmark and in a few other EU countries, centres of reference for the care of people with rare diseases have been established. The impression is that the effect of establishing such centres for these rare diseases in Denmark has been good and that it remains the most rational way of treatment.

A review of current literature with respect to a possible correlation among hospital volume, caseload and outcome of thoracic and cardiovascular surgery supports quite convincingly the theory that, from a probability point of view, the combination of high-volume hospitals with high-volume surgeons produces the best results. During the last decade, thoracic and cardiovascular surgery has to a certain degree been centralized in Denmark, reducing the number of public centres to the five university hospitals. None of these centres is low-volume, and two are high-volume hospitals.

The relation between higher hospital and surgeon volume for better results after vascular surgery has been documented in some areas. In the case of surgery for stenosis of the carotid artery surgeon volume has been found to be inversely related to the postoperative frequency of stroke and death (low volume <6-12 yearly), whereas the relation to hospital volume is more uncertain. For surgery of abdominal aortic aneurysms the same relationship has been documented for hospital volume (low volume

Background: In order to monitor quality and efficiency in the use of health resources for highly specialised medicine, a National Professional Council has since 1990 advised the Norwegian health authorities on the establishing and localisation of such services., Materials and Method: A comprehensive review of both the quality, economy and the geographical distribution of patients in each specialised service has been carried out., Results: 33 defined national programmes were centralised to one hospital only and distributed among seven university hospitals. Eight multiregional programmes were centralised to two hospitals only and included four university hospitals. In 2001, a total of 2711 new patients were treated in these programmes. The system seems to have secured a sufficient patient flow to each programme so as to maintain quality. However, a geographically skewed distribution of patients was noted, particularly in some of the national programmes., Interpretation: In a small country like Norway, with 4.5 million inhabitants, a centralised monitoring of highly specialised medicine seems both rational and successful. By the same logic, however, international cooperation should probably be sought for the smallest patient groups.

Object: The goal of this study was to determine the risk of adverse outcomes after contemporary surgical treatment of meningiomas in the US and trends in patient outcomes and patterns of care., Methods: The authors performed a retrospective cohort study by using the Nationwide Inpatient Sample covering the period of 1988 to 2000. Multivariate regression models with disposition end points of death and hospital discharge were used to test patient, surgeon, and hospital characteristics, including volume of care, as outcome predictors. Multivariate analyses revealed that larger-volume centers had lower mortality rates for patients who underwent craniotomy for meningioma (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.59-0.93, p = 0.01). Adverse discharge disposition was also less likely at high-volume hospitals (OR 0.71, 95% CI 0.62-0.80, p < 0.001). With respect to the surgeon caseload, there was a trend toward a lower rate of mortality after surgery when higher-caseload providers were involved, and a significantly less frequent adverse discharge disposition (OR 0.71, 95% CI 0.62-0.80, p < 0.001). The annual meningioma caseload in the US increased 83% between 1988 and 2000, from 3900 patients/year to 7200 patients/year. In-hospital mortality rates decreased 61%, from 4.5% in 1988 to 1.8% in 2000. Reductions in the mortality rates were largest at high-volume centers (a 72% reduction in the relative mortality rate at largest-volume-quintile centers, compared with a 6% increase in the relative mortality rate at lowest-volume-quintile centers). The number of US hospitals where craniotomies were performed for meningiomas increased slightly. Fewer centers hosted one meningioma resection annually, whereas the largest centers had disproportionate increases in their caseloads, indicating a modest centralization of meningioma surgery in the US during this interval., Conclusions: The mortality and adverse hospital discharge disposition rates were lower when meningioma surgery was performed by high-volume providers. The annual US caseload increased, whereas the mortality rates decreased, especially at high-volume centers.

Objective: Changes in neurosurgical workload can justify requests for hospital resources and guide planning by neurosurgical training programs. Most previous studies have used non-population-based data sources, such as surveys of professional society members, to explore the neurosurgical workload in the United States., Methods: This is a retrospective cohort study of patients in Diagnosis Related Group (DRG) 1 ("Craniotomy other than trauma, age > 17") using the Nationwide Inpatient Sample. Statistical methods were adjusted for complex survey methodology to generate total United States caseload estimates., Results: The total United States DRG 1 caseload increased from 70,800 admissions in 1988 to 105,300 admissions in 2001, a 50% relative increase (P < 0.001). For most diagnostic categories, the relative caseload increase was similar to that for the whole group. Patient age and sex distributions remained stable over time. Medical comorbidities, such as hypertension, chronic pulmonary disease, diabetes, and obesity, became more frequent. Elective admissions increased and in-hospital mortality rates decreased. Length of hospital stay decreased during the first half of the study period and then stabilized. Combined with increasing caseload, this caused total annual inpatient DRG 1 days to increase progressively after 1996. The number of United States hospitals with DRG 1 admissions decreased over time. Per-hospital annual DRG 1 caseloads increased, especially at high-volume centers. For the largest 100 hospitals by DRG 1 caseload, total admissions increased from 8.5% of all United States admissions (1988) to 9.4% (2001), whereas DRG 1 caseload increased disproportionately, from 27% to 38% of the United States aggregate caseload. This is evidence that progressive centralization of DRG 1 admissions took place during the study period., Conclusion: We documented an increase in total caseload and centralization of care for DRG 1 in the United States during the period 1988 to 2001. Defining the reasons for the changes in neurosurgical workload we observed will require further research.

Objective: Large provider caseloads are associated with better patient outcomes after many complex surgical procedures. Mortality rates for pediatric brain tumor surgery in various practice settings have not been described. We used a national hospital discharge database to study the volume-outcome relationship for craniotomy performed for pediatric brain tumor resection, as well as trends toward centralization and specialization., Methods: We conducted a cross sectional and longitudinal cohort study using Nationwide Inpatient Sample data for 1988 to 2000 (Agency for Healthcare Research and Quality, Rockville, MD). Multivariate analyses adjusted for age, sex, geographic region, admission type (emergency, urgent, or elective), tumor location, and malignancy., Results: We analyzed 4712 admissions (329 hospitals, 480 identified surgeons) for pediatric brain tumor craniotomy. The in-hospital mortality rate was 1.6% and decreased from 2.7% (in 1988-1990) to 1.2% (in 1997-2000) during the study period. On a per-patient basis, median annual caseloads were 11 for hospitals (range, 1-59 cases) and 6 for surgeons (range, 1-32 cases). In multivariate analyses, the mortality rate was significantly lower at high-volume hospitals than at low-volume hospitals (odds ratio, 0.52 for 10-fold larger caseload; 95% confidence interval, 0.28-0.94; P = 0.03). The mortality rate was 2.3% at the lowest-volume-quartile hospitals (4 or fewer admissions annually), compared with 1.4% at the highest-volume-quartile hospitals (more than 20 admissions annually). There was a trend toward lower mortality rates after surgery performed by high-volume surgeons (P = 0.16). Adverse hospital discharge disposition was less likely to be associated with high-volume hospitals (P < 0.001) and high-volume surgeons (P = 0.004). Length of stay and hospital charges were minimally related to hospital caseloads. Approximately 5% of United States hospitals performed pediatric brain tumor craniotomy during this period. The burden of care shifted toward large-caseload hospitals, teaching hospitals, and surgeons whose practices included predominantly pediatric patients, indicating progressive centralization and specialization., Conclusion: Mortality and adverse discharge disposition rates for pediatric brain tumor craniotomy were lower when the procedure was performed at high-volume hospitals and by high-volume surgeons in the United States, from 1988 to 2000. There were trends toward lower mortality rates, greater centralization of surgery, and more specialization among surgeons during this period.

To assess the effect of different hospital types or surgical volume on the survival of ovarian cancer patients, a nationwide and population-based analysis was carried out in Finland. The study included all 3,851 ovarian cancer patients operated from 1983-94. The patients were classified according to the hospital of the first surgery. The hospitals were categorized by type (university, central or other hospital) and, separately, into quartiles by the number of operated patients (surgical volume). The patients operated at university hospitals had better survival than those operated in central hospitals, the 5-year relative survival rates (RSR) being 45% (95% CI = 42-48%) and 37% (34-40%), respectively. RSR in the 'other hospital' category was 45% (42-48%). The RSR for the patients operated in the highest volume hospitals was 47% (43-50%), and by decreasing volume (quartile) the RSR was 40% (36-43%), 40% (36-43%) and 42% (38-45%), respectively. After controlling for potential confounding by stage and age using regression models, the results remained practically the same. The results indicate that further centralizing of operative treatment of ovarian cancer may still improve survival rates on a population level in Finland., (Copyright 2002 Wiley-Liss, Inc.)

Objective: To describe the changes of utilization of a psychiatric department following its decentralization into an Upper Austrian region, the Salzkammergut., Methods: 9 months before and after decentralization all kinds of contacts to psychiatric patients (inpatients, outpatients, day clinic patients, patients of consulting psychiatric service) regarding frequency of contacts, case numbers and diagnosis have been evaluated. For the inpatients their legal status was recorded., Results: Since the establishment of the decentralized psychiatric department an increase in the frequency of admissions of inpatients up to 157 % could be revealed. Depressive disorders showed the largest increase of admissions (204 %), remarkable increase was also seen in substance use disorders, neurotic and organic disorders (between 171 % and 183 %). Changes also emerged concerning the legal status of the patients with a decrease of the percentage of involuntary admissions from 26.5 % prior to decentralization to 20.7 % thereafter. Among the patients seen by the consulting service length of stay was higher than usually seen on somatic wards as there was a very high proportion of patients with depressive syndromes., Conclusion: Within the context of decentralization provision of psychiatric care seems to be improved. Treating more patients with depressive and neurotic disorders the staff of the psychiatric ward was confronted to apply more psychotherapeutic interventions to meet the patient's neurotic and suicidal behaviour.

Objectives: To evaluate the appropriateness of emergency referrals for inter-hospital transfers by local physicians in hospitals without intensive care facilities to a regional tertiary paediatric intensive care unit (PICU)., Design: A prospective, descriptive study in a tertiary PICU and hospitals without paediatric intensive care facilities in and around the London area, UK., Patients: All patients (< 18 years) referred for emergency admission to the PICU from district hospitals (n = 436) as well as those admitted through other modes of admission (n = 286) between 1 October 1998 and 30 June 1999 were prospectively studied. Admissions and transfers were deemed appropriate if the risk of mortality using the Paediatric Risk of Mortality (PRISM II) score was greater than 1%, and/or if the patient required a unique ICU-dependent therapy. Effectiveness was estimated using PRISM II derived observed-to-expected mortality ratio. Of the 436 emergency referrals 398 (91.3%) were retrieved and transported to the PICU. Of these, 38 referrals were thought to be inappropriate after telephone consultation and were not transferred. Of the emergency referrals 376 (94.4%) had a mortality risk greater than 1% or required an ICU-dependent therapy on admission day. Thus 86.2% (376/436) of the referrals and 94.4% (376/398) of transfers were considered appropriate. The PRISM II derived standardized mortality rate was 0.694 (95% CI 0.517-0.913) in the overall population and 0.613 (95% CI 0.434-0.843) amongst the emergency referrals., Conclusion: Physicians at local hospitals within a centralized system of delivering paediatric intensive care were able to maintain adequate assessment skills in recognition and requesting for appropriate transfers of the most ill and efficiently utilized resources available at the regional centre.

The study provides empirical data to compare different systems used for hospital admission procedures in a psychiatric clinic. The Psychiatric University Clinic Basel replaced its traditional central admission ward by direct admission to a number of different treatment settings. This change had consequences for both structural and procedural quality. More admissions occurred after prior notice had been given, and these admissions occurred more often at a time of day when more clinic staff were available. The rate of voluntary admissions increased, and the continuity of care, as measured by the number of transfers within the clinic during the first 5 days post-admission, was improved. These findings, which support an interpretation that the treatment conditions were improved, must be balanced against the drawback of delayed decision-making processes with, for example, longer waiting times for the patient. However, the continuity of therapeutic relationships can be increased through further changes in the procedural quality.