Toward a Consensus on Centralization in Surgery
Toward a Consensus on Centralization in Surgery
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DOI：
10.1097/sla.0000000000002965
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发表时间：
2018-11-01
影响因子：
9
通讯作者：
Clavien, Pierre-Alain
中科院分区：
文献类型：
--
作者：
Vonlanthen, Rene;Lodge, Peter;Clavien, Pierre-Alain
目的：批判性地评估高度专业化的手术在欧洲和北美的集中政策，并提出recommends.Background/Methods：大多数国家越来越被迫以合理的成本维持高质量的医疗。一个包罗万象的观点，包括医疗保健提供者，支付者，整个社会和患者，已经普遍失败，可以说是由于不同的原因在环境中。这篇特别的文章遵循3个目的：第一，分析不同国家的集中化医疗政策，第二，分析集中化策略如何影响患者的结局以及其他方面，如医学教育和成本，第三，提出集中化的建议，这可以适用于各大洲。许多国家出于利益的考虑，在以病人为中心的最佳护理之外的因素的基础上，妥协建立了一个卫生保健系统。集中化是一种常见的策略，但各国的模式差异很大，对每个中心或每个外科医生的手术数量的最低要求没有达成共识。大多数国家政策不是部分执行就是没有执行。数据压倒性地表明，将复杂的护理或程序集中在专门中心对护理质量和成本产生积极影响。然而，要求较低集中化阈值数量的国家可能会导致适应症的不适当扩展，因为医院难以满足标准。集中化需要在普通和专业外科医生的培训和资格认证的调整，和病人education.Conclusion/Recommendations：有一个明显的需要在大多数地区有效的集中。不受约束的、纯粹“市场驱动”的方法对患者和社会都是有害的。集中化不应仅仅基于最低数量的程序，而应基于对复杂疾病的多学科治疗，包括24小时提供训练有素的专家。强制性要求提供经过审计的前瞻性数据库，并对护理质量和成本进行监测。
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.