Centers of Excellence — Patient-,Surgeon-,or Bureaucracy- Driven?

The association between high volume surgical center and better outcome is supported by several studies and seems to be more established in procedures such as esophagectomy, pancreatectomy, primary surgery for colon and breast cancer and more recently in urologic oncology (1), although the volume-outcome relationship seems to be more complex than previously thought (2). A multi-disciplinary approach combined with high-volume center is a model for centers for excellence, as shown in bariatric or joint replacement surgery (3, 4).

Although the perioperative mortality rate in non-cardiac surgery in Finland is among the lowest in Europe (5), there are, however, increasing challenges in providing quality service to the population. Increasing demand (aging population, patients' expectations, technological advances allowing new or wider indications for surgery) has lead to longer waiting lists to elective procedures, and the ongoing fragmentation of the surgical field into one-organ specialties has promoted centralization.

Will the establishment of centers of excellence alleviate the current problems? Besides providing high institutional and surgeon volumes, it will bring together and blur the boundaries of specialties working in the same area, such as coronary artery or inflammatory bowel diseases, for example. Concentrating the specialty care into centers of excellence would lead to differences in access to care especially in countries with long distances and scarce population in the more remote areas. Maintaining the motivation of surgeons and other personnel in other hospitals and preventing the migration to centers of excellence could be difficult. Finally, there are many common surgical diseases which do not require a multi-disciplinary approach and would not benefit from centralization, such as acute appendicitis or ankle fractures, to mention a few.

Surgery is provided in three different categories: 1. Acute or emergency surgery to treat or prevent progression to an immediately life-threatening condition caused by acute disease process, external trauma or surgical complication by rapid surgical intervention. Typical pathophysiological entities of this category are major hemorrhage, inflammation or infection, hollow organ obstruction or perforation, and end organ ischemia. Postoperative care usually requires correction of multiple organ dysfunctions in an intensive care unit and sometimes multiple reoperations; 2. Surgery to improve medium- or long-term survival or prevent major disability, such as oncological, spine or complex reconstructive surgery; 3. Surgery to improve quality of life by relieving chronic pain or to improve mobility, such as in degenerative joint disease.

Which of the above mentioned types of surgery would best be provided in centers of excellence and how should they be organized? A center can be formed around a diseased organ combining multiple specialties, such as the heart (cardiology, cardiac surgery) or major arteries (vascular surgery, interventional radiology, “thrombology”). It could be disease-specific, such as centers for morbid obesity, cancer, hernia, osteoarthritis or degenerative back problems, anatomical region -specific, such as pelvic floor surgery, technology-specific (laparoscopic surgery, endoscopy), or even mechanism-based, such as trauma centers.

How can all this be organized? The fundamental solution most likely requires a regional plan. It is futile and unproductive for one institution, even a big academic center, to try to establish one or more centers of excellence on its own. Regional planning would allow a balance between centers of excellence and other hospitals or units by providing multi-disciplinary high quality care to some patient groups and at the same time maintaining sufficient volume, skills and motivation in other hospitals and surgeons by assigning certain surgical patient groups specifically to these hospitals. Why could not there be a general surgery center of excellence for patients with cholelithiasis, hernia, surgery of the spleen or varicose veins, for example?

While emergency surgery (type 1 in the above introduced classification) probably requires some form of centralization to emergency surgery centers (trauma center and trauma system model), some of the diseases requiring type 2 surgery (except rare diseases requiring a multi-disciplinary approach) and especially type 3 surgery could well be provided outside big academic centres as a part of a regional plan. This would obviously not indicate a lower academic level in these institutions since research and teaching in these fields could and should follow the clinical arrangements.