Centralize Pancreatic Surgery Now!

Centralize Pancreatic Surgery Now! EDITORIAL (SOLICITED VIA EM) Stefan Post, MD treatment quality. This is well reflected in the present study by a ancreatic resections are well known to be procedures carrying a rather high overall mortality, and also failure to rescue in 398 P considerable risk of adverse outcomes including death. Twenty- hospitals of the lowest-volume quintile performing on average 5 major seven years ago, Michael Trede was the first to publish a series from pancreatic resections per year. A minimal caseload of 10 cases per year Mannheim of well above 100 consecutive pancreatoduodenectomies for pancreatic surgery was introduced in Germany in 2004. Since then, without any perioperative mortality. Together with several other it has been ignored by many providers, and not enforced by payers or reports from specialized centers, this led to claims often heard during regulators. The present results suggest that centralization and a the 90s that pancreatic resections should be restricted to centers with markedly higher minimal caseload may save many lives in Germany documented mortality rates below 5%. Obviously, this induced a like it already did in the Netherlands and some other countries. The remarkable publication bias in the way that almost no single-center authors estimate very conservatively that 94 deaths may be avoided series was published in the subsequent years with mortality rates annually in Germany. In a more optimistic scenario of centralization, above that threshold. Only data from registries and population-based all units in Germany might achieve at least the results of the highest- analyses drew a dramatically different picture, often with 2-digit volume quintile in the present dataset with a crude mortality rate of mortality rates, especially in subgroups of hospitals. One of the 6.1%, which would be still above the 5% threshold mentioned above; largest and most comprehensive datasets published were the com- this would save around 300 lives per year in Germany and many more plete administrative data on all pancreatic resections performed in in other countries which still have to apply centralization. Germany as published last year in Annals of Surgery, indicating an In an ideal world, despite all their self-confidence, surgeons overall inhospital mortality rate of 10.1%, which was higher than would stop doing pancreatic resections if they are working in hospital expected. In this issue of Annals of Surgery, the same group extends environments, allowing only for low volumes, together with insuffi- their analysis to address the question of a link between hospital cient resources, to rescue patients once they have a serious compli- volume and outcome in a dataset that is unique in its combination of cation. Sadly, it is unrealistic to expect for Germany and other size (>60,000 cases), completeness, and ability for risk adjustments. countries that professional self-regulation may pave the way for Confirming numerous previous reports, they found a profound centralization. Thus, it may be even more important that politicians impact of hospital volume on mortality and morbidity. and healthcare planners in many more countries digest the over- Evidence and also surgical common-sense suggest that 3 main whelming evidence on the volume outcome relation for complex and factors contribute to the risk of complex procedures like pancreatic risky operations like pancreatic resections. Nevertheless, the present resections: the surgeon and his/her abilities, the institutional environ- data underline that centralization alone can never be sufficient to ment, and the patient with his risk profile. The latter may be influenced achieve lowest possible mortality. But it is a necessary and rather again by the surgeon, especially through patient selection and knowing easy step to allow for better practice, training, and outcome. when not to operate. Despite the undisputable fact that surgeonvolume, and also hospital volume, are just crude indicators of experience rather than abilities, its major advantage is that it is so easily measurable, and REFERENCES that it is prone to regulatory interventions. The present study confirms 1. Trede M, Schwall G, Saeger HD. Survival after pancreatoduodenectomy: 118 that institutional experience (hospital volume) has an impressive effect consecutive resections without an operative mortality. Ann Surg. 1990;211: 447–458. on outcome, especially on mortality and failure to rescue, less so on 2. Nimptsch U, Krautz C, Weber GF, et al. Nationwide in-hospital mortality morbidity. The database does not provide any information on surgeon following pancreatic surgery in Germany is higher than anticipated. Ann Surg. volume, but the higher comorbidity of patients operated in lowest- 2016;264:1082–1090. volume hospitals may well reflect the lesser ability of surgeons in low- 3. Krautz C, Nimptsch U, Weber GF, et al. Effect of hospital volume on in-hospital volume hospitals to select the right patients. morbidity and mortality following pancreatic surgery in Germany. Ann Surg. 2017;266. The German healthcare system is 1 of the most complex in the 4. Bjo¨rnberg A. Euro Health Consumer Index 2016. Health Consumer world with a high degree of heterogeneity in hospital ownership, Powerhouse Ltd., 2017. ISBN 978–91–980687–5–7. Available at: http:// numerous payers/insurance companies, multilateral, and sometimes www.healthpowerhouse.com/publications/euro-health-consumer-index-2016/. antagonistic regulatory bodies. Compared with other European Accessed July 1, 2017. countries, it is characterized by the completely unrestricted access 5. de Wilde RF, Besselink MGH, van der Tweel I, et al. Impact of nationwide for everybody, supported by an oversupply of services in too many centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. small general hospitals, resulting in higher scores in quantity than in 2012;99:404–410. From the Department of Surgery; University Medical Center Mannheim, Germany. Disclosure: The author declares no conflicts of interest. Reprints: Professor Stefan Post, Chirurgische Klinik, Theodor-Kutzer-Ufer 1-3; 68167 Mannheim, Germany. E-mail: stefan.post@umm.de. Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/17/26703-0418 DOI: 10.1097/SLA.0000000000002442 418 | www.annalsofsurgery.com Annals of Surgery  Volume 267, Number 3, March 2018 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Surgery Wolters Kluwer Health

Centralize Pancreatic Surgery Now!

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Abstract

EDITORIAL (SOLICITED VIA EM) Stefan Post, MD treatment quality. This is well reflected in the present study by a ancreatic resections are well known to be procedures carrying a rather high overall mortality, and also failure to rescue in 398 P considerable risk of adverse outcomes including death. Twenty- hospitals of the lowest-volume quintile performing on average 5 major seven years ago, Michael Trede was the first to publish a series from pancreatic resections per year. A minimal caseload of 10 cases per year Mannheim of well above 100 consecutive pancreatoduodenectomies for pancreatic surgery was introduced in Germany in 2004. Since then, without any perioperative mortality. Together with several other it has been ignored by many providers, and not enforced by payers or reports from specialized centers, this led to claims often heard during regulators. The present results suggest that centralization and a the 90s that pancreatic resections should be restricted to centers with markedly higher minimal caseload may save many lives in Germany documented mortality rates below 5%. Obviously, this induced a like it already did in the Netherlands and some other countries. The remarkable publication bias in the way that almost no single-center authors estimate very conservatively that 94 deaths may be avoided series was published in the subsequent years with mortality rates annually in Germany. In a more optimistic scenario of centralization, above that threshold. Only data from registries and population-based all units in Germany might achieve at least the results of the highest- analyses drew a dramatically different picture, often with 2-digit volume quintile in the present dataset with a crude mortality rate of mortality rates, especially in subgroups of hospitals. One of the 6.1%, which would be still above the 5% threshold mentioned above; largest and most comprehensive datasets published were the com- this would save around 300 lives per year in Germany and many more plete administrative data on all pancreatic resections performed in in other countries which still have to apply centralization. Germany as published last year in Annals of Surgery, indicating an In an ideal world, despite all their self-confidence, surgeons overall inhospital mortality rate of 10.1%, which was higher than would stop doing pancreatic resections if they are working in hospital expected. In this issue of Annals of Surgery, the same group extends environments, allowing only for low volumes, together with insuffi- their analysis to address the question of a link between hospital cient resources, to rescue patients once they have a serious compli- volume and outcome in a dataset that is unique in its combination of cation. Sadly, it is unrealistic to expect for Germany and other size (>60,000 cases), completeness, and ability for risk adjustments. countries that professional self-regulation may pave the way for Confirming numerous previous reports, they found a profound centralization. Thus, it may be even more important that politicians impact of hospital volume on mortality and morbidity. and healthcare planners in many more countries digest the over- Evidence and also surgical common-sense suggest that 3 main whelming evidence on the volume outcome relation for complex and factors contribute to the risk of complex procedures like pancreatic risky operations like pancreatic resections. Nevertheless, the present resections: the surgeon and his/her abilities, the institutional environ- data underline that centralization alone can never be sufficient to ment, and the patient with his risk profile. The latter may be influenced achieve lowest possible mortality. But it is a necessary and rather again by the surgeon, especially through patient selection and knowing easy step to allow for better practice, training, and outcome. when not to operate. Despite the undisputable fact that surgeonvolume, and also hospital volume, are just crude indicators of experience rather than abilities, its major advantage is that it is so easily measurable, and REFERENCES that it is prone to regulatory interventions. The present study confirms 1. Trede M, Schwall G, Saeger HD. Survival after pancreatoduodenectomy: 118 that institutional experience (hospital volume) has an impressive effect consecutive resections without an operative mortality. Ann Surg. 1990;211: 447–458. on outcome, especially on mortality and failure to rescue, less so on 2. Nimptsch U, Krautz C, Weber GF, et al. Nationwide in-hospital mortality morbidity. The database does not provide any information on surgeon following pancreatic surgery in Germany is higher than anticipated. Ann Surg. volume, but the higher comorbidity of patients operated in lowest- 2016;264:1082–1090. volume hospitals may well reflect the lesser ability of surgeons in low- 3. Krautz C, Nimptsch U, Weber GF, et al. Effect of hospital volume on in-hospital volume hospitals to select the right patients. morbidity and mortality following pancreatic surgery in Germany. Ann Surg. 2017;266. The German healthcare system is 1 of the most complex in the 4. Bjo¨rnberg A. Euro Health Consumer Index 2016. Health Consumer world with a high degree of heterogeneity in hospital ownership, Powerhouse Ltd., 2017. ISBN 978–91–980687–5–7. Available at: http:// numerous payers/insurance companies, multilateral, and sometimes www.healthpowerhouse.com/publications/euro-health-consumer-index-2016/. antagonistic regulatory bodies. Compared with other European Accessed July 1, 2017. countries, it is characterized by the completely unrestricted access 5. de Wilde RF, Besselink MGH, van der Tweel I, et al. Impact of nationwide for everybody, supported by an oversupply of services in too many centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. small general hospitals, resulting in higher scores in quantity than in 2012;99:404–410. From the Department of Surgery; University Medical Center Mannheim, Germany. Disclosure: The author declares no conflicts of interest. Reprints: Professor Stefan Post, Chirurgische Klinik, Theodor-Kutzer-Ufer 1-3; 68167 Mannheim, Germany. E-mail: stefan.post@umm.de. Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/17/26703-0418 DOI: 10.1097/SLA.0000000000002442 418 | www.annalsofsurgery.com Annals of Surgery  Volume 267, Number 3, March 2018 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Journal

Annals of SurgeryWolters Kluwer Health

Published: Mar 1, 2018

References

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