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Strategies for Improving Surgical Care When Is Regionalization the Right Choice? ONLINE FIRST

Karan R. Chhabra, MD1; Justin B. Dimick, MD, MPH2,3
[+] Author Affiliations
1Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
3Department of Surgery, University of Michigan, Ann Arbor
JAMA Surg. Published online July 27, 2016. doi:10.1001/jamasurg.2016.1059
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This Viewpoint considers 3 nuances of the policy debate regarding the regionalization of high-risk surgery by restricting care to high-volume centers of excellence.

Regionalizing high-risk surgery by restricting care to high-volume centers of excellence is a quality-improvement strategy with intuitive appeal. Decades of research have shown that the highest-volume hospitals have better outcomes for major surgery.1 Accordingly, 3 prominent medical centers—Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan—recently announced a “volume pledge” to restrict their own facilities and surgeons from performing any of 10 selected procedures unless they meet volume criteria.2,3 Apart from a voluntary pledge, other policy approaches to regionalization have included the refusal to reimburse low-volume facilities (as Medicare currently does for solid-organ transplants) and tiered insurance benefits (ie, reducing out-of-pocket payments at high-volume hospitals).

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Strategy for Choosing Surgical Centers of Excellence (COE) Based on Procedure Type

To identify the optimal strategy to designate COE, first consider the baseline risk of the procedure. Low-risk procedures should not be regionalized because there is little benefit to offset the drawbacks of regionalized care. High-risk procedures should be further categorized into low- and high-volume procedures. Centers of excellence for low-volume procedures are best chosen with volume as a proxy measure because outcome measurements are unreliable at low volumes. Centers of excellence for high-volume procedures should be chosen based on their actual outcomes whenever possible.

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