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Toward a Consensus on Centralization in Surgery

Vonlanthen, René, MD, MHA*; Lodge, Peter, MD; Barkun, Jeffrey S., MD; Farges, Olivier, MD, PhD§; Rogiers, Xavier, MD, PhD; Soreide, Kjetil, MD, PhD||; Kehlet, Henrik, MD, PhD**; Reynolds, John V., MD††; Käser, Samuel A., MD*; Naredi, Peter, MD, PhD‡‡; Borel-Rinkes, Inne, MD§§; Biondo, Sebastiano, MD, PhD¶¶; Pinto-Marques, Hugo, MD, PhD||||; Gnant, Michael, MD***; Nafteux, Philippe, MD†††; Ryska, Miroslav, MD, PhD‡‡‡; Bechstein, Wolf O., MD, PhD§§§; Martel, Guillaume, MD¶¶¶; Dimick, Justin B., MD||||||; Krawczyk, Marek, MD, PhD****; Oláh, Attila, MD, PhD††††; Pinna, Antonio D., MD‡‡‡‡; Popescu, Irinel, MD§§§§; Puolakkainen, Pauli A., MD, PhD¶¶¶¶; Sotiropoulos, Georgius C., MD, PhD||||||||; Tukiainen, Erkki J., MD, PhD*****; Petrowsky, Henrik, MD*; Clavien, Pierre-Alain, MD, PhD*

doi: 10.1097/SLA.0000000000002965

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.

*Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland

HPB and Transplant Unit, St. James's University Hospital, Leeds, UK

Department of Surgery, McGill University/McGill University Health Centre, Montreal, Quebec, Canada

§Department of Surgery, Hôpital Beaujon, Université Paris Nord Val de Seine, Clichy, France

Department of Surgery at UZ Gent, Gent, Belgium

||Department of Clinical Medicine, University of Bergen, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway

**Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen Denmark

††Trinity Centre for Health Sciences, St. James's Hospital, Clinical Surgery, Dublin, Ireland

‡‡Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden

§§Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands

¶¶Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain

||||Department of HPB and Transplant Surgery, Hospital Curry Cabral, Lisboa, Portugal

***Department of Surgery, Medical University of Vienna, Vienna, Austria

†††Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium

‡‡‡Department of Surgery, 2nd Medical Faculty, Charles University and Central Military Hospital, Prague, Czech Republic

§§§Department of General and Visceral Surgery, Frankfurt University Hospital and Clinics, Frankfurt am Main, Germany

¶¶¶Surgical Oncology Program, Liver and Pancreas Unit, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada

||||||Division of Minimally Invasive Surgery, University of Michigan Health Systems - Ann Arbor, MI

****Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Faculty of Electronics and Information Technology Warsaw University of Technology, Warsaw, Poland

††††Surgical Department, Petz Aladár County Teaching Hospital, Györ, Hungary

‡‡‡‡Department of Surgery and Transplantation, University Hospital Bologna, Bologna, Italy

§§§§General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania

¶¶¶¶Department of Surgery, Helsinki University, Helsinki, Finland

||||||||Department of Surgery, Laiko General Hospital of Athens, Athens, Greece

*****Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland.

Reprints: Pierre-Alain Clavien, MD, PhD, Department of Surgery and Transplantation, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. E-mail:

No funding was received in support of this study.

The authors have no conflicts of interest.

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