At this year’s Controversies and Updates in Vascular Surgery annual meeting (CACVS; 23–25 January, Paris, France), Dittmar Böckler (University Hospital Heidelberg, Heidelberg, Germany) made a case for the centralisation of aortic surgery, detailing 10 reasons why this is “imperative” for patient outcome and safety, cost-efficiency, and education. The audience were subsequently asked if they agreed that aortic surgery should be centralised, with the majority voting in the affirmative.
Böckler began by outlining major challenges in the healthcare system, including staff shortages, increasing costs, and quality control becoming increasingly important. He acknowledged that while medical care differs between countries, challenges in healthcare are “very similar”, at least among industrialised countries.
He noted that since the 1970s there has been a move in Denmark towards there being very few, large-volume hospitals. This change has occurred not only in the vascular space but in medical care overall. In comparison, there are roughly 2,000 hospitals in Germany, with over half a million hospital beds. Böckler summarises the situation as “over-care and over-supply”.
Looking at the treatment of abdominal aortic aneurysms (AAA) in Germany in particular, a quality assurance survey revealed that 60% of hospitals perform less than five procedures per year. “There is a problem in my mind,” Böckler commented.
Benchmarking the country, Böckler noted that Germany is third ranked country with the most hospital beds, and second after the USA in terms of money spent on the healthcare system. In the Heidelberg catchment area, 72 hospitals offer round-the-clock aortic surgery on their website. “I do not believe that,” remarked Böckler, adding that in London, there are just six or seven specialised vascular centres.
Ten reasons for centralisation
After outlining the situation in Germany, Böckler detailed 10 reasons why aortic surgery should be centralised:
- The prevalence and incidence of AAA is falling in both men and women, largely due to smoking cessation, which is leading to a change in epidemiology.
- There is a “huge diversity” of aortic pathologies and treatment modalities in open surgery, requiring complication prevention and management. Böckler stressed that there needs to be one to two aortic specialists on call 24/7, availability of an intensive care unit (ICU) 24 hours a day, access to pre- and intraoperative imaging (including fusion and cone beam CT), specific devices in stock, and special settings and skills.
- There is a correlation between caseload and outcome. Böckler outlined a study by Peter Holt (St. George’s University Hospitals NHS Foundation Trust, London, UK) and colleagues, published in the British Journal of Surgery in 2012, which concluded that there is a long-term benefit to patients who undergo elective AAA repair in a high-volume hospital. He also detailed European Society for Vascular Surgery (ESVS) clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms, which recommended that AAA repair should only be considered in centres with a minimum caseload of 30 repairs and should not be performed in centres with a yearly caseload of less than 20.
- There is a correlation between surgeon volume and outcome. Böckler outlined a study by James T McPhee (Boston Medical Center, Boston, USA) et al, published in the Journal of Vascular Surgery in 2010, which analysed 5,972 open repair cases and 8,121 endovascular aneurysm repair (EVAR) cases. Institutional volume was classified as low (less than seven), medium (seven to 30), and high (more than 30). In open repair, institutional correlated with mortality. Surgeon volume was defined as low (less than or equal to two), medium (three to nine), and high (more than 9). Mortality was 8.7% with low-volume surgeons, 4.8% with medium-volume surgeons, and 3.3% with high-volume surgeons (p=0.02).
- Hospital volume influences the method of treatment. Böckler presented a graph showing that in a low-hospital volume you are less likely to adapt endovascular treatment options, whereas higher volume institutions offer more endovascular treatment, even in emergency. “Success and quality really depends on experience and volume, not only in AAA care but also in fenestrated and very complex aortic procedures,” he added.
- Centralisation will impact emergency management. “In terms of ruptured AAA (rAAA) we have data showing that in a low-volume, low-bed capacity, you have higher mortality and a higher turndown rate, meaning you do not treat as many patients, even those who may be treated by endovascular means,” Böckler detailed.
- Centralisation leads to specialisation and that will influence outcome. Considering data related to speciality and mortality, Böckler pointed out that general surgeons have a 50% morality at 30 days treating rAAA compared to 33% for vascular surgeons.
- There is a correlation between infrastructure and outcome, “which is mainly better in bigger hospitals,” Böckler remarked. He then noted that larger hospitals are more likely to have a hybrid operating room (OR), for example, which he sees as crucial for EVAR surgery.
- Centralisation will help to improve the education of the next generation of surgeons. “We need experience and therefore volume in order to educate and train,” said Böckler.
- Hospital volume correlates with costs of inpatient surgery. In general, lower volume hospitals have higher costs for inpatient surgery and you have a higher 30-day readmission rate, which in turn costs money. “You save some money for the system if you treat patients in large volume hospitals,” Böckler concluded.
Böckler concluded: “Firstly, there is a strong relation between hospital volume, infrastructure, and quality. Secondly, mortality is influenced by many factors, such as operator caseload, protocols, experience, and finally, complex aortic especially really is cost-effective only if you do it with high caseload. Patient outcomes, safety, cost control, education, and the management/changing framework of the healthcare system depends on the centralisation of aortic surgery.