To the Editor:
Centralization and regionalization of pediatric cardiac surgery (PCS) is an accepted way to improve surgical results and patient care
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; however, numerous obstacles to achieving these goals remain, as very well described by Dr Vervoort.2
When trying to understand the factors contributing to the positive effects of centralization, looking at the Swedish experience might offer some insights.In Sweden, PCS was centralized from 4 centers to 2 centers in late 1992. The number of annual operations at Lund more than doubled initially, to 300 to 400. Over the years, the number stabilized at 275 to 300 operations annually. The case mix has changed to include more complex cases, including those involving Norwood surgery, as well as a move toward early correction. Overall 30-day mortality was reduced from 9.7% in 1988 to 1991 to 1.9% in 1995 to 1997.
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Operative risk has improved even further in subsequent years, recorded as 0.6% in 2010 to 2019.The increased surgical volume was a sufficient rationale for creating a dedicated team of pediatric cardiac surgeons. But with an annual operative volume of approximately 300 and the need for surgical competence available 24/7, the need to optimize surgical exposure and training remains. Therefore, we have adopted a system that involves 4 or 5 staff surgeons, 2 or 3 senior surgeons, and 2 surgeons at a more junior level. Everyone participates in all operations as an operating surgeon or assisting surgeon depending on case complexity. This gives us the capability of assembling the best possible surgical team for all patients while maximizing surgical exposure and facilitating training for all.
After centralization pediatric cardiology, PCS and pediatric anesthesiology were organizationally merged, which allowed for better coordination and shorter decision making pathways. This has facilitated the recruitment of highly trained staff at all levels of support. In Sweden, by long tradition, anesthesiologists are trained in both perioperative and intensive care. This enabled us to create a pediatric intensive care unit (ICU) with a focus on congenital heart disease and PCS. In most complex cases, the pediatric anesthesiologist responsible for perioperative care will follow the patient to the ICU and continue with ICU care. This allows for a seamless transferal of the patient without any loss of momentum.
An annual meeting, inviting all medical doctors and staff involved in the care of patients with congenital heart disease nationwide, is organized by the 2 operating centers. The annual results from both centers are reviewed and discussed, with special focus on morbidity and mortality. The Swedish National Board of Health conducts regular national audits of the 2 centers, focusing on surgical results, availability of care, and waiting times for elective surgery.
The centralization and regionalization of PCS has significantly improved results of PCS in Sweden. Nonetheless, it is important that we don't consider it “problem solved” after centralization. It is very much a work in progress to maintain and continuously improve the outcomes for children with congenital heart disease.
References
- Commentary: Regionalization = excellence.J Thorac Cardiovasc Surg. 2021; 161: 2157
- Centralization and regionalization of congenital heart surgery in a globalized world.J Thorac Cardiovasc Surg. 2021; 161: e481
- Centralization of pediatric heart surgery in Sweden.Pediatr Cardiol. 2000; 21: 353-357
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Published online: November 20, 2020
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- Centralization and regionalization of congenital heart surgery in a globalized worldThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 6
- PreviewCongenital heart surgery is complex and requires dedicated services to optimize surgeons' skills and patient outcomes. Centralization and regionalization of services enables a pooling of surgical volume by centers and surgeons, whilst trying to limit geographic barriers for patients as a result of such decisions. Backer1 illustrates that regionalization enables the pursuit of excellence in congenital heart surgery using the example of Sweden's shift from 4 to 2 centers in 1992.
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