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It's not enough to be good



You have to keep practicing as well.

The way our health systems are organized has impacts on outcomes. Multiple small centers doing complex surgery and looking after fragile patients only infrequently will likely have poorer outcomes overall. Large centers which gain experience in those procedures, which develop protocols and approaches, and practice frequently are likely to do better, by which I mean to have more babies who are alive at the end.

It seems so self-evident, that to keep saying it should be redundant, but it isn't; despite all the evidence that is out there, we still see a deterioration in regionalization, some of which is driven by the idea that the medicine is just a business like any other, so we should let the market decide who is going to do critical procedures. The idea, I guess is that if a center kills enough babies, then eventually they will receive fewer referrals.

Or you could take a different approach and say that highly critical care should be restricted to a few centers, and other centers should not be allowed to do those procedures.

These two new publications address this issue.

Karamlou T, Jacobs ML, Pasquali S, He X, Hill K, O'Brien S, et al. Surgeon and Center Volume Influence on Outcomes After Arterial Switch Operation: Analysis of the STS Congenital Heart Surgery Database. The Annals of Thoracic Surgery. 2014;98(3):904-11.

The arterial switch procedure is highly demanding, both in terms of technical skills of the surgeon, and peri-operative support. This article confirms that both the volume of the surgical center and the number of cases performed per surgeon are important in survival rates.

Kastenberg ZJ, Lee HC, Profit J, Gould JB, Sylvester KG. Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA Pediatrics. 2014.

The progressive de-regionalization of neonatal care in some parts of the USA has led to multiple small units with little experience looking after critically ill babies. These data show that high volume, high-level NICUs have significantly lower mortality for infants suffering from NEC.

Which is consistent with a recent article from the EpiCure2 study that I already blogged about, showing that overall, tertiary centers have better outcomes for tiny babies than centers without tertiary NICUs.

None of which should be surprising, but the implications for the organization of our health care are often ignored.

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