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The essential requirements for an HPB centre to deliver high-quality outcomes

  • Author Footnotes
    † Current address: Department of Surgery, Lithuanian University of Health Sciences, Eiveniu str. 2, 50009 Kaunas, Lithuania
    Povilas Ignatavicius
    Footnotes
    † Current address: Department of Surgery, Lithuanian University of Health Sciences, Eiveniu str. 2, 50009 Kaunas, Lithuania
    Affiliations
    Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland

    Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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  • Christian E. Oberkofler
    Affiliations
    Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland

    Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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  • Jan Philipp Jonas
    Affiliations
    Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland

    Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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  • Beat Mullhaupt
    Affiliations
    Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland

    Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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  • Pierre-Alain Clavien
    Correspondence
    Corresponding author. Address: Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Department of Surgery & Transplantation, University Hospital Zurich Rämistrasse 100, CH-8091 Zurich (Switzerland); Tel.: +41 44 255 33 00.
    Affiliations
    Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland

    Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
    Search for articles by this author
  • Author Footnotes
    † Current address: Department of Surgery, Lithuanian University of Health Sciences, Eiveniu str. 2, 50009 Kaunas, Lithuania

      Summary

      The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in ‘virtual’ HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre’s beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of “centre of reference” limited to actual, as opposed to virtual, centres.

      Keywords

      Introduction

      Therapeutic approaches for many complex diseases have changed from a discipline-specific approach to a multidisciplinary decisional process over the past 20 years. This has led to the development of highly specialised centres for cardiovascular diseases,
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      In 2006, we presented the new concept of an actual, in contrast to virtual, HPB centre, including its structure, processes and treatment of specific diseases.
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      We believe that such a centralised multidisciplinary approach is the best way to achieve quality outcomes in a cost-effective manner. Such an HPB centre must also work closely with the transplant centre, sharing interdisciplinary expertise and resources. New features of the redesigned centre include (a) full support from hospital management and the local health department, (b) dedicated and trained full-time nurses, specialised clinical nurses and other medical support staff, (c) integration of a specialised intermediate care unit (IMC) located in the HPB unit, (d) medical teams academically and financially linked to their respective departments, e.g. hepatologists to the Department of Gastroenterology and HPB surgeons to the Department of Surgery, (e) a clear assignment of specific conditions, e.g., upper gastro-intestinal bleeding to the gastroenterology team or acute pancreatitis to the surgical team, (f) interaction between the centre’s physicians on a daily basis with weekly rounds and interdisciplinary tumour boards.
      The establishment of centres has also been driven by the need to centralise the treatment of rare diseases and the performance of complex procedures to achieve a minimally required volume and secure sufficient expertise and resources to optimise outcomes
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      correlate with better outcome, there is evidence that centres that perform too many surgeries may face a decline in several outcome parameters after reaching a certain plateau (breaking point) (Fig. 1).
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      Recent benchmark studies have shown that centres that operate mostly on complex cases report better outcomes compared to centres that treat mainly benchmark (optimal) cases.
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      Figure thumbnail gr1
      Fig. 1Association between centre volumes and outcomes.
      Quality of care is closely related to the accurate and prospective collection of data, not only for administrative purposes but also for quality assessment and potential research projects. The centre must incorporate the patient’s perspective into their evaluation.
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      Centralisation of care may be the most important step to achieve better outcomes.
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      For intrahepatic cholangiocarcinoma, for example, treatment at large academic medical centres is associated with lower 90-day mortality, better overall survival, and higher rates of negative resection margins.
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      Therefore, the aim of this article is twofold. First, we performed a literature review on the essential requirements for an “ideal” HPB centre and second, we conducted a large international survey to understand current practices and outcomes related to centralisation of HPB cases around the world. Finally, we aim to consider this information in the context of over 15 years of experience at our HPB centre in Zurich, Switzerland.
      Due to the development of many novel therapeutic approaches to complex HPB diseases, there is a growing need for specialised multidisciplinary teams to deliver high-quality outcomes.

      Study design

      First, we conducted a literature review on the essential requirements for an HPB centre to provide high-quality care. Since data on this topic are very sparse, we have focused our search on specific characteristics of quality such as the impact of patient volume at the level of the hospitals or surgeons, centralisation of care and specialisation. Based on the available literature and experience gained in our HPB centre, which was established in 2006,
      • Clavien P.A.
      • Müllhaupt B.
      • Pestalozzi B.C.
      Do we need a center approach to treat patients with liver diseases?.
      we have attempted to define the main requirements for an HPB centre to achieve high-quality outcomes.
      To understand current practices around the world regarding an integrated approach to patients with HPB diseases, we conducted a global online survey of established facilities caring for this patient population.
      Finally, we critically evaluated the goals we set 15 years ago, when we established the Swiss HPB centre at our institution.
      • Clavien P.A.
      • Müllhaupt B.
      • Pestalozzi B.C.
      Do we need a center approach to treat patients with liver diseases?.
      During these years, we have identified several shortcomings and obstacles that we would like to share to guide the future design of an optimal HPB centre.

      Review of the literature

      A standardised systematic review of the literature was not possible due to the scarcity and heterogeneity of available data. Therefore, we focused on the most relevant publications from the last 15 years on the requirements for a centre to deliver high-quality outcomes.
      Most of the publications address the impact of hospital and/or surgeon volume on outcomes.
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      Toward a consensus on centralization in surgery.
      We also examined how centre or individual surgeon caseloads can affect outcomes depending on the respective procedure or underlying diseases. A large study by Nathan et al. from the USA showed that a higher volume of liver resection (type not specified) was associated with a reduction of in-hospital mortality, although surgeon volume per se did not affect outcome. In contrast, when the influence of pancreatic resection volume was examined, a significant correlation was found between individual surgeon volume and a lower in-hospital mortality rate.
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      The authors conclude that quality improvement efforts must be procedure specific. For some procedures, such as liver resections, the intervention should be primarily targeted at the hospital level, whereas for others, such as pancreatic resections, the target should extend to individual surgeon caseloads. This statement is supported by a recent systematic review and meta-regression that found no difference in mortality or postoperative pancreatic fistula rates when minimally invasive pancreatoduodenectomy was performed at high-volume vs. low-volume centres.
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      Data on the cost-effectiveness of treatment for HPB patients in high-volume centres is still scarce, and controversial. Some studies clearly document cost savings with centralisation or a centre approach.
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      In contrast, another study analysing 96,107 cases of liver resection suggested that liver resection at high-volume centres (>150 cases/year) was associated with $5,109 (95% CI 4,409–5,809, p <0.001) more cost per case compared to lower volume centres (1–50 cases/year). However, the same study documented a significantly higher postoperative survival at high-volume centres, leading the authors to conclude that liver surgery at high-volume centres is cost saving considering both direct and indirect costs due to longer survival.
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      The positive effect of centralising the performance of pancreaticoduodenectomy was shown by the Dutch Pancreatic Cancer Group in the Netherlands. Centralisation was associated with higher resection rates, higher R0 resection rate and better overall survival.
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      An association of surgeon and centre volume with outcomes of pancreatic surgery has already been shown. However, the impact of other involved specialists, like anaesthesiologists has been far less well studied. A multicentre study involving 14 hospitals in the USA showed that participation of high-volume anaesthesiologists in pancreatic surgery (pancreaticoduodenectomy or distal pancreatectomy) was associated with decreased costs of $2,278 per case
      The literature describing the essential requirements for an HPB centre is scarce, and absolute requirements are not uniformly accepted.
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      Failure to rescue is an important outcome measure as it reflects the failure to prevent a death resulting from a treatment-related complication.
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      The application effects of personalized nursing on the perioperative period of hepatobiliary surgery: a systematic review and meta-analysis.
      The centre must also consider the patient’s perspective. After surveying patients with HPB carcinomas who were scheduled for pancreatectomy, Fong et al. found that patients choose hospitals based on hospital factors (e.g., hospital reputation), team characteristics (e.g., surgical volume), distance from the hospital, referral or recommendation, continuity of care, and insurance considerations (public, private). Timely planning for diagnosis and treatment was cited as one of the most important factors for patients and their caregivers in selecting a hospital.
      • Fong Z.V.
      • Lim P.-W.
      • Hendrix R.
      • Castillo C.F.
      • Nipp R.D.
      • Lindberg J.M.
      • et al.
      Patient and caregiver considerations and priorities when selecting hospitals for complex cancer care.
      Quality improvement is not possible without adherence to the regularly updated guidelines. The National Comprehensive Cancer Network (NCCN) began publishing clinical practice guidelines as early as 1990. Unfortunately, the current situation is far from satisfactory. A 2012 study of California’s largest hospitals (with more than 400 beds) found that only one-third of hospitals adhered to NCCN guidelines when treating patients with pancreatic cancer. The same study highlights that the risk of death could be reduced by nearly 40% if hospitals adhered to the guidelines.
      • Visser B.C.
      • Ma Y.
      • Zak Y.
      • Poultsides G.A.
      • Norton J.A.
      • Rhoads K.F.
      Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes.
      Another approach to improve outcome quality may rely on a regional or nationwide quality improvement programme. For example, more than 20 years ago, such an approach was undertaken in Canada. The main goal was to develop high-quality surgical oncology programmes that were patient-centred, multidisciplinary, and integrated. An outcome analysis after the implementation of these changes showed that the total number of hospitals performing pancreatic surgery was dramatically reduced to a few centres and the mortality rates after pancreatic surgery decreased dramatically in a more than double-digit manner.
      • Langer B.
      Role of volume outcome data in assuring quality in HPB surgery.

      Worldwide survey among hospitals delivering care to HPB patients

      In the absence of official directories of HPB centres or high-volume liver departments, we used the following websites for our search i) the International Hepato-Pancreato-Biliary Association (IHPBA) (https://www.ihpba.org/27_HPB-Fellowship-Registry.html), ii) European Surgical Association (https://www.europeansurgicalassociation.org), and iii) the Compagnons Hépato-Biliaires website (https://compagnons-hb.com/les-membres-compagnons). Finally, we identified experts working at academic centres who have contributed significantly to HPB surgery with publications in peer reviewed journals over the past 10 years. Invitations to participate were sent personally by e-mail by one of the authors (PAC), who emphasized the relevance of the study. In the absence of a response, a personal reminder was sent 2 weeks later. Importantly, each participant agreed to complete the survey by themselves rather than delegating this task to younger colleagues. The survey included 56 questions covering a variety of topics, including the structure and processes of their institutions, how outcomes are measured, and training opportunities (Questionnaire and Table S1).
      Quality of care is closely linked to caseloads and monitoring of clinically relevant outcome parameters.
      Of 143 centres contacted, 107 (75%) responded to the 56-question questionnaire. Sixty-three of the responding participants (59%) were from Europe, 17 (16%) from North America, 6 (5%) from South America, 19 (18%) were from Asia, and 2 (2%) from Australia (Fig. 2). Participants answered some general questions on the size and type of their hospital, as well as other questions about the structure. We also asked about the type of treatment and number of patients with HPB diseases undergoing operations, as well as the relevant specialties. The survey also included several questions about research and related liver transplant programmes. Survey completeness was achieved by 94% of respondents, who took an average of 15 minutes (4–70 minutes) to complete the survey.
      Figure thumbnail gr2
      Fig. 2Map of worldwide responses to survey. Countries in which the participants of the survey are working are coloured in red.
      Most participants were from academic hospitals (89%). All participating departments were in hospitals with more than 100 beds, and nearly half of those hospitals (46%) reported having more than 1,000 beds. Intermediate care units are present in the majority (85%) of centres; a quarter of these IMC beds (26%) are exclusively for patients with HPB disorders. In one-third (31%), intensive care unit (ICU) beds are specifically designated for patients with HPB diseases.
      Half (55%) of the surveyed centres treat more than 500 patients with HPB diseases annually, with only 17 (16%) treating more than 1,000 HPB patients annually. As not all patients admitted to HPB departments require surgery, only 20 centres (19%) report more than 500 patients with HPB diseases undergoing surgery per year. Half (51%) of HPB units or centres are officially certified at the local or national level.
      In more than half (58%) of the centres, patients with HPB diseases undergo operations in dedicated operating rooms (1-2 rooms per week). These operations are performed by HPB surgeons operating only on patients with HPB diseases in 58% of hospitals, and by general surgeons with expertise in treating HPB disorders in 41% of hospitals. Patients with severe injuries to the liver, biliary tract, and pancreas are mostly operated on by specialised HPB surgeons (77%). In half of the hospitals (49%), patients with moderate to severe pancreatitis are treated in specialised HPB units.
      Regular (daily – 35%, 1-3 times per week – 40%) multidisciplinary bedside rounds take place in 64% of the units. Surgeons, gastroenterologists/hepatologists and fellows participate in 87%, 64% and 68%, respectively, whereas oncologists (33%), radiologists (31%), dietitians (34%) and physician assistants (PAs: 36%) participate less frequently. Multidisciplinary tumour boards (MDTs) are held in most departments (96%), with the participation of oncologists, gastroenterologists, surgeons, radiologists, and interventional radiologists. Morbidity and mortality (M&M) conferences are held 1–4x per month in 88% of departments. Interestingly, 13 (12%) respondents answered that they do not hold M&M conferences.
      PAs are an important part of the healthcare system, especially in the USA. They have an advanced education in general medicine and can treat patients with significant autonomy. However, they still work in a team practice, with physicians and other healthcare providers. In 42 (40%) of the centres, there is a PA for inpatients with HPB disorders. Outpatient PAs exist in 36 (34%) centres. As noted above, PAs participate in regular multidisciplinary bedside rounds in 36% of centres and in the MDT in 34% of centres.
      Two-thirds (68%) of HPB surgeons have completed a formal training (national and/or international HPB fellowship). More than half (56%) of hospitals have an established HPB fellowship programme, with 1–20 (median 2) fellows per year. Fellows are hosted from the same country (27%), around the world (17%), or both (35%), whereas this information was missing for the other surveyed participants. The duration of the programme ranges from 1 to 3 years with most of the hospitals (68%) having 2-year training programmes, 17% offering a 1-year and 12% a 3-year fellowship programme. In more than half (58%) of cases, liver transplantation is also included in the HPB fellowship programme. However, only 19% of HPB fellowship programmes are accredited nationally or internationally (IHPBA, AHPBA, A-PHPBA, E-AHPBA). After completion of the fellowship, some fellows stay in the same hospital (35%) and some (28%) go back to their country of origin. Almost all responders (94%) indicated that the presence of fellows improved the quality of care, and some (27% of responders) even indicated that the presence of fellows reduced the rate of failed rescues. In units with liver transplant programmes, 20% of liver transplants are performed by fellows with the assistance of fully trained transplant or HPB surgeons.
      Enhanced recovery after surgery protocols are implemented in the majority (79%) of HPB units. In contrast, other standardised protocols such as care plans (standardised internal guidelines on treatment of patients) and standard operating procedures are used less often (57%).
      Almost all participants claim to be able to combine their daily clinical work with ongoing research projects (93%). Seventy-three percent (73%) of centres reported ongoing randomised controlled trials and more than half (61%) of HPB units rely on the support of a dedicated study nurse. Dedicated (protected) time for clinical research is only provided to physicians in 44 centres (43%). Thirty-seven percent (37%) reported that they have a budget for research, and sixty-two (59%) reported that industry-sponsored research projects are currently underway. Interventional radiologists and interventional gastroenterologists are available 24/7 in most departments (95% and 88%, respectively). Two-thirds of the hospitals (71%) have dedicated anaesthesiologists specialised in treating patients with HPB diseases.
      The benefit of high caseloads per hospital vs. individual surgeons differs according to the type of surgery.
      Most of the surveyed hospitals in North (89%) and South (100%) America have a liver transplant programme. However, these programmes run independently of HPB units. In contrast, only two-thirds (66%) of hospitals in Europe have such a programme. One-third of hospitals (31%) perform more than 100 liver transplants annually. In Europe, almost half (42%) of hospitals treat patients after liver transplantation in the same unit with HPB patients. Interestingly, in two-thirds (58%) of hospitals with liver transplant programmes in North America, patients are treated in a separate transplant unit after liver transplantation (Table 1). In more than a half of hospitals, liver transplantations are performed by either specialised transplant surgeons or HPB surgeons (59%).
      Table 1Differences of the transplantation programme among different regions.
      EuropeNorth AmericaSouth AmericaAsia-Pacific
      Number of participants6218621
      Transplantation programme39 (66%)16 (89%)6 (100%)14 (67%)
      Liver transplantations/year
       <102 (5%)1 (6%)0 (0%)0 (0%)
       10–5010 (24%)2 (12%)5 (83%)9 (64%)
       50–10017 (42%)5 (29%)1 (17%)2 (14%)
       >10012 (29%)9 (53%)0 (0%)3 (22%)
      Liver transplantations are done by
       Transplant surgeons10 (23%)12 (80%)0 (0%)5 (38%)
       HPB surgeons18 (42%)1 (7%)4 (67%)4 (31%)
       Both15 (35%)2 (13%)2 (33%)4 (31%)
      Patients with liver transplant are treated at
       Together with other surgical patients3 (7%)4 (23%)2 (33%)1 (7%)
       HPB unit19 (42%)2 (12%)1 (17%)5 (36%)
       Separate unit16 (36%)10 (59%)3 (50%)7 (50%)
       Other7 (15%)1 (6%)0 (0%)1 (7%)
      Liver transplantation is part of HPB fellowship22 (35%)12 (67%)5 (83%)13 (62%)
      ERAS, enhanced recovery after surgery; GE, gastroenterologist; ICU, intensive care unit; IMC, intermediate care unit; MDT, multidisciplinary tumour board; M&M, Morbidity and Mortality; OR, operating room; RCT, randomised controlled trial.
      Based on our experience of 15 years since establishing the Swiss HPB centre and based on the performed literature review, we formed a list of requirements for HPB centres to deliver high-quality outcomes (Box 1). After analysing the survey data, we stratified the participating centres according to the listed requirements (Table 2). Interestingly, only one-third (35%) of the facilities surveyed would meet all or nearly all (>90%) of the requirements (Group A). More than half (64%) of the surveyed facilities meet between 50% and 90% (Group B), whereas only 1.8% meet less than 50% of the requirements to qualify as an HPB centre (Group C).
      Requirements for hepato-pancreato-biliary centres to deliver high-quality outcomes.
      Table 2Stratification of the participating centres according to the fulfillment of the proposed requirements for the HPB centre.
      Group AGroup BGroup C
      Number of centres (n)37 (34%)68 (64%)2 (2%)
      Number of hospital beds
       100–5006 (16%)10 (15%)1 (50%)
       500–1,00013 (35%)28 (41%)
       >1,00018 (49%)30 (44%)1 (50%)
      Number of ICU beds
       <102 (3%)
       10–5016 (43%)26 (38%)2 (100%)
       50–10010 (27%)31 (46%)
       >10011 (30%)9 (13%)
      HPB patients/year
       <1001 (3%)1 (50%)
       100–50014 (38%)41 (62%)1 (50%)
       500–1,00010 (27%))17 (26%)
       >1,00010 (27%)7 (11%)
       I don’t know2 (5%)1 (1%)
      Operated HPB patients/year
       <1002 (5%)2 (3%)1 (50%)
       100–50024 (65%)54 (82%)1 (50%)
       500–1,0009 (24%)9 (14%)
       >1,0001 (3%)1 (1%)
       I don’t know1 (3%)
      Certified HPB unit22 (59%)32 (47%)2 (100%)
      Transplantation programme28 (76%)46 (67%)1 (50%)
      Liver transplantation/year
       <102 (6%)1 (2%)
       10–507 (23%)19 (41%)
       50–1008 (26%)16 (35%)1 (50%)
       >10014 (45%)10 (22%)
      Surgeons with fellowship30 (81%)40 (59%)1 (50%)
      Fellowship programme34 (92%)24 (35%)
      HPB anesthesiologist33 (89%)41 (60%)
      Interventional radiologist 24 h37 (100%)61 (90%)2 (100%)
      Interventional GE 24 h34 (92%)57 (84%)1 (50%)
      Multidisciplinary rounds34 (92%)32 (47%)1 (50%)
      MDT37 (100%)62 (91%)2 (100%)
      Regular M&M36 (97%)56 (82%)
      ERAS31 (84%)48 (71%)2 (100%)
      Study nurse26 (70%)37 (54%)1 (50%)
      RCT ongoing33 (89%)42 (62%)1 (50%)
      Research projects ongoing36 (97%)61 (90%)1 (50%)
      Industry-sponsored research26 (70%)36 (53%)
      Dedicated budget for research14 (38%)25 (37%)
      Group A: fulfilling 90-100% of the requirements, Group B: fulfilling 50-90% of the requirements, Group C: fulfilling less than 50% of the requirements. ERAS, enhanced recovery after surgery; GE, gastroenterologist; ICU, intensive care unit; MDT, multidisciplinary tumour board; M&M, morbidity and mortality; RCT, randomised controlled trial.

      Swiss HPB centre

      The Swiss HPB centre at the University Hospital Zurich, Switzerland, was opened in 2005 as a government-sponsored facility. One of the main goals was to create a multidisciplinary, centralised unit with surgeons, gastroenterologists/hepatologists, and oncologists. Beds were shared among surgeons and gastroenterologists, while the oncologists served as consultants. The Swiss HPB centre had 24 regular beds including a 4-bed unit dedicated to intermediate care. More than 1,200 liver resections and 700 pancreas resections have been performed in this centre. A major component of the centre included training of national and international fellows in HPB surgery and liver transplantation. Already 16 fellows from 11 countries have been trained. Since opening, the centre has been involved in the publication of more than 300 research articles. Several internationally recognised developments for the treatment of liver diseases have been developed in recent years at the Swiss HPB centre, in collaboration with our research laboratories at the University Hospital or Federal Institute of Technology (ETH).
      • Eshmuminov D.
      • Becker D.
      • Bautista Borrego L.
      • Hefti M.
      • Schuler M.J.
      • Hagedorn C.
      • et al.
      An integrated perfusion machine preserves injured human livers for 1 week.
      ,
      • Clavien P.A.
      • Dutkowski P.
      • Mueller M.
      • Eshmuminov D.
      • Bautista Borrego L.
      • Weber A.
      • et al.
      Transplantation of a human liver following 3 days of ex situ normothermic preservation.
      We have achieved a large part of what we set out to do when we founded the centre. Patients with HPB diseases are centralised and managed at the centre. An interventional radiologist and an interventional gastroenterologist are available 24 hours a day, 7 days a week. A specialised MDT is held weekly to discuss and decide on the optimum therapeutic approaches for patients with HPB diseases, and a weekly M&M conference is held to discuss not only each complication but also complex cases in which therapy goes beyond established guidelines (Box 2).
      Achieved goals of the Swiss HPB centre since its creation in 2005.
      However, we have faced several obstacles. For example, centralisation of HPB patients is not always possible for logistical reasons, and patients with complex HPB diseases must sometimes be treated in other units, although covered by the same HPB specialists. The organisation and coordination of regular multidisciplinary bedside rounds is not possible owing to the involvement of all the participating specialists (surgeons, gastroenterologists/hepatologists and oncologists) in multiple tasks at the same time. Unfortunately, as part of a reorganisation of the hospital, the decision was made to centralise IMC beds which no longer belong to the HPB centre.

      Discussion

      Every stakeholder in healthcare knows that hospitals staffed by qualified specialists working as a team, with experience treating many patients, offer the best chance for quality care. The question however remains, what are the essential requirements to succeed in delivering high-quality care in a cost-effective manner. This question is particularly relevant in the complex field of liver and pancreas diseases, which have benefited from many innovations covering many specialties over the past 2 decades. Such proliferation of competitive treatments, often with a low level of evidence, has led to controversies and even confusion among experts. For example, a recent study disclosed poor agreement among liver surgeons treating patients with colorectal liver metastases,
      • Ignatavicius P.
      • Oberkofler C.E.
      • Chapman W.C.
      • DeMatteo R.P.
      • Clary B.M.
      • D’Angelica M.I.
      • et al.
      Choices of therapeutic strategies for colorectal liver metastases among expert liver surgeons: a throw of the dice?.
      indicating the need for standardisation and compliance with guidelines. The best strategy to achieve those goals is an actual centre run by an interdisciplinary and collaborative team of experts.
      In this study, we could highlight several key factors influencing quality of care and outcomes (Box 1). The first line is the availability of a structured unit dedicated to patients with HPB diseases, integrating doctors and nurses. Continuous training, e.g. through formal fellowships and research projects at many levels may best secure a consistency in the choice of therapies and knowledge of guidelines. Then, regular meetings including structured M&M or MDT conferences with the inherent sharing of different point of views secure timely feedback that should lead to consensus approaches including better compliance with guidelines and improvement in patient care.
      However, our survey covering more than 100 centres worldwide indicates that most responders do not work in actual, but rather ‘virtual’, HPB centres, with only one-third fulfilling most of the criteria. We would suggest that such optimal centres may be called “centres of reference”. Most other centres are ‘virtual’ in the sense that they failed to offer a dedicated space with interdisciplinary experts and beds. ‘Virtual’ centres run their practice through doctors working within the frame of their respective departments and processing cases not differently than for any other patients. Half of the respondents do not offer a training programme, and one-third failed to have interdisciplinary common meetings or bedside rounds. We may speculate that this relates to a lack of commitment from the various departments, like surgery or medicine, and possibly to inadequate institutional support that focuses primarily on administrative organigrams and budgets, or more crudely said “rentability”. Medicine in many countries, including wealthy countries, follows the widely diffused rules of microeconomics and is thereby guided by algorithms and figures generated by managers, who have limited medical background, knowledge about quality of care, or patient contact. Today, managers are compulsory in modern hospitals but must work under the leadership of medical experts. For example, the Swiss HPB centre developed IMC beds within the centre that had many advantages, including continuity of care from nurses, ancillary personnel, residents, and surgical fellows. Most patients undergoing major liver or pancreatic procedures transited for 1–2 days in the IMC before being readmitted to their standard room, obviating the need for costly ICU stays. Despite a clear improvement in care from the patient and medical perspectives, a decision was made to centralise IMC beds as part of a reorganisation at the level of the hospital. In our opinion, centralisation of beds and uniform approaches at the level of the hospital, while sometimes justified, are major obstacles to the high-quality care of patients. Contrarily, when patients are treated in “closed” (patients are managed by trained intensivist) vs. “open” (patients are managed by other specialist and intensivists are available for consultation) ICUs, the mortality rate is lower.
      • Yang Q.
      • Du J.L.
      • Shao F.
      Mortality rate and other clinical features observed in open vs closed format intensive care units: a systematic review and meta-analysis.
      However, larger trials are needed to confirm this data.
      Only one-third of HPB centres surveyed meet most of the proposed criteria to qualify as a “centre of reference”.
      Following a comprehensive review of the literature, it became apparent that the need to offer quality care differs according to the procedures used.
      • Nathan H.
      • Cameron J.L.
      • Choti M.A.
      • Schulick R.D.
      • Pawlik T.M.
      The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship.
      ,
      • Csikesz N.G.
      • Simons J.P.
      • Tseng J.F.
      • Shah S.A.
      Surgical specialization and operative mortality in hepato-pancreatico-biliary (HPB) surgery.
      For example, complex liver surgery, including liver transplantation, depends on the centre volume of cases with little or no impact from the individual surgeon caseloads. In contrast, complex pancreatic surgery, which mostly follows standardised procedures, relies more on the individual surgeon’s caseload or expertise rather than the centre volume. This implies that such factors must be considered to optimise centre structure and processes.
      Interestingly, we recently discovered that for most procedures, including liver and pancreas surgery, operating on complex cases significantly improves outcome in all categories of patients.
      • Rössler F.
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      • Song G.
      • Lin Y.-H.
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      • et al.
      Defining benchmarks for major liver surgery: a multicenter analysis of 5202 living liver donors.
      ,
      • Mueller M.
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      • Benzing C.
      • et al.
      Perihilar cholangiocarcinoma - novel benchmark values for surgical and oncological outcomes from 24 expert centers.
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      Benchmarks in pancreatic surgery: a novel tool for unbiased outcome comparisons.
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      Defining benchmark outcomes for pancreatoduodenectomy with portomesenteric venous resection.
      While this observation might seem quite intuitive, this is now a characteristic feature of expert centres of reference, which must deal with highly complex cases, and not limit their practice to benchmark (i.e., optimal) cases. The management of complex cases requires additional expertise, with many specialists involved in the pre- and postoperative care! This logically leads to better outcomes.
      It is of paramount importance to convince patients and society on “how to measure outcome?” This remains a controversial topic, with different answers depending on perspective. From an economic or governmental point of view, it might be how to treat the most patients within a reasonable budget, whereas an individual patient would like to know “where should I go to receive the best care?”.
      • Svederud I.
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      Patient perspectives on centralisation of low volume, highly specialised procedures in Sweden.
      ,
      • Fong Z.V.
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      • Hendrix R.
      • Castillo C.F.
      • Nipp R.D.
      • Lindberg J.M.
      • et al.
      Patient and caregiver considerations and priorities when selecting hospitals for complex cancer care.
      An international consensus conference held in June 2022 in Zurich, Switzerland proposed novel endpoints and considered many perspectives including an economic point view. An independent Jury established the final statements (to be published in Nature Medicine). Such initiatives will hopefully minimise controversies about how best to treat patients. A recently established marker of good surgical practice is the notion of “failure to rescue”, which tests the competence of a centre to detect complications at an early stage, and thereby prevent clinical deterioration of the patient which may lead to death.
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      Failure-to-rescue in patients undergoing pancreatectomy: is hospital volume a standard for quality improvement programs? Nationwide analysis of 12,333 patients.
      ,
      • Elfrink A.K.E.
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      Factors associated with failure to rescue after liver resection and impact on hospital variation: a nationwide population-based study.
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      The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer.
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      • et al.
      The impact of hospital volume on failure to rescue after liver resection for hepatocellular carcinoma.
      • Gleeson E.M.
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      Patient-specific predictors of failure to rescue after pancreaticoduodenectomy.
      This depends on the actual attention provided to individual patients by careful and competent clinicians. For example, it has been shown that formal fellowship programmes with board-certified trainees may significantly contribute to lessening the incidence of failure to rescue at HPB centres.
      • Altieri M.S.
      • Yang J.
      • Yin D.
      • Frenkel C.
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      • Telem D.A.
      • et al.
      Presence of a fellowship improves perioperative outcomes following hepatopancreatobiliary procedures.
      It is also possible that the availability of artificial intelligence may further minimise failure to rescue. In the process of a centre of reference, failure to rescue must be assessed for each patient with a poor outcome and be analysed at regular M&M conferences.
      Accurate monitoring of outcomes
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      Assessment of textbook outcome in laparoscopic and open liver surgery.
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      Assessing textbook outcomes following liver surgery for primary liver cancer over a 12-year time period at major hepatobiliary centers.
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      A multi-institutional international analysis of textbook outcomes among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma.
      is feasible exclusively with proper data collection organised by independent clinical nurses or data managers. Residents are notoriously inefficient when it comes to recording negative events.
      • Dindo D.
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      • Clavien P.-A.
      Quality assessment in surgery: riding a lame horse.
      Any accountable budget must include resources to comply with accurate data collection for self-analysis of outcome parameters, and often to comply with regulatory governmental or professional organisations, leading to national and international accreditation.
      In addition to these objective criteria, patients look at other factors like timely scheduling of appointments to see an expert, to be examined and eventually receive treatment. In patients newly diagnosed with a cancer, the readily availability of a treatment plan was identified as the single most important factor for patients and their caregivers when selecting a hospital.
      • Fong Z.V.
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      • et al.
      Patient and caregiver considerations and priorities when selecting hospitals for complex cancer care.
      ,
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      Whether liver transplantation must be integrated into a HPB centre for enhanced quality of care is unclear, but at the very least a strong link must be developed between HPB and transplantation units and possibly the presence of transplantation experts at every MDT meeting. The survey showed that most of the surveyed hospitals (89%) in North America have a liver transplantation programme in the hospital. However, in the USA, unlike in Europe and Asia, transplantation centres are commonly independent units that utilise a multi-organ approach, which renders connections with HPB experts more problematic. How this dichotomy may impact on quality of care in patients with liver diseases is unclear and should be further investigated. It might also be suspected that in centres with liver transplantation units, the liver transplantation experience of particular surgeons is not necessarily the most important factor, but rather the hospital in which liver transplantations are performed may have better developed facilities and easier access to other experts (endoscopy, interventional radiology and etc.).
      • Csikesz N.G.
      • Simons J.P.
      • Tseng J.F.
      • Shah S.A.
      Surgical specialization and operative mortality in hepato-pancreatico-biliary (HPB) surgery.
      A limitation of this review is the paucity of available literature describing the essential requirements for an HPB centre to deliver high-quality outcomes and the inability to link centre structure to outcome data. The survey is obviously biased by targeting mostly academic or large centres that are aiming for quality improvements. Indeed, very few centres in the real-world would qualify as centres of reference, magnifying the need for more data linking types of care delivery and quality. This probably can be solved only with national programmes for quality improvement that encompass multiple perspectives.
      In summary, this 3-step analysis shows that there are few true centres of reference and that there is a need to re-design HPB or liver centres according to criteria that go beyond the structures or processes established by managers mostly focused on short-term budgets or cost saving. When evaluating outcomes of individual patients or related to centres, medical perspectives, e.g. using complication grading
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      or global markers of morbidity like the Charlson comorbidity index,
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      Abbreviations

      HPB, hepato-pancreato-biliary; ICU, intensive care unit; IMC, intermediate care unit; NCCN, National Comprehensive Cancer Network; MDT, multidisciplinary tumour board; M&M, morbidity and mortality; OR, odds ratio; PAs, physician assistants.

      Financial support

      The authors received no financial support to produce this manuscript.

      Authors’ contributions

      Conception and design of the survey: PI, CEO, BM, PAC; analysis and interpretation of the data: PI, CEO, JPJ; literature review: PI, CEO, JPJ; drafting the article, critical revision, and final approval: PI, CEO, JPJ, BM, PAC.

      Conflict of interest

      All authors have nothing to disclose.
      Please refer to the accompanying ICMJE disclosure forms for further details.

      Acknowledgements

      Mustapha Adham (Edouard Herriot Hospital, Lyon, France), Vatche G. Agopian (Ronald Reagan UCLA Medical Center, Los Angeles, USA), Luca Aldrighetti (San Raffaele Hospital, Milan, Italy), Ruslan Alikhanov (Moscow Clinical Scientific Center, Moscow, Russia), Roland Adnersson (Lund University Hospital, Lund, Sweden), Thomas Armstrong (University Hospital Southampton NHS Foundation Trust, Southampton, UK), Philippe Bachellier (Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France), Deniz Balci (Ankara University School of Medicine, Ankara, Turkey), Giedrius Barauskas (Lithuanian University of Health Sciences, Kaunas, Lithuania), Ryan R. T. Barroso (Rizal Medical Center, Manila, Philippines), Wolf O. Bechstein (University Hospital Frankfurt, Germany), Frederik Berrevoet (Ghent University Hospital and Medical School, Ghent, Belgium), Marc Besselink (Amsterdam University Medical Center, Amsterdam, Netherlands), Karim Boudjema (University Hospital Rennes, Rennes, France), Matteo Cescon (S. Orsola Malhigi Hospital, University of Bologna, Bologna, Italy), Albert C. Y. Chan (University of Hongkong, Hongkong, China), William Chapman (Washington University School of Medicine, Washington, USA), Kenneth Chavin (Medical University of South Carolina, Charleston, USA), Daniel Cherqui (Hôptial Paul Brousse, Paris, France), Laurence Chiche (Bordeaux Hospital University Center CHU, Bordeaux, France), Stephen Chung (Vancouver General Hospital, Vancouver, Canada), Umberto Cillo (University Hospital of Padua, Padua, Italy), Ruben Ciria (University Hospital Reina Sofía, Cordoba, Spain), Bryan Clary (UC San Diego, San Diego, USA), Michael D’Angelica (MSK Cancer Center, New York, USA), ronal P. DeMatteo (Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA), Christo Dervenis (Metropolitan Hospital, Athens, Greece), Jiahong Dong (Beijing Tsinghua Changgung Hospital, Beijing, China), Jean C. Edmond (Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA), Joris Erdmann (Amsterdam University Medical Center, Amsterdam, Netherlands), Joan Figueras (Hospital Universitari Dr. Josep Trueta, Barcelona, Spain), Constantino Fondevila (Hospital Clinic, University of Barcelona, Barcelona, Spain), Amanda Foster (Fiona Stanley Hospital, Murdoch, Australia), Helmut Friess (Klinikum rechts der Isar der Technischen Universität München, Munich, Germany), Giuseppe Kito Fusai (Royal Free Hospital, London, UK), Thomas Gruenberger (Vienna South Clinicum Favoriten, Vienna, Austria), Jean Gugenheim (Centre Hospitaliere Universitaire de Nice, Nice, France), Alfredo Gugliemi (G. B. Rossi’ Hospital, University of Verona, Verona, Italy), Thilo Hackert (Universitätsklinikum Heidelberg, Heidelberg, Germany), Ho-Seong Han (Seoul National University Hospital, Ceoul, South Korea), Faisal Hanif (Bahria International Hospital, Lahore, Pakistan), Roberto Hernandez-Alejandro (University of Rochester Medical Center, Rochester, USA), Johnny C. Hong (Medical College of Wisconsin, Milwaukee, USA), Cem Ibis (Istanbul Faculty of Medicine, Istanbul, Turkey), Ilgin Özden (Istanbul Faculty of Medicine, Istanbul, Turkey), Jae-Won Joh (Samsung Medical Center, Seoul, South Korea), Juan Manuel Rico Juri (Imbanaco Medical Center, Cali, Colombia), Koo Jeong Kang (Keimyung University School of Medicine, Daegu, South Korea), Jörg Kleef (Universitätsklinikum Halle, Halle, Germany), Norihiro Kokudo (Tokyo University Hospital, Tokyo, Japan), Hauke Lang (University Hospital Mainz, Mainz, Germany), Réal Lapointe (Centre Hospitalier de l’Université de Montréal, Montreal, Canada), Kristoffer Lassen (Oslo University Hospital, Oslo, Norway), Mickael Lesurtel (Croix Rousse University Hospital, Lyon, France), Peter Lodge (St. James’s University Hospital, Leeds, UK), Rafael López-Andújar (Hospital Universitari I Politècnic La Fe, Valencia, Spain), Valerio Lucidi (Hôpital Erasme – Cliniques Universitaires de Bruxelles, Brussels, Belgium), Hugo Pinto Marques (Centro Hospitalar de Lisboa Central, Lisbon, Portugal), Oscar Mazza (Hospital Italiano de Buenos Aires, Buenos Aires, Argentina), Lucas McCormack (Hospital Alemán de Buenos Aires, Buenos Aires, Argentina), Ravi Mohanka (Global Hospital, Mumbai, India), Masato Nagino (Nagoya University Graduate School of Medicine, Nagoya, Japan), Peter Naredi (Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden), Attila Oláh (Petz Aladar Teaching Hospital, Györ, Hungary), Ronbert Padbury (Southern Adelaide Local Health Network, Adelaide, Australia), Timothy M. Pawlik (Ohio State University Wexner Medical Center, Columbus, USA), Wojciech G. Polak (Erasmus MC, University Medical Center, Rotterdam, Netherlands), Irinel Popescu (Institutul Clinic Fundeni, Bucharest, Romania), Graeme Poston (Aintree University Hospital, Liverpool, UK), Andreas A. Prachalis (King’s College, London, UK), Raaj Praseedom (Addenbrooke’s Hospital, Cambridge, UK), Johann Pratschke (University Hospital Charité, Berlin, Germany), Francois-René Pruvot (Lille University Hospital, Lille, France), Dejan Radenkovic (Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia), Jose M. Ramia Angel (Hospital General Universitario de Alicante, Alicante, Spain), Diego Ramisch (Fundación Favaloro University Hospital, Buenos Aires, Argentina), Jean Marc Régimbeau (CHU Amiens-Picardie, Amiens, France), Mohamed Rela (Dr. Rela Institute & Medical Center, Chennai, India), Inne Borel Rinkes (University Medical Center Utrecht, Utrecht, Netherlands), Ricardo Robles-Campos (Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain), Gonzalo Sapisochin (Toronto General Hospital, Toronto, Canada), Stefan Schneeberger (Universitätsklinik Innbsruck, Innsbruck, Austria), Richard Schulick (University of Colorado Anschutz Medical Campus, Denver, USA), Gregory Sergeant (Jessa Hospital, Hasselt, Belgium), Alejandro Serrablo (Miguel SErvet University Hospital, Zaragoza, Spain), Shimul A. Shah (University of Cincinnati College of Medicine, Cincinnati, USA), Shailesh V. Shrikande (Tata Memorial Hospital, Mumbai, India), Kjetil Søreide (Stavanger University Hospital, Stavanger, Norway), Georgios C. Sotiropoulos (Metropolitan Hospital, Athens, Greece), Olivier Soubrane (Hôpital Beaujon, Paris, France), Kestutis Strupas (Vilnius University Hospital, Vilnius, Lithuania), Malin Sund (Norrlands University Hospital, Umeå, Sweden), Orlando Jorge M. Torres (UDI Hospital – Rede D’Or São Luiz, São Luis, Brazil), Victor Hugo Torres-Cueva (Hospital Nacional G. Almenara Irigoyen, Lima, Peru), Guido Torzilli (Humanitas University Hospital, Milan, Italy), Christian Toso (Geneva University Hospital, Geneva, Switzerland), Go Wakabayashi (Ageo Central General Hospital, Ageo, Japan), Jens Werner (LMU Klinikum, Munich, Germany), Stephen J. Wigmore (Royal Infirmary of Edinburgh, Edinburgh, UK), Christopher L. Wolfgang (NYU Langone Health, New York, USA), Tiffany Cho-Lam Wong (University of Hong Kong-Shenzen Hospital, Hong Kong, China), Masakazu Yamamoto (Tokyo Women’s Medical University, Tokyo, Japan), Herbert Zeh (UT Southwestern Medical Center, Dallas, USA), Krzysztof Zieniewicz (Medical University of Warsaw, Warsaw, Poland).

      Supplementary data

      The following are the supplementary data to this article:

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