Authors: Paul Chumas Tom Kenny Charles Stiller
Publish Date: 2011/03/10
Volume: 153, Issue: 6, Pages: 1231-1236
Abstract
In this issue Solheim et al 15 present data from the Norwegian Cancer Registry looking at the 5year survival for children with brain tumours in relation to centre volume and outcome As these authors indicate centralisation of services is very topical at the present time Certainly in England paediatric craniofacial services have been largely centralised for many years and there is presently a review of how best to deliver the rest of paediatric neurosurgery 14 Likewise in Holland there are discussions over centralisation of paediatric brain tumours and there has already been centralisation of craniofacial and epilepsy surgery and centralisation of paediatric neurosurgery has already begun in France 9 In countries without socialised medicine there is a move by insurance companies to seek treatment for their patients in accredited centres The driver for these changes is a desire to improve the quality of careDue to the rarity of paediatric brain tumours and the fact that paediatric neurosurgeons spend most of their time doing hydrocephalus work “adult” neurooncology surgeons might be better equipped to undertake such surgery ie the “transferable skills” component of neurosurgery is underscoredMany studies have been undertaken on this topic since the landmark paper by Luft et al 13 in 1979 which showed an inverse relationship between surgical volume and mortality These studies have shown that this relationship varies from one type of surgery to another In general the more complex the surgery the greater the improvement in outcome with increasing volume and the point of “plateauing” for both individuals and for institutions varies markedly depending on the condition being treated To the proponents of centralisation these studies confirm the intuitive belief that in surgery as in all other walks of life “practice makes perfect”Those critical of this approach argue that case volume as a proxy for quality is too imprecise and often concentrates on institutional volume when it should focus on individual surgeon volume This is understandable as institutional volume is often a proxy for resources and ability to set up an environment that allows the development of individual expertise Both individual surgeon and institutional “experience” may independently influence outcome Critics also argue that the disruption and inconvenience to the patient by centralisation is out of proportion to any potential benefits gained 10 15
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