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Do we need a center approach to treat patients with liver diseases?

2006; Elsevier BV; Volume: 44; Issue: 4 Linguagem: Inglês

10.1016/j.jhep.2006.01.015

1600-0641

Pierre‐Alain Clavien, Beat Müllhaupt, Bernhard C. Pestalozzi,

Healthcare Systems and Technology

It remains controversial which setting is best for the delivery of care in a specific area of medicine such as liver diseases. Should care be given through integrated interdisciplinary units including in- and outpatient facilities or through traditional departmental structures? In many instances choices are made on the basis of political and economic considerations often driven by department or division chiefs, and personal interest. The availability of data on the quality of care and cost may eventually influence how hospitals will organize the delivery of care and allocate resources. In this review we would like to make the case for a center approach, respecting the various components of medical specialties. First, we will present the concept of a center including available scientific evidence favoring such an approach. Then, we will attempt to evaluate centers from different perspectives, including the physician, patient, department and division chiefs, and hospital perspectives. The evaluation of cost is assessed in a separate article in this forum by F. Delcò [1]. The Oxford dictionary (Oxford, English Dictionary, Oxford University Press, 2005) defines centre (Greek: kemtron ‘sharp point’) as ‘a point from which something spreads or to which something is directed’. The American Heritage Dictionary describes it as ‘a place where a particular activity or service is concentrated’. Although some liver treatment units have branded themselves as true centers, many are virtual centers, where the facilities for in- and outpatient care are not commonly shared. In these cases the terminology is used to emphasize, that different groups of physicians and surgeons care for the same group of patients although in different locations and is mostly misused to serve the purpose of marketing. In Table 1, we are proposing what we believe are minimal criteria to qualify for the term ‘center’. It is paramount to have centralized facilities offering common nursing and paramedical staff. A list of diseases should be available to allocate patients to the various specialties within the center. In Table 2 we provide as an example our algorithm in the Swiss Hepato-Pancreatico-Biliary (HPB) center. Liver transplantation patients should be included in this center, unless a transplantation center with the same structure is available.Table 1Minimal criteria to qualify as a ‘liver’ centerInterdisciplinary, centrally located inpatient facility, including beds for surgery, hepatology/gastroenterology and oncologyInterdisciplinary, centrally located outpatient facility with joint consultations, including surgery, hepatology/gastroenterology and oncologyDedicated experts available 24 h a dayNursing staff dedicated to patients with liver diseases including clinical nursesSpecialized training programs in HPB surgery and hepatology/gastroenterology, and possibly oncology (e.g. formal accredited fellowship)Research infrastucture to enable clinical trials and basic research, including availability of comprehensive database and study nurses dedicated to the center Open table in a new tab Table 2Repartition of patients based on diagnosis among specialties in the Swiss HPB centerGastroeterology–Hepatology Hepatitis (all forms) Cirrhosis (all forms including decompensation, ascites, portal hypertensive bleeding, hepatic encephalopathy, hepato-renal syndrome, spontaneaous bacterial peritonitis) Work-up of liver transplantation patients (mandatory consultation by transplant surgeon) Complications in patients on the waiting list (mandatory consultation by transplant surgeon) Management of patients on the waiting list (e.g. chemo-embolization of HCC) (mandatory consultation by transplant surgeon) Endoscopic HPB procedures requiring hospitalisation Percutaneous and chemoembolization in patients with poor liver reserve (e.g. child B/C cirrhosis)Oncology Adjuvant or neoadjuvant chemotherapy of HPB malignancies Regional chemotherapy using hepatic arterial infusion and pump for primary or secondary liver tumors Complications related to oncologic treatments PTLD or other post transplant non resectable tumorsSurgery All surgeries for HPB diseases (except simple cholecystectomy) Re-hospitalisation for complications related to HPB surgery All abdominal pain related to HPB diseases (e.g. pancreatitis, cholangitis) (mandatory consultation by gastroenterology and hepatology, if treated non operatively) Work-up of donor for living related transplantation Post liver and pancreas transplantation complications (mandatory consultation by gastroenterology/hepatology) Percutaneous and chemoembolization in patients with good liver reserve (e.g. child A cirrhosis) Open table in a new tab Several studies have demonstrated that patient outcome is better in specialized high volume centers [[2]Birkmeyer J.D. Stukel T.A. Siewers A.E. Goodney P.P. Wennberg D.E. Lucas F.L. Surgeon volume and operative mortality in the United States.N Engl J Med. 2003; 349: 2117-2127Crossref PubMed Scopus (2545) Google Scholar]. As an example, a recent study showed that the mortality rate after liver resection for hepatocellular carcinoma is lower in specialized high volume compared to low volume units [[3]Glasgow R.E. Showstack J.A. Katz P.P. Corvera C.U. Warren R.S. Mulvihill S.J. The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma.Arch Surg. 1999; 134: 30-35Crossref PubMed Scopus (166) Google Scholar]. Similarly, it could be shown that specialized care for patients with decompensated liver cirrhosis improves outcome compared to patient management by generalists [[4]Bini E.J. Weinshel E.H. Generoso R. Salman L. Dahr G. Pena-Sing I. et al.Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis.Hepatology. 2001; 34: 1089-1095Crossref PubMed Scopus (57) Google Scholar]. A recently published study even demonstrated a superior long-term survival for pancreatic and hepatic resections at high-volume centers [[5]Fong Y. Gonen M. Rubin D. Radzyner M. Brennan M.F. Long-term survival is superior after resection for cancer in high-volume centers.Ann Surg. 2005; 242: 540-544PubMed Google Scholar]. These data provide compelling evidence that specialized care for patients with liver disease improves outcome, but it does not yet prove that an interdisciplinary approach as outlined above significantly impacts on patient management and outcome. These data are currently still lacking. There is, however, indirect evidence from other medical fields that an integrated interdisciplinary approach improves patient care. Several randomized controlled trials could show that an interdisciplinary approach in stroke units with specialized medical care, nursing and rehabilitation programs positively affects outcome of stroke patients [6Langhorne P. Dennis M.S. Stroke units: the next 10 years.Lancet. 2004; 363: 834-835Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 7Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev; 2002:CD000197.Google Scholar]. Also the care of patients with chronic heart failure is improved by a multidisciplinary team approach involving cardiologists, nephrologists, pneumologists and endocrinologists, as well as nutritionists and exercise physiologists [[8]Akosah K.O. Schaper A.M. Havlik P. Barnhart S. Devine S. Improving care for patients with chronic heart failure in the community: the importance of a disease management program.Chest. 2002; 122: 906-912Crossref PubMed Scopus (49) Google Scholar]. These data provide the basis to also treat patients with liver, bile duct and pancreatic diseases in an interdisciplinary center with the aim to further assess the impact of such an approach on patient outcome and satisfaction. First, we would like to look at the medical perspective. We would contend that major biases exist in offering a specific therapy related to the referral of a patient to a specialist or the background training of the surgeon. For example, a patient with HCC is more likely to undergo a liver resection or liver transplantation, respectively, if an oncologic or transplant surgeon is or is not involved. Possibly, a bile duct stricture is more likely to undergo serial endoscopic or percutaneous dilatation rather than surgery if an interventional gastroenterologist or radiologist is the sole caregiver. On the same line, the availability of broadly trained HPB surgeons [[9]Belghiti J. Who should perform liver transplantation? Should that be the transplant surgeon, the hepatobiliary surgeon, or the general surgeon? Part II: The Hepatobiliary Surgeon..J Hepatol. 2006; 44: 649-651Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] or the availability of a combined team of non transplant and transplant liver surgeons in the center will minimize biases, as all therapies are available within the center. Next, nursing staff and all ancillary caregivers dealing with a broad variety of medical and surgical liver diseases will likewise gain high competence, and thereby enhance quality of care. The concept of a clinical nurse makes full sense in a center setting. Clinical nurses work very close to the physicians by coordinating patient care, particularly in an interdisciplinary outpatient facility. Clinical nurses play also a pivotal role in securing adequate outpatient preoperative work-up. Finally, we would like to postulate that the accessibility to the whole spectrum of HPB diseases enhances satisfaction and motivation of the personnel involved in the care of this special population. Next, centers may offer the greatest value from a patient perspective. Patients have a rising demand for an increasing knowledge of the best care, and more and more patients look for various therapeutic options. A center proposing the availability of comprehensive and competent specialists may appear very attractive by providing the best evidence that the most suitable treatment will be offered for a specific problem regardless of the expertise of a single individual. Additionally, patients travelling long distances in the outpatient facilities of a center will benefit from a multidisciplinary expert evaluation, enabling them to make a ‘one stop’ informed decision. On the same token, referring physicians greatly appreciate interdisciplinary recommendations, and can refer patients to ‘the center’ without having to decide whether she/he should send them to an oncologist, a hepatologist, a general or a transplantation surgeon. There could be a legitimate concern from department or division chiefs that they may loose the control of an important area in their field. This could also be felt as a loss of income or a failure to train residents or young staff members [[10]Tuttle-Newhall J.E. Diehl A.M. What impact does a specialized center for transplantation and hepatobiliary disease have on post-graduate resident training of gastroenterologists and surgeons?.J Hepatol. 2006; 44: 659-662Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. These concerns must be addressed carefully with the aim of benefits at all levels in the hospital. For example, residents should get proper training through fixed rotations within the center. In their training, they will be exposed to conditions traditionally belonging to other departments and locations. For example, in the department of surgery and internal medicine in Zurich, residents rotate in the center for at least 6 months, and young staff members in general surgery and internal medicine (Oberarzt) also rotate on a 3 monthly basis. A transparent ‘cahier de charges’ is followed to enable comprehensive training of the respective specialized fellows as well as appropriate exposure to the field for the rotating physicians. Finally, department and division chiefs are responsible in academic institutions to foster research and innovative therapy. From this angle a center setting represents an ideal platform, as patients are centrally located and the identification of cases qualifying for specific studies and protocols are optimised. Additionally, through an increased volume of patients, contributions toward research and innovative therapies are more likely to occur. Studies must be coordinated through the availability of study nurses fully dedicated to the center and comprehensive database. Here, centers might be seen as only adding to the complexity of the academic structure, as the hospital leadership must deal with departments and inter-departmental structures. The challenge set out for the hospital leadership is to selectively enable the development of centers while preserving the department responsible for the training of specific areas of medicine. In Fig. 1 we present the structure of the Swiss HPB center to illustrate a possible mechanism of development and control. The main incentive for the hospital leadership might be the putative better care and possibility to attract more patients as well as to decrease the cost through a better delivery of care and shorter hospital stay [[1]Delcò F. Muller M.J. Does a liver center make sense from a cost perspective?.J Hepatol. 2006; 44: 642-646Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. In conclusion, we believe that a center approach offers the best setting for the optimal treatment of patients with complex HPB diseases. To enable accountability and credibility, the term center should be applied only on the basis of well-defined criteria, most likely being limited to academic institutions due to the important task of performing research and offering innovative treatments. We are convinced that this interdisciplinary model of delivering health care will become standard and will be recognized as the best way to optimize care in a specialized field of medicine.