Measures to Achieve Quality in Minimally Invasive Hepato-Pancreato-Biliary (HPB) Surgery

Abstract

Minimally invasive techniques in hepato-pancreato-biliary (HPB) surgery have been increasingly adopted over the last decade, facilitated by the guidance of several international consensus meetings and statements. Increasing evidence has shown that appropriately applied minimally invasive surgery (MIS), utilizing laparoscopic and robotic platforms, improves perioperative outcomes without sacrificing safety or oncological efficacy. The accelerating global dissemination of complex MIS approaches to the subspecialized practice of HPB surgery presents challenges to the volume-outcome quality paradigm that has predominated the field. In this context, additional measures of the quality of care applicable to broader populations and settings are required. CHALLENGES TO HOSPITAL PROCEDURAL VOLUME AS A QUALITY MEASURE The Donabedian paradigm of evaluating the quality of healthcare outlines 3 assessment domains: structure, process, and outcome. Many studies on the quality of surgical care have concentrated on the variation in hospital volumes and associated differences in outcomes. The focus on the structural domain of hospital volume has led to the centralization of hepatic and pancreatic surgery. However, equipoise still exists regarding the absolute numbers and types of cases a center must perform to maximize outcomes. Almost half of the advanced economies (19 of 40) classified by the International Monetary Fund (Figure 1) have a population of less than 6 million,1 which is less than the population of New York City, London, Seoul, or Tokyo. In such countries, the absolute number of patients indicated for complex HPB surgery is low by global standards, and those who receive MIS are even fewer. Even in more populous countries, the number of complex HPB procedures performed by most hospitals is small, despite efforts at regionalization and implementation of volume thresholds. In the United States of America, over 3 quarters (77%) of pancreatectomies for cancer occurred at intermediate or low volume Commission on Cancer facilities,2 and the proportion of complex HPB surgical procedures undertaken via an MIS approach is low.3 In Italy, the increasing demand for MIS has resulted in laparoscopic liver resection proliferating in smaller volume centers throughout the country.4FIGURE 1.: Advanced economies as classified by the International Monetary Fund.1 Orange: population greater than six million. Blue: population less than six million. (Adapted from Wikimedia Commons contributors. File:BlankMap-World.svg [Wikimedia Commons, the free media repository website]. March 13, 2022. Available at https://commons.wikimedia.org/w/index.php?title=File:BlankMap-World.svg&oldid=637937980. Accessed July 21, 2022).In the specific case of the authors’ country, Aotearoa/New Zealand has a land size similar to the state of Colorado, but due to its geographic distribution, to travel from the northernmost city to its southernmost is akin to travelling from New York City to Orlando, Florida—crossing 9 different states. As an example of volume, the total national number of pancreatectomies has remained relatively stable at around 150 cases (90 pancreaticoduodenectomies and 60 distal pancreatectomies) per year for the last 10 years.5 Our population has significant health literacy and consistently high expectations of the universally available, publicly funded health system. Consequently, centralization and other methods solely focused on increasing individual hospital procedural volume as a quality improvement initiative may not be feasible in certain jurisdictions, such as countries with small populations, sizeable geographic separation, and high community expectations. There is also evidence that centralization disproportionately affects more vulnerable populations, increasing barriers to receiving care and potentially perpetuating inequity.6 There is growing recognition that absolute procedural numbers are likely a proxy for other structural and process elements