Improving Outcomes With Subspecialization and Regionalization

Hospital and surgeon performance is being more closely scrutinized due to rising costs, increasing patient expectations, demands for greater transparency, and concerns over quality, efficiency, and safety. As neurosurgeons, we can directly improve the quality metrics being examined and also the safety and quality of care delivered. Neurosurgery has moved toward expertise and experience of both surgeons and care teams, and evidence exists that both can improve quality of care and patient satisfaction. Many studies suggest that high-volume surgeons and medical centers deliver higher quality care for patients and procedures. Experience is recognized as a key driver of individual surgical performance, giving rise to a learning curve. Since there are fewer training hours available, methods are being developed to accelerate the neurosurgical learning curve via such things as simulation training. Provider volume has been shown to have an impact on postoperative mortality, complications, and costs in neurosurgery particularly for craniotomy, transsphenoidal surgery, ventriculoperitoneal shunt operations, and carotid endarterectomy. At the hospital level, increased case volume is even more strongly associated with improved outcomes. Lastly, there is evidence that patients are more satisfied and have a favorable hospital care experience if they believe they are being cared for in a center of excellence by providers and hospitals with extensive training and experience in their particular problem area. Thus, the best available evidence would suggest that quality and safety of neurosurgical care can be improved when surgeons and hospitals focus and outcomes are improved when care is delivered by experienced high-volume providers and care teams.