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AANS Neurosurgeon | Volume 28, Number 1, 2019

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Counterpoint: Keep it Close to Home

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Editor’s Note: To read another perspective on regionalization of care, read “Point: Regionalization of Emergency Neurosurgical Care Improves Patient Outcomes.”

We exist in an era of increasing demand for fiscal restraint with concurrent pressure for quality and expertise. The arguments for centralized versus local control and the best interests of the populace are as old as civilization itself. As applied to the delivery of neurosurgical care, you have the large academic centers and development of proclaimed centers of excellence on one hand, and community- based surgeons on the other. Putting ego aside, at the heart of any questions of delivery of health care is the balance that must be achieved between quality of care, expertise, timely access and the patient and family experience. To use an analogy, although most of us would prefer to be transported in a Ferrari or Maserati, it would be an impractical and expensive luxury to use for your daily commute, errands or family vacation.

What is Meant by ”Access?”
One argument put forward by proponents of a regionalized system of care is the vague, poorly defined concept of “improved access.” For me, this term incorporates two separate qualities. The first element is temporal. For patients, their families, primary-care physicians or other referral sources, obtaining vital answers and guidance with respect to a frightening new diagnosis or complex pathology is paramount.

The second element involves clarification of what in particular a patient needs “access” to.  This can mean many things, such as diagnostic tests and treatment information, an expert evaluation (physical examination and clinical assessment), surgical intervention, clinical trials or follow-up care, to state just a few examples. I cannot agree in this light that many of these divergent, but basic elements are accomplished better, and in a more-timely fashion in a larger regional center, especially when there is often a burden of travel and additional personal expenses for patients and their families under already stressful circumstances.

Defining an Elusive Term: “Better Care”
The next key point to evaluate is the contention that “better care” is delivered in regionalized centers of excellence. Once again, I caution that this vague term must be considered carefully for the broad range of its implied meaning. At a very fundamental level, to argue that regional centers deliver better care is to suggest that the knowledge and skills of community and non-regionalized specialists are lesser or inadequate for the vast majority of situations that patients seek our care. 

This argument strikes at the very underpinning of our training, examinations, credentialing, CME and professional licensing principles. Others would argue on the basis of outcomes. For example, if you look at surgical volumes as a benchmark, it is probably more true that the non-regionalized, community based surgeon is performing far more cases than the regionalized “expert” who also has the burden of travel, lecturing, administration and research to contend with.

Patients in a non-regionalized setting are more likely, in my view, to achieve access to a clinical trial that is more suited to their particular pathology than to be sequestered into the local academic center “pet project”. It is also very important for us to collectively evaluate the psychosocial impact on our patients and their families when we use the media and social media to advocate for regional centers of excellence.

I consistently see patients express anxiety, confusion and even distrust as to whether they are getting “the best care”. Many families incur substantial financial strain in order to chase this elusive “best care”, which is in many instances inappropriate. Furthermore, the under-acknowledged consequences of travel for care is the isolation it creates for patients from their friends, extended family and community of support. 

Finally, and of extreme importance, is the anxiety, frustration and fear that arises with complications once the patient has returned home and is far away from their “expert”. What is far more important in all of these discussions is the integrity of all of us as neurosurgeons, regardless of our situation and location, as we advocate for our patients. We must be honest about our skills and get the important, rare and challenging cases such as complex arteriovenous malformations, craniopharyngiomas, hypothalamic hamartomas and spinal deformities to the right people and settings.

It’s Time to Redirect Our Discussion and Energies
It is my opinion that we should shift our focus away from the relatively nebulous debate of regionalized versus non-regionalized care. Both are absolutely necessary. We must be honest about the fact that probably less than five percent of our patients truly need a center of excellence for rare or challenging pathology. We must be very cautious of an Orwellian position that “some are more equal than others” and ego-driven motivation.

What is a much more relevant dialogue, is how we evolve from here as a professional community. How do we engage all our professional colleagues with education, skills and up-to-date knowledge acquisition? How do we create collaboration and facilitate broad understanding and access to meaningful trials such as the pivotal paradigm shift to adaptive research initiatives like I Spy2, GBM-agile and LOGLIO?  How do we navigate through new engineering and techniques to validate them and then achieve affordable, broad access to meaningful technology? 

These are the issues that should inform our discussions and focus our collective energies.

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