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AANS Neurosurgeon | Volume 28, Number 2, 2019

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Point: Regionalization of Emergency Neurosurgical Care Improves Patient Outcomes

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Editor’s Note: To read another perspective on regionalization of care, read “Counterpoint: Keep it Close to Home.”

Nearly a decade ago, the Institute of Medicine (IOM) issued a landmark report, Hospital Based Emergency Care: At the Breaking Point (1). The 2006 report highlighted the fragmented and variable nature of care received by over 100 million patients in emergency rooms across the U.S. The IOM called for greater regionalization of care, including better communication and coordination among emergency responders, hospitals and physicians to help achieve more timely access to care and better patient outcomes. Notable attention was paid to uneven rates of emergency access to on-call specialists, including neurosurgeons.

The Volume-Outcome Relationship
Over the past 10 years and beyond, within most surgical subspecialties, a prevailing consensus has coalesced around the volume-outcome relationship; namely, the more operations a surgeon performs, the better the expected patient outcomes. Such findings validate numerous single-surgeon series highlighting the learning curve in performing novel or complex procedures, and they parallel findings extending out to the hospital and system level. These volume-outcome results have served as a major impetus to centralize care in high-volume regional centers of excellence. These centers often need to achieve specified patient benchmarks (e.g. low 30-day mortality) as well as possess certain facilities (e.g. a neuro-intensive care unit) and personnel (e.g. an on-call intensivist) in order to meet criteria for inclusion as a center. An extension of this policy-oriented work has focused on regionalization of care, which concerns itself with the coordination of pre-hospital emergency care and triage within specified geographic catchall regions. 

Federal, state and local funding has been used to develop emergency infrastructure in regionalized networks throughout the U.S., particularly as related to trauma. Perhaps the best example of such coordinated effort has been the Maryland Trauma Center Network, where state-wide funding has defined catchall areas throughout the state with patients funneled to nine adult trauma centers, two pediatric trauma centers or five specialty referral centers, including neurotrauma, depending on their geographic location and type of injury. There are 11 helicopters stationed at seven pre-defined locations throughout the state to help shuttle patients to pre-specified centers if ground transportation is anticipated to be lengthy.

Additionally, the Maryland Trauma Physician Services Fund was established in 2003 to help stabilize this trauma system by ensuring adequate physician coverage and reimbursement for statewide trauma. In 2010, a similar though smaller trauma network was established in the Midwest, namely the Northern Ohio Trauma System (NOTS). Recent data from NOTS demonstrated that over the two years following its inception, there was a 24-percent decrease in mortality of traumatic brain injury (TBI) patients relative to the two years preceding its inception (2). This finding was hypothesized to be a result of better coordinated regional care and triage, although additional prospective studies are needed to validate this conclusion.

Shaping the Future of Health Care
In truth, the primary arguments in support of regionalization are intuitive as well as practical in nature: when high-volume centers staffed by experienced providers treat triaged patients in an expedited and coordinated fashion, better outcomes are achieved. In addition, some super-specialized care, such as deployment of precision medicine strategies to use tumor genomics to mathematically model cancer to individualize cancer care for glioblastoma multiforme (GBM) patients or running immunotherapy clinical trials for GBM, practically speaking, would be very hard to decentralize. Indeed, a recent consensus session of the Congress of Neurological Surgeons (CNS) found that 85 percent of surveyed neurosurgeons were in favor of regionalized emergency care (3).

Meaningful movements toward greater centralization beyond the realm of trauma surgery will require cooperation between specialists, patient advocacy groups and hospital administrators, as well as the political will and broad financial support to develop and maintain the necessary infrastructure and training to keep this model of care viable and effective. Nearly a decade after the IOM report, we owe it to our future patients to help shape health care in a way that gives them the greatest chance at achieving the best outcomes.

References
1. Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health Care System. Hospital Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press; June 2006.

2. Kelly ML, Banerjee A, Nowak M, Steinmetz M, Claridge JA. Decreased mortality in traumatic brain injury following regionalization across hospital systems. J Trauma Acute Care Surg. 2015 Apr;78(4):715-20.

3. Byrne RW, Bagan BT, Bingaman W, Anderson VC, Selden NR. Emergency neurosurgical care solutions: acute care surgery, regionalization, and the neurosurgeon: results of the 2008 CNS consensus session. Neurosurgery. 2011 Apr;68(4):1063-7.

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