Commentary: Regionalization = Excellence

Abstract

As I read the manuscript submitted by Dr Ramgren and colleagues from Lund, Sweden, I noted that their review of infants with atrioventricular septal defect (AVSD) began in 1993. 1 Given my interest in the regionalization of care, I recognized that was exactly 1 year after Sweden centralized the care of children with congenital heart disease from 4 to 2 dedicated centers. 2 Suddenly this review became not simply another article on surgical techniques and results, but possibly an outcomes analysis of the regionalization strategy embarked upon in 1992. At that time Sweden (population 10 million) centralized congenital heart surgery from 4 centers to 2 centers; 1 in Lund and 1 in G€ oteborg. What was the effect of this decision on children born with an AVSD and treated in Lund, Sweden?What I found was that the outcomes for patients with an AVSD at this center clearly supports the hypothesis that regionalization of care improves results. The results were superb! Their nearly 30-year experience with more than 300 patients with an AVSD resulted in an operative mortality of only 1%. The freedom from left atrioventricular valve-related reoperation was remarkable at 93% at 20 years. Finally, there was no difference in outcomes between young infants (mean age, 1.6 months) versus older infants (mean age, 5.1 months). Those are truly some of the finest results I have ever seen reported for AVSD repair!The authors themselves point out that continuous improvements in pre-and postoperative management secondary to Sweden's centralization strategy facilitated the improved clinical outcomes. The authors note that the 1992 centralization of Sweden's pediatric cardiac surgery centers not only provided sufficient patient volumes but also facilitated recruitment of highly trained staff at all levels of support to ensure the highest possible standards of care.

Patient‐reported barriers to prenatal diagnosis of congenital heart defects: A mixed‐methods study

“…We find that barriers such as distance to care traverse patient, hospital and societal levels, where patient‐level barriers such as access to transportation, and societal‐level barriers such as receiving time off work both impact the ability to obtain prenatal diagnosis. This further supports that subsidizing travel costs alone does not overcome distance barriers 26,27 . Our work highlights the importance of testing multilevel interventions.…”

“…This further supports that subsidizing travel costs alone does not overcome distance barriers. 26,27 Our work highlights the importance of testing multilevel interventions.…”

“…This finding suggests that subsidized costs for travel or ridesharing may not overcome distance barriers without other support or programming. 26,27 As of January 2023, there is no federal paid sick leave policy for employers to pay for short-term illness or travel time for medical care; only 15 states provide paid sick leave to eligible employees. 41 the great arteries, tetralogy of Fallot, and total anomalous pulmonary venous return remain elusive diagnoses.…”

“…Our analysis suggests that distance barriers are highly related to the opportunity cost of foregone work. This finding suggests that subsidized costs for travel or ridesharing may not overcome distance barriers without other support or programming 26,27 . As of January 2023, there is no federal paid sick leave policy for employers to pay for short‐term illness or travel time for medical care; only 15 states provide paid sick leave to eligible employees 41 .…”

Reply: Regionalization: One genotype, multiple phenotypes

“…This discussion began with my recognition that the results of atrioventricular septal defect repair in Sweden were dramatically improved when care was regionalized from 4 centers to 2 centers. 2 Vervoort 3 expanded on this concept and encouraged us to focus on regionalization of care for these children on a global level. He pointed out the confounding issues of revenue, pride, and politics.…”