Anticipated effects of centralising complex gastrointestinal surgery in a rural area in Germany - perspective of health professionals: a qualitative study

Abstract

Background: For centralising complex gastrointestinal surgery, minimum volume standards have been implemented in Germany. To increase centralisation and thus patient safety, the minimum volume standards for complex oesophageal and pancreatic surgery were set to rise in 2023 and 2025, respectively. Hospitals that do not meet these minimum volume standards will lose authorisation to perform these surgical procedures and are not eligible for reimbursement. Volume-outcome studies focus on patient outcomes at high or low hospital volumes. Other impacts on the service, professionals (e.g. medical training) are not covered. Therefore, the study aims to add health care professionals’ perspectives on centralisation in Brandenburg, a sparsely populated federal state in the East of Germany. It investigates what effects they anticipate and aims to identify potential solutions. Methods: We conducted 19 semi-structured expert interviews with regional health care professionals (diverse professions and specialisations, hospital and outpatient) and patient representatives between 07/2022 and 01/2023. Interviews were transcribed and analysed according to qualitative content analysis. Results: Healthcare professionals and patient representatives anticipated a trend towards consolidating complex oesophageal and pancreatic surgery into a few number of specialised clinics for surgical procedures (specialised centres). Conversely, there could be a rise in the number of clinics no longer offering these procedures, but instead focusing on serving as regional centres to provide general care, diagnostics, and post-discharge follow-ups for oesophageal and pancreatic patients. This redistribution might also have unintended effects on treatments beyond the scope of the minimum volume standards and could influence medical training programs and the recruitment of medical staff. Fostering structural collaboration among hospitals was suggested as a solution. Conclusions: The results indicate that centralisation could not only influence outcome quality and accessibility, but could also lead to a range of other consequences. Especially in sparsely populated areas, meeting new minimum volume standards proves to be demanding in terms of both patients accessing complex gastrointestinal surgery and facilitating effective communication between specialised centres and regional centres or local healthcare providers.