OBJECTIVES: To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations. BACKGROUND/METHODS: Most countries are increasingly forced to maintain quality medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents. RESULTS: Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education. CONCLUSION/RECOMMENDATIONS: There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.

Department of Clinical Medicine University of Bergen Department of Gastrointestinal Surgery Stavanger University Hospital Stavanger Norway

Department of General and Digestive Surgery Bellvitge University Hospital University of Barcelona and IDIBELL Barcelona Spain

Department of General and Visceral Surgery Frankfurt University Hospital and Clinics Frankfurt am Main Germany

Department of General Transplant and Liver Surgery Medical University of Warsaw Faculty of Electronics and Information Technology Warsaw University of Technology Warsaw Poland

Department of HPB and Transplant Surgery Hospital Curry Cabral Lisboa Portugal

Department of Plastic Surgery Helsinki University Hospital Helsinki Finland

Department of Surgery 2nd Medical Faculty Charles University and Central Military Hospital Prague Czech Republic

Department of Surgery and Transplantation University Hospital Bologna Bologna Italy

Department of Surgery and Transplantation University Hospital of Zurich Zurich Switzerland

Department of Surgery at UZ Gent Gent Belgium

Department of Surgery Helsinki University Helsinki Finland

Department of Surgery Hôpital Beaujon Université Paris Nord Val de Seine Clichy France

Department of Surgery Laiko General Hospital of Athens Athens Greece

Department of Surgery McGill University McGill University Health Centre Montreal Quebec Canada

Department of Surgery Medical University of Vienna Vienna Austria

Department of Surgery Sahlgrenska University Hospital Gothenburg Sweden

Department of Surgery University Medical Center Utrecht Utrecht the Netherlands

Department of Thoracic Surgery University Hospital Leuven Leuven Belgium

Division of Minimally Invasive Surgery University of Michigan Health Systems Ann Arbor MI

General Surgery and Liver Transplantation Fundeni Clinical Institute Bucharest Romania

HPB and Transplant Unit St James's University Hospital Leeds UK

Section for Surgical Pathophysiology The Juliane Marie Centre Copenhagen Denmark

Surgical Department Petz Aladár County Teaching Hospital Györ Hungary

Surgical Oncology Program Liver and Pancreas Unit The Ottawa Hospital University of Ottawa Ottawa Ontario Canada

Trinity Centre for Health Sciences St James's Hospital Clinical Surgery Dublin Ireland

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