Medical perspective

First, we would like to look at the medical perspective. We would contend that major biases exist in offering a specific therapy related to the referral of a patient to a specialist or the background training of the surgeon. For example, a patient with HCC is more likely to undergo a liver resection or liver transplantation, respectively, if an oncologic or transplant surgeon is or is not involved. Possibly, a bile duct stricture is more likely to undergo serial endoscopic or percutaneous dilatation rather than surgery if an interventional gastroenterologist or radiologist is the sole caregiver. On the same line, the availability of broadly trained HPB surgeons or the availability of a combined team of non transplant and transplant liver surgeons in the center will minimize biases, as all therapies are available within the center. Next, nursing staff and all ancillary caregivers dealing with a broad variety of medical and surgical liver diseases will likewise gain high competence, and thereby enhance quality of care. The concept of a clinical nurse makes full sense in a center setting. Clinical nurses work very close to the physicians by coordinating patient care, particularly in an interdisciplinary outpatient facility. Clinical nurses play also a pivotal role in securing adequate outpatient preoperative work-up. Finally, we would like to postulate that the accessibility to the whole spectrum of HPB diseases enhances satisfaction and motivation of the personnel involved in the care of this special population.

Patient perspective

Next, centers may offer the greatest value from a patient perspective. Patients have a rising demand for an increasing knowledge of the best care, and more and more patients look for various therapeutic options. A center proposing the availability of comprehensive and competent specialists may appear very attractive by providing the best evidence that the most suitable treatment will be offered for a specific problem regardless of the expertise of a single individual. Additionally, patients travelling long distances in the outpatient facilities of a center will benefit from a multidisciplinary expert evaluation, enabling them to make a 'one stop' informed decision. On the same token, referring physicians greatly appreciate interdisciplinary recommendations, and can refer patients to 'the center' without having to decide whether she/he should send them to an oncologist, a hepatologist, a general or a transplantation surgeon.

Department or division chief perspective

There could be a legitimate concern from department or division chiefs that they may loose the control of an important area in their field. This could also be felt as a loss of income or a failure to train residents or young staff members. These concerns must be addressed carefully with the aim of benefits at all levels in the hospital. For example, residents should get proper training through fixed rotations within the center. In their training, they will be exposed to conditions traditionally belonging to other departments and locations. For example, in the department of surgery and internal medicine in Zurich, residents rotate in the center for at least 6 months, and young staff members in general surgery and internal medicine (Oberarzt) also rotate on a 3 monthly basis. A transparent 'cahier de charges' is followed to enable comprehensive training of the respective specialized fellows as well as appropriate exposure to the field for the rotating physicians. Finally, department and division chiefs are responsible in academic institutions to foster research and innovative therapy. From this angle a center setting represents an ideal platform, as patients are centrally located and the identification of cases qualifying for specific studies and protocols are optimised. Additionally, through an increased volume of patients, contributions toward research and innovative therapies are more likely to occur. Studies must be coordinated through the availability of study nurses fully dedicated to the center and comprehensive database.

Hospital perspective

Here, centers might be seen as only adding to the complexity of the academic structure, as the hospital leadership must deal with departments and inter-departmental structures. The challenge set out for the hospital leadership is to selectively enable the development of centers while preserving the department responsible for the training of specific areas of medicine. Here we present the structure of the Swiss HPB center to illustrate a possible mechanism of development and control. Themain incentive for the hospital leadership might be the putative better care and possibility to attract more patients as well as to decrease the cost through a better delivery of care and shorter hospital stay [1]. In conclusion, we believe that a center approach offers the best setting for the optimal treatment of patients with complex HPB diseases. To enable accountability and credibility, the term center should be applied only on the basis of well-defined criteria, most likely being limited to academic institutions due to the important task of performing research and offering innovative treatments. We are convinced that this interdisciplinary model of delivering health care will become standard and will be recognized as the best way to optimize care in a specialized field of medicine.

[1] Journal of Hepatology 44 (2006): 639-662

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