高風險手術集中化政策之探討

A review of how centralization policies affect high-risk surgeries

探討醫療照護服務量與照護結果關係的研究(volume-outcome research)發展已相當成熟，也因為有大量的實證證據顯示在某些特定手術處置的服務量與不良照護結果呈現顯著的負向關係，許多國家的學者及政策制定者紛紛提出手術集中化的相關衛生政策，期望將病人導引至高服務量或高專業性的醫療機構就醫，使病人獲得最佳的照護並改善整體照護結果。本文針對手術集中化政策發展歷程、各國實施策略、實施後影響及對於我國的啟示作為探討及文獻回顧的主軸，期望能作為國內制訂改善高風險手術照護品質政策之借鏡。經由文獻探討發現，手術處置集中化政策通常著重在高風險或罕見的手術（如：心臟手術處置、癌症手術或兒童相關手術處置），政策的介入方式主要分成兩種：「設定最低服務量閾值(Minimum volume standards)」及「指定轉診中心(Designated referral centers)」。文獻指出，多數國家實施手術集中化後對於照護結果確實有正面之影響，但同時也有降低就醫可近性之疑慮。我們建議台灣未來針對提升手術處置照護品質制訂相關政策時，可以將集中化政策納入政策規劃之中，並且進一步評估手術集中化後可能帶來之成效。

A great deal of evidence from volume-outcome studies has indicated that surgical volume is negatively associated with adverse surgery outcomes; therefore, researchers and policymakers in many countries have advocated for the Centralization of certain surgical procedures. Centralization should improve outcomes and increase the level of care by ensuring that patients are referred to high-quality providers. This article reviews (1) the development of centralization policies and (2) centralization strategies applied in the United States, Canada, and countries in Europe and Asia. We also discuss the impacts that centralization policies have had on surgery outcomes as well as implications for the future of centralization policies in Taiwan. The vast majority of centralization policies focus on rare or high-risk surgeries, such as those performed to treat heart problems or cancer. There are currently two types of intervention: setting minimum volume standards and selecting designated referral centers. A review of relevant literature showed that, for most countries, centralization policies led to better healthcare outcomes; however, some studies noted that centralization can reduce accessibility to care. Nonetheless, we suggest that Taiwan consider adopting centralization as a policy to improve the quality of healthcare. However, future research will be required to estimate the effectiveness of centralization on high-risk surgeries.