The road to regionalization in congenital heart surgery: a narrative review

Objective: This review article will highlight the current state of pediatric cardiac surgical care delivery in the United States (U.S.), examine the data that supports regionalization along with the potential drawbacks of such a system, specifically with regard to how these efforts might impact socioeconomic status (SES) and racial/ethnic disparities. We will also discuss global implications for regionalization, and whether emerging healthcare delivery systems should be based on this concept. Background: Concentrating pediatric cardiac surgical care to regional high-volume specialty centers would likely improve patient survival and promote more efficient use of resources. Recent initiatives in two states have proposed minimum volume requirements for pediatric cardiac surgery programs. However, implemented poorly, such a change could exacerbate accessibility issues and would face obstacles in the U.S., including regulatory constraints, antitrust actions and balancing of financial incentives. Real-world studies, as well as theoretical models, indicate that patients undergoing pediatric cardiac surgery at high-quality centers with larger volumes fare better. Other paradigms for care delivery exist across the U.S., including healthcare satellite systems and tiered systems. These alternative models that consist of a large hospital that participates in specialty care for neighboring associated small hospitals or designate certain centers (usually higher tiered centers) to provide a cache of services. Both models usually require financial alignment, geographic proximity among the participants, and extensive care coordination that defines thresholds for referral of care to the larger hospital. Methods: A comprehensive narrative review on congenital heart surgery (CHS), regionalization, and healthcare policy efforts was carried out. PubMed was used to search articles published on the topic in the past 20 years. The search yielded 944 studies, of which 38 satisfied the inclusion criteria for narrative review. Conclusions: There are no easy answers to the complex questions of whether and how pediatric cardiac surgery should be regionalized to specialty centers in the U.S. or on an international level. Nevertheless, although evidence supports centralization to save lives and lower costs, implementation is challenged by financial and social reasons. Existing centralized services, as exist for organ transplantation and transcatheter valve replacement, demonstrate that regionalization makes sense for complex interventions.