Editorial The goal of modern health care is to improve outcomes and reduce costs. Centralisation, defined as the reorganisation of healthcare services into fewer specialised units, is one of the common strategies. The rationale is that increasing the volume and variety of cases promotes the development of highly specialised services, increases experience and efficiency, facilitates training, limits costs and reduces clinical variability [1–3]. The notion of focussing on volume to promote specialist expertise is well established in surgery. There is a clear association between volume of surgical cases and survival, even if workload increases [1]. Obvious examples are large cardiovascular units and trauma centres. The reasons for better outcomes are multifactorial, including expert teams, a high-level infrastructure with evidence-based protocols and standardised governance processes, state-of-the-art diagnostic tests and therapies, and cost-effective purchasing (Table 1). Critical care medicine is a complex, expensive and resource intensive specialty where centralisation has also received attention. A retrospective study of >20,000 mechanically ventilated, non-surgical adult patients concluded that ICU and hospital mortality were significantly lower in high-volume hospitals [4]. The “Conventional ventilatory support versus Extracorporeal membrane oxygenation (ECMO) for Severe Adult Respiratory failure” (CESAR) trial showed that outcomes were better in all patients transferred to the specialist unit regardless of whether they received ECMO or not [5]. Neurocritical care units have been shown to improve patient outcomes and reduce mortality, resource utilisation and costs compared to district hospitals [6]. Apart from specialist-led care, rapid access to neurosurgical intervention plays a role. Finally, a review of centralised paediatric critical care in Australia revealed that the odds ratio of mortality in the UK versus Australia was 2.09 [7]. The authors estimated that 453 deaths a year in the UK could be avoided if all children requiring mechanical ventilation for >12–24 h were transferred to specialist paediatric ICUs. However, the association between volume and outcomes is not consistently seen. Data from 2812 US hospitals showed that quality of care for elderly patients with pneumonia was lower among hospitals with the highest rates of ICU admission [8]. Similarly, an analysis of > 18,000 ECMO patients revealed that mortality was higher in high-volume compared to low-volume centres [9]. Whether this represents selection bias, differences in criteria for applying ECMO or any other variation in practice is unclear. Centralisation of limited resources has other unpredictable negative effects which can be broadly categorised into factors related to the geographical distance between centres, transport, the effects on staff in non-specialist centres, and the psychological impact on the patient and their relatives. Serious in-transit critical events may occur, including equipment failure and technical problems [10–12]. A review of 5144 urgent land transports revealed that critical events occurred in approximately 1 in 15 transports [12]. Hypotension was the most common incident. An observational study of > 10,000 patients with potentially life-threatening conditions showed an association between journey distance to hospital and mortality after adjustment for age, sex, clinical category and illness severity [10]. A 10-km increase in distance was associated with a 1% absolute increase in mortality. In contrast, a Canadian retrospective case-cohort study did not find an association between duration of transport and hospital mortality [13]. Instead, a longer time spent by paramedics at the sending hospital was associated with shorter length of stay in the referring hospital. At an institutional level, centralisation may lead to a reduction in available specialists in regional centres and the closure of specialty programmes, resulting in reduced job satisfaction and staff morale [11]. Another drawback is the impact on families and relatives, together with longer travel times and increased costs. Furthermore, patients are removed from their local networks which makes it more challenging to organise

中文翻译：

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远程医疗时代重症监护服务集中化到什么程度？

社论 现代医疗保健的目标是改善结果并降低成本。集中化，定义为将医疗服务重组为较少的专业单位，是常见的策略之一。其基本原理是增加病例的数量和种类可以促进高度专业化服务的发展，增加经验和效率，促进培训，限制成本并减少临床变异性 [1-3]。专注于数量以促进专业知识的概念在外科手术中已经确立。即使工作量增加，手术病例数与生存率之间也存在明显关联 [1]。明显的例子是大型心血管病房和创伤中心。获得更好结果的原因是多方面的，包括专家团队、具有循证协议和标准化治理流程、最先进的诊断测试和治疗以及具有成本效益的采购的高级基础设施（表 1）。重症监护医学是一个复杂、昂贵且资源密集型的专业，集中化也受到了关注。一项对超过 20,000 名机械通气、非手术成年患者的回顾性研究得出结论，大容量医院的 ICU 和住院死亡率显着降低 [4]。“针对严重成人呼吸衰竭的常规通气支持与体外膜肺氧合 (ECMO)”(CESAR) 试验表明，无论是否接受 ECMO，所有转入专科病房的患者的结果都更好 [5]。与地区医院相比，神经重症监护病房已被证明可以改善患者预后并降低死亡率、资源利用率和成本 [6]。除了专家主导的护理外，快速获得神经外科干预也很重要。最后，对澳大利亚集中儿科重症监护的审查显示，英国与澳大利亚的死亡率优势比为 2.09 [7]。作者估计，如果所有需要机械通气超过 12-24 小时的儿童都转移到专科儿科重症监护病房，英国每年可以避免 453 人死亡。然而，量和结果之间的关联并不一致。来自美国 2812 家医院的数据显示，ICU 入住率最高的医院对老年肺炎患者的护理质量较低 [8]。同样，分析 > 18,000 名 ECMO 患者显示，与低容量中心相比，高容量中心的死亡率更高 [9]。这是否代表选择偏倚、应用 ECMO 标准的差异或实践中的任何其他变化尚不清楚。有限资源的集中还有其他不可预测的负面影响，这些负面影响可以大致归类为与中心之间的地理距离、交通、对非专科中心工作人员的影响以及对患者及其亲属的心理影响有关的因素。可能会发生严重的在途关键事件，包括设备故障和技术问题 [10-12]。对 5144 次紧急陆路运输的审查显示，大约 15 次运输中就有 1 次发生了危急事件 [12]。低血压是最常见的事件。一项 > 10 的观察性研究，000 名可能危及生命的患者在调整年龄、性别、临床类别和疾病严重程度后，显示到医院的路程与死亡率之间存在关联[10]。距离增加 10 公里，死亡率绝对增加 1%。相比之下，加拿大的一项回顾性病例队列研究未发现转运持续时间与住院死亡率之间存在关联[13]。相反，护理人员在派遣医院花费的时间越长，在转诊医院的住院时间就越短。在机构层面，集中化可能导致区域中心可用专家的减少和专业项目的关闭，从而降低工作满意度和员工士气[11]。另一个缺点是对家人和亲戚的影响，加上更长的旅行时间和增加的成本。此外，患者被从他们的本地网络中移除，这使得组织起来更具挑战性