Conceptualizing the Organization of Surgical Services; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries”

Document Type : Commentary


Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada


According to Iverson and colleagues’ thoughtful analysis, decisions to decentralize or regionalize surgical services must take into account contextual realities that may impede the safe execution of certain delivery models in lowand middle-income countries (LMICs), and should be governed by procedure-related considerations (specifically, volume, patient acuity, and procedure complexity). This commentary suggests that, by shifting attention to the mechanisms whereby (de)centralization may exert beneficial impacts, it is possible to generate guidance applicable to countries across the socioeconomic spectrum. Four key mechanisms can be identified: decentralization (1) minimizes the need for patients to travel for care and, (2) obviates certain system-induced delays once patients present; centralization (3) facilitates the maintenance of a workforce with sufficient expertise to offer services safely, and (4) conserves resources by limiting the number of sites. The commentary elucidates how context- and procedure-related factors determine the importance of each mechanism, allowing planners to prioritize among them. Although some context factors have special relevance to LMICs, most can also appear in high-income countries (HICs), and the procedure-related factors are universal. Thus, evidence from countries at all income levels might be fruitfully combined into an integrated body of context-sensitive guidance.


  1. Iverson KR, Svensson E, Sonderman K, et al. Decentralization and regionalization of surgical care: a review of evidence for the optimal distribution of surgical services in low- and middle-income countries. Int J Health Policy Manag. 2019;8(9):521-537. doi:10.15171/ijhpm.2019.43
  2. Hamilton SM, Johnston WC, Voaklander DC. Outcomes after the regionalization of major surgical procedures in the Alberta Capital Health Region (Edmonton). Can J Surg. 2001;44(1):51-58.
  3. Kreindler SA, Siragusa L, Bohm E, Rudnick W, Metge CJ. Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes. Can J Surg. 2017;60(5):349-354. doi:10.1503/cjs.000517
  4. Kreindler SA, Zhang L, Metge CJ, et al. Impact of a regional acute care surgery model on patient access and outcomes. Can J Surg. 2013;56(5):318-324. doi:10.1503/cjs.007012
  5. Amato L, Fusco D, Acampora A, et al. Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data. Epidemiol Prev. 2017;41(5-6 (Suppl 2)):1-128. doi:10.19191/ep17.5-6s2.p001.100
  6. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Healthcare. New York: McGraw-Hill; 2009.
  7. Kreindler SA. Six ways not to improve patient flow: a qualitative study. BMJ Qual Saf. 2017;26(5):388-394. doi:10.1136/bmjqs-2016-005438
  8. Celso B, Tepas J, Langland-Orban B, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60(2):371-378. doi:10.1097/01.ta.0000197916.99629.eb
  9. Chang V, Blackwell RH, Yau RM, et al. Variable surgical outcomes after hospital consolidation: implications for local health care delivery. Surgery. 2016;160(5):1155-1161. doi:10.1016/j.surg.2016.05.027
  10. Diaz JJ Jr, Norris PR, Gunter OL, Collier BR, Riordan WP, Morris JA Jr. Does regionalization of acute care surgery decrease mortality? J Trauma. 2011;71(2):442-446. doi:10.1097/TA.0b013e3182281fa2
Volume 10, Issue 4
April 2021
Pages 218-220
  • Receive Date: 22 November 2019
  • Revise Date: 19 April 2020
  • Accept Date: 19 April 2020
  • First Publish Date: 01 April 2021