Factors to consider when seeking better results in placenta accreta spectrum.

Abstract

We appreciate the interest of Professor Matsuzaki et al1 in our paper. They address the relation between the volume of placenta accreta spectrum (PAS) patients attended and interdisciplinary team training. We found that lack of experience is the most frequently related factor to unfavorable results in PAS.2 The number of times a professional performs a specific procedure is critical in improving results, especially for complex diseases. Nevertheless, it is necessary to consider other activities (Figure 1) that are well summarized in the care models, called “bundles”.3 Although it is easy to focus on the execution (response to the surgical challenge), there are three additional components of quality care: some precede treatment, such as readiness, recognition, and prevention, and the other follows it, reporting and systems learning. Matsuzaki et al's comment is of great operational importance in regions where there is no standard of care for PAS. There are few PAS care centers with high-quality standards, and there is also ignorance of the importance of referring patients to these centers. Establishing a “minimun volume standard” to define hospitals that are candidates to become referral centers should not hide the fundamental task of all “low-volume centers”—that of early identification of patients with risk factors or abnormal findings in the prenatal images, and then sending them to those “high-volume centers”. There is an interdependence of centers that only works when considering the strengths of each type of hospital and betting on the “regionalization” of care. Few activities show interest in quality better than research and inter-institutional collaboration. Exposing oneself to one’s peers demands both internal improvement and self-criticism processes that are the basis of the four domains of the postpartum hemorrhage bundles applied to PAS.3 We agree with the need for multicenter studies that evaluate not only the relation between volume and results but also the impact of fixed interdisciplinary teams (or “PAS teams”) that favor the contact of all patients in a center, with a reduced number of specialists who improve their skills by increasing their frequency of exposure to PAS. Although it takes time, with effort and dedication this human group becomes a high-performance team.4 Although the term “centers of excellence” has been postulated to describe those hospitals with exceptional characteristics in terms of cases attended volume, resources, and work dynamics.5 We consider that establishing rigid requirements to “endorse” a hospital for the care of PAS patients may be inappropriate given the diverse realities in multiple countries (availability of resources and specialists, teamwork possibilities, and others). Thus, the “PAS team” of a hospital with three PAS cases per month, each of them attended by one of six specialists, may have a less steep “training curve” than that of another hospital with one case per month, in which the same two surgeons evaluate the prenatal images, attend the surgeries, and meet with the pathology group in all cases, to finally carry out debriefing and periodic joint growth activities at the group or even regional level through inter-institutional discussions facilitated by virtual meetings or telepresence during surgical procedures.