Background: The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort. Methods: Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds. Results: A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively). Conclusion: The best performance model for centralization involved a threshold for volume combined with a mortality threshold.

Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014–2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients.