Introduction

Pancreatic cancer (PC) has the worst prognosis among solid malignancies and carries the most remarkable mortality rate. Although clinical research and practice have increased the likelihood of prolonged survival in recent years, the diagnostic and therapeutic path remains extremely demanding. When feasible, radical surgery combined with systemic chemotherapy offers the highest chances for long-term survival, with highly specialized centers in pancreatic surgery leading to better clinical outcomes when compared to low-volume ones [1,2,3,4,5]. The majority of patients diagnosed with PC will need palliative and end-of-life care [6,7,8].

Each phase of the clinical pathway, from first diagnosis to therapeutic decisions and follow-up, requires specialized knowledge and skills. Among these, surgery represents a crucial step, together with histopathology, medical oncology, radiotherapy, and palliative care. Nonetheless, each patient must be treated for their unique nutritional [9, 10] and psychological [11, 12] needs. Integrating simultaneous and palliative treatment, from the earliest phases to end-of-life care, requires a multidisciplinary approach to a care continuum.

As translational research is often slow, improvement can be found in organizational innovation, namely, designing a different, most efficient, and effective patient’s journey. The so-called disease units represent new organizational, patient-centric models of care, where various medical professionals and stakeholders share their contributions and knowledge, and actions are tailored according to the disease and the single patient’s needs [13]. In general terms, a disease unit differs from a simple multidisciplinary board in several aspects, including:

  • A more comprehensive number and variety of stakeholders involved in the process beyond medical professionals.

  • The presence of professional figures aiming at bridging the knowledge and organizational gaps between the patient and the medical staff, fostering, whenever possible, co-production and shared decision-making dynamics [14,15,16,17].

  • The creation, collection, and sharing of medical information about the patient, but also in an aggregate way for clinical and research purposes.

  • The definition and monitoring of each step of care by balancing those medical activities that may be more complex or require higher specialization or instruments than those that may be easily present in less specialized centers.

The European debate on disease units is now lively when it comes to PC. Pancreas units, depending on national or regional regulation, are requested to have specified characteristics and minimal requirements, leaving to hub centers defined activities (i.e., surgery) and to spokes some others (i.e., endoscopy, medical treatment, biopsies). Still, there is an open debate and lack of literature on how these pancreas units should be designed, which organizational model they should follow, and how knowledge should be created, captured, and shared in a multistakeholders’ approach.

Starting from these premises, the PUECOF (Pancreas Unit Expert Consensus on the Organizational Factors) study aims to test a possible organizational model through a Delphi panel, seeking an expert consensus among surgical leaders involved in the European pancreatic surgery scenario. In their role as hybrid managers with some managerial responsibilities [18, 19], surgical leaders represent key figures in setting up the “rules of the games” in establishing such new organizational structures. The study was endorsed by the European–African Hepato-Pancreato-Biliary Association (E-AHPBA).

Methods

Design and setting

A Delphi survey [20, 21] was designed starting from the recent literature on healthcare organization science [13], stakeholders’ engagement [14], knowledge translation [22], and non-technical skills [23,24,25]. The survey was conceived by a multidisciplinary panel encompassing scholars in general surgery, healthcare management, organization science, social statistics, and healthcare policies. The final version of the survey was revised by the steering committee (LC, FDM, GM, GBu, and IF) and audited by E-AHPBA to grant the endorsement, which was given in October 2022.

The experts included in the panel were gathered from the members’ list of E-AHPBA. The criteria for selecting the participants were: renowned leadership in pancreatic surgery practice and research within the E-AHPBA community, affiliation to high-volume centers, and diversity in gender and countries to cover most of the E-AHPBA area of interest.

Thirty-eight surgical leaders from 17 countries were personally invited via email to join the initiative. The project was advertised on the E-AHPBA website, although participation was by invitation only. Thirty experts accepted the invitation and participated in the first round. Twenty-six experts participated in the second round, with a response rate of 87%. Data collection was carried out between November 2022 and March 2023 through Google Forms.

Survey and statistical analysis

The Delphi survey included some descriptive statistics and four sections, namely the organizational factors (14 items), the stakeholders (18 items), the non-technical skills (1 + 16 items), and the processes and knowledge translation facilitators (31 items). All items needed to be voted on by the expert panel on a Likert scale from 1 (not important) to 9 (very important). A positive consensus (inclusion) was gathered for those items voted with a mean of over 7. A negative consensus (exclusion) was defined for those items voted with a mean of 3 or below.

Another round of discussion had to be made for those items voted from 3.1 to 6.9 as the average. The Delphi round 2 survey was designed to revote the factors that did not reach a consensus by expressing the same macro-concepts in a different way than round 1 to avoid bias. Fifteen items were brought forward in round 2.

The Delphi questionnaires for both round 1 and 2, and the definition of the macro-topics brought forth in round 2 are reported in Appendix 1.

Statistical analysis was conducted using R (RStudio version 2023.06.1.524) [26].

Results

Descriptive statistics

Thirty surgical leaders responded to round 1. The sample included practitioners from 14 countries, with Italy as the most represented one (12 participants, equal to 40%). Surgeons were mostly males, with only one female. The vast majority of them declared more than 20 years of experience in pancreatic surgery (21, 70% of the sample), and most of them were from academic institutions (26, 87%). 60% of them hold leadership roles as department chiefs, 73% of them were over 50 years old, more than half of the sample was from high-volume centers, with more than 81 surgical resections performed per year.

Table 1 reports some of the descriptive statistics about the sample.

Table 1 Descriptive statistics about the sample
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Section 1 : organizational factors

The first section was about the organizational factors that were most important when establishing a pancreas unit. Among the initial 14 factors, half of them reached a consensus in round 1, while the others had to be brought forward in round 2.

The best-rated factor was the need to organize frequent meetings about multidisciplinary clinical professionals, which is an already common task in the multidisciplinary board. Other highly rated factors included the definition of team leaders for each clinical and organizational function, the presence of metrics and key performance indicators to assess the quality of the healthcare service, and the need to introduce case managers to support and guide the patient throughout the journey.

The items to be brought forth included the use of technology (e.g., telemedicine tools) to support the relationships with both staff and patients and knowledge dissemination through the press and media.

Table 2 reports the results of round 1 concerning the section about the organizational factors.

Table 2 Organizational factors: round 1 results
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In round 2, all the remaining items got full consensus. However, the sample was not equally distributed, especially about the potential contribution of press and media, which recorded a standard deviation of 1.94, dividing the participants between those more open to the new tools and those skeptical.

Table 3 reports the results of round 2 concerning the section about the organizational factors.

Table 3 Organizational factors: round 2 results
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Section 2 : stakeholders

The second section was about the stakeholders to be engaged in a pancreas unit. Notably, among the initial 18 subjects, only 3 of them (17%) reached a consensus in round 1, while the remaining 15 had to be brought forward in round 2.

The only actors that were recognized as necessary were those traditional medical professionals (like surgeons, oncologists, radiation therapists, and palliative care specialists) who are part of the already-established care path. These actors received an overall rating of 8.4 out of 9 and a low standard deviation of 0.61. The other two stakeholders who received a consensus (still with lower degrees) were non-traditional clinical professionals (like physiotherapists and psychologists) and the patient.

Table 4 reports the results of round 1 concerning the section about stakeholders.

Table 4 Stakeholders: round 1 results
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Most of the stakeholders received a consensus while reconnected to those macro-themes brought forth to round 2, except for private firms and industry leaders (mean 5.99, standard deviation 2.12). Again, a high standard deviation denotes that the sample is widely distributed.

Table 5 reports the results of round 2 concerning the section about stakeholders.

Table 5 Stakeholders: round 2 results
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Section 3 : non-technical skills

All the items about non-technical skills receive full consensus in round 1, without discussing and evaluating the topic further. Interestingly, the worst-rated factor was the importance of non-technical or soft skills in general terms. The best-rated skills were ethics, teamwork, professionalism, and leadership.

Table 6 reports the results of the section about non-technical skills.

Table 6 Non-technical skills: round 1 results
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Section  4: facilitators

The last section concerned the tools (technical, non-technical, technological, and creative) that could facilitate the knowledge-sharing dynamics within a pancreas unit. Notably, all the items received full consensus in round 1, without the need to continue the dialog in round 2. Still, not all the factors received the same level of agreement and importance.

The best-rated facilitators included mentoring and leadership, clinical cases, participation in national and international meetings, training, and clinical guidelines. The worst-rated items were co-production, leaflets and brochures, design elements, and testimonials.

Table 7 reports the results of the section about facilitators.

Table 7 Facilitators: round 1 results
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Discussion

The new pancreas units represent a unique and immense opportunity for pancreatic cancer care, including raising the quality of care for patients and the quality of work for clinical professionals. The new organizational model may bring several benefits to pancreatic surgeons, for instance, in the number of treated cases, professional development through networking, easier coordination with colleagues and patients thanks to the formal establishment of professional figures such as case managers, and more opportunities to connect with research institutions and industry leaders for joint projects and trials. Moreover, one more potential benefit of creating pancreas units may be reducing pancreatic surgeon burnout. Indeed, pancreatic surgery has elevated morbidity and mortality when compared to essentially every other intracavitary procedure. The development of pancreas units may enhance camaraderie among pancreatic surgeons, and the added support of non-surgical pancreatic experts such as round-the-clock interventional radiologists and endoscopists could help mitigate the difficulties of providing pancreatic surgical care [27, 28].

The debate about the most meaningful organizational factors, stakeholders, and procedures to be established in this new care concept is still open, and so is the design of an “ideal” pancreas unit. The results of the PUECOF study are intriguing and can contribute to the current debate on organizational innovation in surgery.

Regarding the organizational factors and the meaningful stakeholders, the enquired surgical leaders still seem stuck to a traditional model of care. Indeed, the best-rated item was about the need to carry on multidisciplinary meetings to discuss the patient’s case, a routine task that represents the primary paradigm in surgical oncology today. In line with this result, surgeons feel more comfortable enquiring those medical professionals who are part of the tumor board, such as surgeons, oncologists, radiation therapists, and palliative care specialists. They are also open to connecting and discussing with less traditional medical professionals, for instance, in the fields of nutrition and psychology, as recommended by the latest literature on pancreatic cancer care [9,10,11,12].

Interestingly enough, surgeons consider patients as relevant parties, while other stakeholders are not, neither the patient’s family nor the caregivers. These results are in contrast with the recognized pillars of the modern healthcare system, which is based on patient-centric concepts like co-production and shared decision-making. Modern oncology requires clinicians to engage the patient as much as possible, considering the circumstances [29,30,31], to co-design, co-plan, co-decide, and co-execute the oncological care [14, 32]. The concept of co-production has recently been also applied to surgery [14], and one first experience has been planned also in pancreatic cancer care [33]. Patients who are fully engaged in their own care record higher levels of satisfaction and adherence to the care plan [29, 30]. Therefore, it is important even for surgeons to second these elements when they are feasible.

Surgeons are also less likely to engage with other stakeholders, such as other clinicians from partner institutions or other pancreas units, universities, scientific societies, patients’ associations, NGOs, and industry firms. Surgical leaders seem less willing to go far beyond their operating room, as the meaningful partners they need are just outside it. Also these findings are in contrast with the most recent trends describing the healthcare ecosystem as an open one [34, 35], and the need for a multistakeholder approach [14], in which each actor has a role and can contribute to the ultimate goal, namely, the patient’s satisfaction and quality of care.

However, the role of professional figures such as nurse navigators, case managers [36], or advanced nurse practitioners [37] emerges. These professionals aim to connect the patients and the clinical staff, offering technical and non-technical support throughout the entire care journey. Surgeons are also sensitive to the organizational dimension through the definition of functional leaders and chiefs and the establishment of metrics and key performance indicators. In contrast, there is less trust in the use of telemedicine to support the relationships between medical professionals and the patient.

About the non-technical skills, in line with the current surgical literature [23, 25], surgical leaders recognized their importance. The best-rated items are represented by ethics, teamwork, professionalism, leadership, decision-making, and communication, which stress the importance of team dynamics within the operating room [38]. Interestingly, less importance is devoted to managing stress, ideas creation ability, agility, coping with fatigue, and coordination, even if pancreatic surgery is known to be technically complex with long operating times [39, 40].

Last but not least, concerning the facilitators, again, surgeons seem more comfortable when employing traditional instruments, like mentoring, clinical reports and critical review of complicated cases, participation in national and international meetings, training, clinical guidelines, and evidence-based methods. They have less trust in modern concepts like the above-mentioned co-production or marketing-oriented tools like leaflets and brochures, design and visual elements, and testimonials, who may share their personal experience with others.

Although the establishment of pancreas units will not change the technical content of pancreatic surgery, it can foster the progress of research and innovation thanks to the multistakeholder perspective in terms of new pharmaceutical treatments to improve resection rates, surgical techniques, or new frontiers in the use of telemedicine and e-health tools in pancreatic care and follow-up. It is an exciting scenario where everyone must contribute and offer an effort to change the paradigm to fight one of the worst oncological diseases.

Conclusions

The debate on the new pancreas units has just started. Our exciting results depict a picture that sees surgical leaders still comfortable in their traditional role. Indeed, those organizational factors that reached full consensus are those closer to the actual situation and procedures, while surgeons are still reluctant to recognize more modern concepts like multistakeholder engagement and co-production dynamics.

The above-described scenario has a substantial impact on new essential needs in surgical education for the next generation of surgical oncologists. Both academic institutions and scientific societies will have the strategic role of promoting such a paradigm shift, sharing knowledge and best practices about what is and will go on in pancreatic cancer care.

Limitations

As with all pieces of research, ours has limitations. First of all, our Delphi panel members are not equally distributed, with many coming from Italy, where the debate on pancreas units is particularly lively because of the recent regulation of the Lombardy Region [13, 41] and the creation of a dedicated focus group by the Ministery of Health [42]. Despite our efforts, gender diversity is not met, with only 1 woman out of 30 total participants, reflecting the scenario of a (still) male-dominated domain. Moreover, the literature and the topic of pancreas units are still in their infancy. As the theme progresses, we may expect more intriguing inputs and experiences to be included in the debate. Inquiring different clinical professionals other than surgeons, such as oncologists, gastroenterologists, and also nurses, about their perception of the meaningful organizational factors may create valuable synergies with the thoughts of surgical leaders. Our limitations can, therefore, represent new exciting research avenues for researchers in surgery and healthcare management to design, disseminate, and assess the “ideal” pancreas unit model of care.