title: Importance of hospital volume in the overall management of pancreatic cancer.
abstract: OBJECTIVE
  To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995.
  
  
  BACKGROUND
  Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent.
  
  
  METHODS
  Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume.
  
  
  RESULTS
  Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively.
  
  
  CONCLUSIONS
  Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.
authors.affiliation: Department of Surgery, Robert Wood Johnson Clinical Scholars Program, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-2196, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Sosa
authors.forename: H M
authors.initials: HM
authors.lastname: Bowman
authors.forename: T A
authors.initials: TA
authors.lastname: Gordon
authors.forename: E B
authors.initials: EB
authors.lastname: Bass
authors.forename: C J
authors.initials: CJ
authors.lastname: Yeo
authors.forename: K D
authors.initials: KD
authors.lastname: Lillemoe
authors.forename: H A
authors.initials: HA
authors.lastname: Pitt
authors.forename: J M
authors.initials: JM
authors.lastname: Tielsch
authors.forename: J L
authors.initials: JL
authors.lastname: Cameron
mesh_terms: D000368:Aged; D003365:Costs and Cost Analysis; D003430:Cross-Sectional Studies; D005260:Female; D013502:General Surgery; D017721:Hospital Costs; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008396:Maryland; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D012306:Risk; D013514:Surgical Procedures, Operative / Q000191:economics* / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D000078329:Workforce