title: Influence of specialization on the management and outcome of patients with pancreatic cancer.
abstract: BACKGROUND
  Cancer care is increasingly specialized. Relationships between pancreatic cancer care, mortality and patterns of clinical practice among the full spectrum of patients, including those with irresectable tumours, are not well understood.
  
  
  METHODS
  A cohort of 782 patients diagnosed prospectively with pancreatic cancer in 29 acute hospitals in England and Wales over 1 year were followed for 2-3 years. The effects of doctors' and hospitals' specialization, indicated by annual patient volumes, on operative mortality rates, survival times, and test and treatment provision were studied. Multiple logistic and Cox regression models were used to control for prognostic factors and treatments, providing adjusted odds and hazard ratios associated with a higher volume of ten patients annually.
  
  
  RESULTS
  Patients managed by higher-volume hospitals survived significantly longer (hazard ratio 0.88 (95 per cent confidence interval (c.i.) 0.83 to 0.93); P < 0.001). They were more likely to undergo cytological examination (odds ratio (OR) 1.21 (95 per cent c.i. 1.01 to 1.35)), resection (OR 1.44 (1.17 to 1.79)) and biliary stenting (OR 1.17 (1.02 to 1.34)), and were less likely to have bypass surgery (OR 0.66 (0.55 to 0.78)). Patients of higher-volume doctors were more likely to undergo endoscopic retrograde cholangiopancreatography (OR 1.59 (1.19 to 2.11)), percutaneous transhepatic cholangiography (OR 1.50 (1.12 to 2.00)), laparoscopy (OR 1.81 (1.07 to 3.06)), resection (OR 1.84 (1.29 to 2.61)) and bypass surgery (1.71 (1.25 to 2.33)).
  
  
  CONCLUSIONS
  Specialization appears to improve survival and to promote more thorough investigation.
authors.affiliation: Medical Research Council Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK. gngmomb@med.uovs.ac.za
authors.forename: M O
authors.initials: MO
authors.lastname: Bachmann
authors.forename: D
authors.initials: D
authors.lastname: Alderson
authors.forename: T J
authors.initials: TJ
authors.lastname: Peters
authors.forename: C
authors.initials: C
authors.lastname: Bedford
authors.forename: D
authors.initials: D
authors.lastname: Edwards
authors.forename: S
authors.initials: S
authors.lastname: Wotton
authors.forename: I M
authors.initials: IM
authors.lastname: Harvey
mesh_terms: D002983:Clinical Competence; D015331:Cohort Studies; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008505:Medical Staff, Hospital; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery*; D011446:Prospective Studies; D013038:Specialization; D016019:Survival Analysis; D016896:Treatment Outcome; D014852:Wales / Q000453:epidemiology