Quality pancreatic cancer care: it's still mostly about volume.

Even the most optimistic of oncologists must view with dismay the minimal improvement in overall survival for pancreatic adenocarcinoma. Progress has been made in diagnosis, selection of patients for operation, and resection, with markedly decreased mortality but persistent morbidity following operation and minimal survival improvement with adjuvant chemotherapy. These improvements have had secondary benefits for patients who are suspected of having pancreatic adenocarcinoma but who prove to have less lethal histological diagnoses and improved survival following resection. In this issue of the Journal, Bilimoria et al. (1) identify a series of " potential quality indicators " that have been ranked by 20 " pancre-atic cancer experts " for validity. The National Cancer Data Base (NCDB) was used to assess adherence with the valid indicators at both the patient and hospital levels. Of the 43 valid indicators, 26% assessed structural factors, 44% clinical process of care, 9% treatment appropriateness, 9% effi cacy, and 11% outcomes. Patient and hospital adherence to individual indicators essentially varied from less than 7% to 100%! Most hospitals were adherent with fewer than half of the 10 component indicators used to develop a composite score of quality care. What are we to take from these data? As the authors conclude , there is considerable variability in the management of pancreatic cancer in the United States. They also suggest that there is variability in the " quality " of pancreatic cancer management , but is that true? Operative mortality and, to a lesser extent, morbidity do vary widely among hospitals, and for the patient, operative mortality is a crucial matrix. However, given the high cost of medical care, it seems facetious to suggest that pancreatic cancer patients in most major cities could improve their perioperative survival by 200% – 400% by spending relatively little money to travel to a hospital with a higher quality of pancreatic cancer management. Centralization to high-volume institutions would seem to be an appropriate way to improve patient operative survival. The relationship between hospital volume, system clinical resources, and mortality in pancreatic resection was addressed recently (2), where it was found that system clinical resources infl uence operative mortality more than volume, although hospital volume was strongly associated with the presence of such support services. Bilimoria et al. (1) have developed indicators of high-quality care, assessed hospital compliance, and attempted to develop a composite measure of " quality " of hospital-level care. This attempt …