review of literature on clinical pancreatology - The Pancreapedia

Quality <strong>of</strong> lifeOne study was designed to assess postoperative changes in the quality <strong>of</strong> life (QoL) <strong>of</strong>patients after surgical treatment for pancreatic cancer in a prospective single-centre studythat included 54 patients with pancreatic cancer. Patients with potentially resectable tumoursunderwent pancreaticoduodenectomy (n=26), a double-bypass procedure (DBP) (n=17) orlaparotomy (n=11). They were asked to complete a questionnaire before and at 1, 2, 3 and 6months after surgery. QoL was assessed using the EORTC QLQ-C30 and EORTC QLQ-PAN26 questionnaires (European Organization for Research and Treatment <strong>of</strong> CancerQuality <strong>of</strong> Life Questionnaire C30 and PAN26). The patients did not demonstrate significantdifferences in the assessment <strong>of</strong> their global health status. Although, after resection, patientsgave a positive assessment <strong>of</strong> most parameters in question, after DBP they reported someaggravation <strong>of</strong> most <strong>of</strong> the symptoms. The majority <strong>of</strong> patients did not have aggravatedsymptoms after laparotomy. It was concluded that the study had shown the value <strong>of</strong>conducting both curative and palliative resection for QoL. Bypass procedures should beperformed in cases <strong>of</strong> non-resectable pancreatic cancer with accompanying jaundice and/orgastric outlet obstruction in patients with a life expectancy <strong>of</strong> at least 6 Montis [521].Quality <strong>of</strong> carePancreatic cancer outcomes vary considerably among hospitals. Assessing pancreaticcancer care by using quality indicators could help reduce this variability. However, validquality indicators are not currently available for pancreatic cancer management, and acomposite assessment <strong>of</strong> the quality <strong>of</strong> pancreatic cancer care in the United States has notbeen done. Potential quality indicators were therefore identified from the <strong>literature</strong>,consensus guidelines, and interviews with experts. A panel <strong>of</strong> 20 pancreatic cancer expertsranked potential quality indicators for validity based on the RAND/UCLA AppropriatenessMethodology. The rankings were rated as valid (high or moderate validity) or not valid.Adherence with valid indicators at both the patient and the hospital levels and a compositemeasure <strong>of</strong> adherence at the hospital level were assessed using data from the NationalCancer Data Base (2004-2005) for 49 065 patients treated at 1134 hospitals. Summarystatistics were calculated for each individual candidate quality indicator to assess the medianranking and distribution. Of the 50 potential quality indicators identified, 43 were rated asvalid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (26 %) assessedstructural factors, 19 (44 %) assessed clinical processes <strong>of</strong> care, four (9 %) assessedtreatment appropriateness, four (9 %) assessed efficiency, and five (12 %) assessedoutcomes. Patient-level adherence with individual indicators ranged from 50 percent to 97percent, whereas hospital-level adherence with individual indicators ranged from 7 to 100percent. Of the 10 component indicators (contributing 1 point each) that were used todevelop the composite score, most hospitals were adherent with fewer than half <strong>of</strong> theindicators (median score = 4; interquartile range = 3-5). Based on the quality indicatorsdeveloped in this study, there is considerable variability in the quality <strong>of</strong> pancreatic cancercare in the United States. Hospitals can use these indicators to evaluate the pancreaticcancer care they provide and to identify potential quality improvement opportunities [522].OrganizationThe authors systematically <strong>review</strong>ed the association between provider case volume andmortality in 101 publications involving greater than 1 million patients with esophageal, gastric,hepatic, pancreatic, colon, or rectal cancer, <strong>of</strong> whom more than 70,000 died. The majority <strong>of</strong>studies addressed the relation between hospital surgical case volume and short-termperioperative mortality. Few studies addressed surgeon case volume or evaluated long-termsurvival outcomes. Common methodologic limitations were failure to control for potential