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ObjectiveTo 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. Summary Background DataPrevious 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. MethodsAnalysis 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 lowvolume 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. ResultsIncreased 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. ConclusionsPatients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.In the present cost-conscious health care environment, there is considerable interest among health care policy makers and payers concerning the regional referral of patients to hospitals that have special expertise in a given procedure.

ObjectiveTo examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. MethodsThe study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume-low (Յ5), medium (5 to 10), and high (Ͼ10)-and hospital volume-low (Ͻ40), medium (40 to 70), and high (Ն70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. ResultsDuring the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The lowvolume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high-or medium-volume hospitals. ConclusionsA skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed Ͼ10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in lowvolume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.Numerous studies have examined the association of surgeon case volume with clinical outcomes for various procedures and have shown higher surgeon volume to be associated with improved outcomes. This phenomenon has been described for an increasing number of procedures, including coronary artery bypass, angioplasty, gastrectomy, esophagectomy, thyroidectomy, arthroplasty, and aortic aneurysm repair. [1][2][3][4][5][6][7][8] We and others have reported a similar relation between surgeon volume and improved clinical and economic outcomes for resections of colon and rectal cancer.9 -18 Our study showed that in-hospital death, length of stay, and total hospital charges were found to be significantly inversely related to surgeon volume, with the best results being achieved by the high-volume surgeon group who performed Ͼ10 cases per year.