DO SPECIALISTS DO IT BETTER - THE IMPACT OF SPECIALIZATION ON THE PROCESSES AND OUTCOMES OF CARE FOR CANCER-PATIENTS

Objective. To assess the impact of specialization on processes and out comes of care for cancer patients. Data source: Papers published in En glish between 1980 and 1995 and identified through MEDLINE and Embase (MeSK terms: NEOPLASM (exploded), and PHYSICIAN PRACTICE PATTERNS (or DECISION MAKING, ATTITUDE OF HEALTH PERSONNEL, QUALITY OF HEALTH CARE, DELIVERY OF HEALTH CARE, HEALTH EDUCATION or OUTCOME ASSESSMENT HEALT H CARE), or through the reference lists of review articles. Study sele ction: Studies providing information on the association between qualit y of care indicators for cancer patients and clinician/centre degree o f specialization. A total of 47 papers concerning 46 empirical studies were considered. Data extraction: For studies using process of care i ndicators, the proportion of specific procedures performed by speciali sts and non-specialists was abstracted. For studies using outcome indi cators (e.g., mortality), the effect of specialization was quantified in terms of odds ratio (OR) expressing relative reduction in risk of d eath. The duality of individual studies using process or outcome indic ators was assessed according to study design, avoidance of selection b ias in patient identification and data analysis, degree of adjustment of the comparison between clinicians/centres with different levels of specialization. Data synthesis: Specialized centres/clinicians fared b etter both when process and outcome indicators were used. While the fo rmer varied widely in different studies and their clinical relevance w as often questionable, mortality was consistently lower when care was provided by specialized centres/clinicians, with the effect size being greater in smaller studies. For breast cancer, where all the studies were of sufficiently good quality, a pooled estimate of the effect of specialization was performed which showed that specialized cancer carl was associated with an 18% (95% CI: 12%-23%) reduction in mortality. Conclusions: Despite the fact that care provided by specialized centre s/clinicians appeared to be better both when assessed in relation to p rocess indicators and to mortality this evidence should be considered far from conclusive because of major methodological flaws in these stu dies. Relative to current efforts to promote evidence-based policymaki ng, this review underscores the limited capability of scientific infor mation to provide reliable guidelines for structuring better health ca re systems.