Grilli R, Minozzi S, Tinazzi A, Labianca R, Sheldon T A, Liberati A
Unit of Clinical Policy Analysis, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
Ann Oncol. 1998 Apr;9(4):365-74. doi: 10.1023/a:1008201331167.
To assess the impact of specialization on processes and outcomes of care for cancer patients.
Papers published in English between 1980 and 1995 and identified through MEDLINE and Embase (MeSH 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 HEALTH CARE), or through the reference lists of review articles.
Studies providing information on the association between quality of care indicators for cancer patients and clinician/centre degree of specialization. A total of 47 papers concerning 46 empirical studies were considered.
For studies using process of care indicators, the proportion of specific procedures performed by specialists and non-specialists was abstracted. For studies using outcome indicators (e.g., mortality), the effect of specialization was quantified in terms of odds ratio (OR) expressing relative reduction in risk of death. The quality of individual studies using process or outcome indicators was assessed according to study design, avoidance of selection bias in patient identification and data analysis, degree of adjustment of the comparison between clinicians/centres with different levels of specialization.
Specialized centres/clinicians fared better both when process and outcome indicators were used. While the former varied widely in different studies and their clinical relevance was 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 care was associated with an 18% (95% CI: 12%-23%) reduction in mortality.
Despite the fact that care provided by specialized centres/clinicians appeared to be better both when assessed in relation to process indicators and to mortality, this evidence should be considered far from conclusive because of major methodological flaws in these studies. Relative to current efforts to promote evidence-based policy-making, this review underscores the limited capability of scientific information to provide reliable guidelines for structuring better health care systems.
评估专业化对癌症患者护理流程及结果的影响。
1980年至1995年间以英文发表的论文，通过MEDLINE和Embase检索（医学主题词：肿瘤（展开）、医师执业模式（或决策制定、卫生人员态度、卫生保健质量、卫生保健提供、健康教育或卫生保健结果评估）），或通过综述文章的参考文献列表获取。
提供癌症患者护理质量指标与临床医生/中心专业化程度之间关联信息的研究。共纳入47篇涉及46项实证研究的论文。
对于使用护理流程指标的研究，提取专科医生和非专科医生执行特定程序的比例。对于使用结果指标（如死亡率）的研究，专业化的效果以优势比（OR）量化，即表示死亡风险相对降低的比例。根据研究设计、患者识别和数据分析中避免选择偏倚的情况、不同专业化水平的临床医生/中心之间比较的调整程度，评估使用流程或结果指标的个体研究质量。
无论是使用流程指标还是结果指标，专科中心/临床医生的表现都更好。虽然前者在不同研究中差异很大且其临床相关性往往存疑，但由专科中心/临床医生提供护理时死亡率始终较低，在较小规模的研究中效应量更大。对于乳腺癌，所有研究质量都足够好，对专业化效果进行了汇总估计，结果显示专科癌症护理可使死亡率降低18%（95%置信区间：12% - 23%）。
尽管从护理流程指标和死亡率方面评估时，专科中心/临床医生提供的护理似乎更好，但由于这些研究存在重大方法学缺陷，该证据远非确凿无疑。相对于当前促进循证决策的努力，本综述强调了科学信息为构建更好的卫生保健系统提供可靠指南的能力有限。
