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Effective Triage of Early Stage Lung Cancer Patients in Community Hospitals Yields Low Surgical Mortality
*Christopher T Ducko, *Carlos E Bravo-I˝iguez, *Mauricio Perez Martinez, *Katherine W Armstrong, *Jon O Wee, *Michael T Jaklitsch, *Raphael Bueno, Scott J Swanson
Brigham and Women's Hospital, Boston, MA

Objective: Delivery of high quality Thoracic Surgery in community hospitals is inhibited by low case volume, leading to transfers to tertiary care centers. We developed a model of a rotating team of academic surgeons with daily presence at community hospitals. The hospital site and surgical procedure was selected based on the surgeon’s knowledge of resources at each institution allowing for appropriate patient triage. Cases requiring higher level resources were referred to the academic center.
Design: Cases identified using Quality Assurance cross-referenced to billing database
Setting: Community/Academic Hospitals
Patients: Referred sample, 218 patients (2006-2012)
Interventions: None
Main Outcome Measures: 30 day morbidities, mortality
Results: 34 (15%) patients referred to the tertiary hospital due to: patient choice (18), neoadjuvant treatment (13) or operative risk (3). Of the 184 community hospital resections: 110 (60%) lobectomies, 2 segments, 64 wedges and 8 combined resections. No 30 day mortalities. Charlston Co-morbid index was a median 8 (range 0-16). Tobacco exposure was mean 48 pack years. 68 morbid events in 53/184 (29%) resections: atrial fibrillation 15 (8%), delirium 16 (9%), UTI 10 (5%), PTX requiring tube 6 (3%), pneumonia 4 (2%), hemorrhage 4 (2%), other 13 (7%). Of 184 resections, 133 (72%) patients had lung cancer. Of those, 96 (72%) were stage I, 19 (14%) stage II, 13 (10%) stage III and 5 (4%) stage IV. KM Survival curves show overall 5-year survival for 96 stage I patients was 75.3%, for 19 stage II patients was 67.4%.
Conclusion: Presence at targeted community hospitals of experienced academic surgeons can yield high-volume benchmarks within low volume hospitals. This model benefits the growth of thoracic services at community hospitals without compromising quality care.


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