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Original article
The impact of the ‘hub and spoke’ model of care for lung cancer and equitable access to surgery
  1. Aamir Khakwani1,
  2. Anna L Rich2,
  3. Helen A Powell1,3,
  4. Laila J Tata1,
  5. Rosamund A Stanley4,
  6. David R Baldwin2,
  7. John P Duffy5,
  8. Richard B Hubbard1,3
  1. 1Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
  2. 2Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
  3. 3Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
  4. 4Falls and Fragility Audit Programme Manager Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
  5. 5Department of Thoracic Surgery, Nottingham University Hospitals, Nottingham, UK
  1. Correspondence to Dr Aamir Khakwani, Division of Epidemiology and Public Health, University of Nottingham, Nottingham NG5 1PB, UK; aamir.khakwani{at}


Objectives To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for non-small cell lung cancer (NSCLC).

Design Cross-sectional study from individual patients, between 1January 2008 and 31March 2012.

Setting Linked National Lung Cancer Audit and Hospital Episode Statistics datasets.

Participants 95 818 English patients with a diagnosis of NSCLC, of whom 12 759 (13%) underwent surgical resection.

Main outcome measure Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre.

Results Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%.

Conclusions Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery.

  • Lung Cancer
  • Thoracic Surgery
  • Non-Small Cell Lung Cancer
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