title: Transfer between hospitals as a predictor of delay in diagnosis and treatment of patients with Non-Small Cell Lung Cancer - a register based cohort-study.
abstract: Lung cancer is the second most frequent cancer diagnosis in Denmark. Although improved during the last decade, the prognosis of lung cancer is still poor with an overall 5-year survival rate of approximately 12%. Delay in diagnosis and treatment of lung cancer has been suggested as a potential cause of the poor prognosis and as consequence, fast track cancer care pathways were implemented describing maximum acceptable time thresholds from referral to treatment. In Denmark, patients with lung cancer are often transferred between hospitals with diagnostic facilities to hospitals with treatment facilities during the care pathway. We wanted to investigate whether this organizational set-up influenced the time that patients wait for the diagnosis and treatment. Therefore, the objective of this study was to uncover the impact of transfer between hospitals on the delay in the diagnosis and treatment of Non-Small Cell Lung Cancer (NSCLC).
  
  
  
  We performed a historical prospective cohort study using data from the Danish Lung Cancer Registry (DLCR). All patients diagnosed with primary NSCLC from January 1st 2008 to December 31st 2012 were included. Patients with unresolved pathology and incomplete data on the dates of referral, diagnosis and treatment were excluded.
  
  
  
  A total of 11 273 patients were included for further analyses. Transfer patients waited longer for treatment after the diagnosis, (Hazard ratio (HR) 0.81 (0.68-0.96)) and in total time from referral to treatment (HR 0.84 (0.77-0.92)), than no-transfer patients. Transfer patients had lower odds of being diagnosed (Odds Ratio (OR) 0.82 (0.74-0.94) and treated (OR 0.66 (0.61-0.72) within the acceptable time thresholds described in the care pathway.
  
  
  
  Fast track cancer care pathways were implemented to unify and accelerate the diagnosis and treatment of cancer. We found that the transfer between hospitals during the care pathway might cause delay from diagnosis to treatment as well as in the total time from referral to treatment in patients with Non Small-Cell Lung Cancer. The difference between no-transfer and transfer patients persists after adjusting for known predictors of delay.
authors.affiliation: Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, Odense University Hospital, University of Southern Denmark, Sdr. Boulevard 29, Entrance 216, ground floor East, DK-5000, Odense C, Denmark. maria.iachina@rsyd.dk.
authors.forename: Maria
authors.initials: M
authors.lastname: Iachina
authors.affiliation: OPEN, Odense Patient data Exploratory Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.|The Danish Lung Cancer Registry, Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark.
authors.forename: Erik
authors.initials: E
authors.lastname: Jakobsen
authors.affiliation: OPEN, Odense Patient data Exploratory Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.|QuintilesIMS, Copenhagen, Denmark.
authors.forename: Anne Kudsk
authors.initials: AK
authors.lastname: Fallesen
authors.affiliation: OPEN, Odense Patient data Exploratory Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
authors.forename: Anders
authors.initials: A
authors.lastname: Green
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis* / Q000628:therapy; D003718:Denmark; D005260:Female; D006761:Hospitals; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D011446:Prospective Studies; D012017:Referral and Consultation; D012042:Registries; D015996:Survival Rate; D061665:Time-to-Treatment
keywords: Diagnosis; Lung cancer; Transfer; Treatment