In 2015, surgeons in the Lung Transplant Program at Brigham and Women’s Hospital performed 26 lung transplants. After significant investments in surgical staff, quality and processes, the program tripled its volume over a two-year period, performing 75 lung transplants in 2017. During this period of rapid growth, many outcomes were also improved, including a decrease in the length of hospital stay from 24 days (2015) to approximately 15 days (2017) and increased one-year survival to over 90 percent.
“When you’re trying to grow volume, it’s typically quite challenging to focus on quality and outcome improvements, so it’s extraordinary that we were able to move the needle in these areas while our volume tripled,” says Hilary J. Goldberg, MD, medical director of the Lung Transplant Program within the Lung Center at Brigham and Women’s Hospital.
Transplant volume expands as outcomes improve
Many factors led to the rapid increase in lung transplant volumes and significant investments were made to certain areas following a rigorous, data-driven analysis of key metrics within the Lung Transplant Program. From 2015 to 2017, several initiatives resulted in the following improvements:
- Substantial decrease in length of stay during the index hospitalization for transplant patients
- Improvement in graft and patient survival rates at one year
- Increased infrastructure to support urgent evaluations and listings, including expansion of the mechanical circulatory support program
- Ongoing efforts to improve both process (unplanned procedure cancellations, expedited evaluation process), and outcome (renal function, venous thromboembolism rates) in candidates and recipients
Hari R. Mallidi, MD, joined the Lung Transplant Program in 2015, as its program and surgical director. Two additional surgeons and a surgical transplant fellow were also recruited to build a dedicated staff of transplant surgeons that would allow multiple transplants to occur 24-7-365 with no interruption.
“As the transplant program continues to grow, we aim to double the number of pulmonary medicine physicians to complement our program’s surgical depth,” says Dr. Mallidi. The program is now recruiting two additional transplant pulmonologist to join the growing team.
Expanding the donor and recipient pool
To help support a data-driven improved evaluation of donor and recipient suitability, Drs. Mallidi and Goldberg welcomed R. Duane Davis, MD, to the transplant program as a visiting lecturer and consultant. President of the International Society of Heart and Lung Transplantation, Dr. Davis was chief of the Lung Transplant Program at Duke University (the second largest lung transplant program in the U.S.), and is one of the world’s most prolific lung transplant surgeons.
“We committed to evaluating all possible donor offers, even donors that had been declined by other centers. While this increased cost within the program, due to an increase in dry runs, it ultimately resulted in a much greater rate of transplantation,” says Dr. Mallidi.
In addition, the program has utilized all available technologies to expand the number of patients they could add to the recipient list. This involved an increased willingness to transplant sicker and more risky candidates, at the cost of potentially worsening outcomes.
“These interventions might have increased risk and worsened outcomes. Instead, our outcomes improved. This is a testament to the processes and structure that were already in place upon my arrival,” says Dr. Mallidi.
Experts in the Lung Transplant Program plan to use more technology to further expand the donor pool, including expanding the donor population by increasing the use of ex-vivo lung perfusion (EVLP), which allows staff to sustain organs for longer periods of time so they can perform more evaluation and optimization.
In his role as the executive director of ECMO (Extra-Corporeal Membrane Oxygenation), Dr. Mallidi says that ECMO support will be increasingly utilized as they evaluate and transplant more patients who are critically ill from lung disease.
Collaboration drives growth
“I think our growth is a testament to our extraordinarily collaborative team. Everyone in the program contributed, from nursing to administration to pharmacy to social work. Everyone was invested, everyone had the same goal. Within our program, everyone also has an equal seat at the table, everyone’s voice is equally important,” says Dr. Goldberg.
Looking forward, with the increased volume and enhanced infrastructure, the Lung Transplant Program aims to expand both translational and clinical research programs in both end-stage lung disease and lung transplantations.
To refer a patient to the Lung Transplant Program, please contact Melissa Centeio at (617) 278-0502.