Fragmentation in specialist care and stage III colon cancer

Abstract

Background Patients with cancer frequently transition between different types of specialists and across care settings. We explored how frequently the medical and surgical oncologic care of stage III colon cancer patients occurs across more than one hospital and whether this is associated with mortality and costs. Methods This is a retrospective SEER-Medicare cohort study of 9,075 stage III colon cancer patients diagnosed between 2000 and 2009 receiving both surgical and medical oncologic care within one year of diagnosis. Patients were assigned to the hospital where they had their cancer surgery and to their oncologist's primary hospital, and then characterized according to whether these hospitals were same or different. Outcomes included all-cause mortality, subhazards for colon cancer specific mortality, and cost of care at 12 months. Results 37% of patients received their surgical and medical oncologic care from different hospitals. Rural patients were less likely than urban patients to receive medical oncologic care from the same hospital (OR 0.62, 95%CI 0.43-0.90). Care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality but resulted in lower costs at 12 months (dollars saved $5493, 95%CI $1799, $9525), 8% of median cost. Conclusions Delivery of surgical and medical oncology care at the same hospital was associated with lower costs; however, reforms which seek to improve outcomes and cost through integrating complex care will need to address the significant proportion of patients receiving care across more than one hospital.

Effect of fragmentation of cancer care on treatment use and survival in hepatocellular carcinoma

“…Only 2 previous studies have described the association of patient-and hospital-related factors with the use of multiple facilities. 3 Because adjuvant therapy has been shown to improve OS for patients with stage III colorectal cancer and is the current recommendation of the National Comprehensive Cancer Network guidelines, the limitation of the failure of adjustment for neoadjuvant and adjuv ant therapy could significantly bias survival data. In a study examining FC in patients with breast cancer seen at an academic institution or a community hospital through linked patient records, patients who were younger, were of Asian race/ethnicity, lived in high-socioeconomic status neighborhoods, and had early-stage disease were more likely to receive FC.…”

“…In 2013, the Institute of Medicine identified fragmentation of cancer care as a priority area for improving patient-centered initiatives aimed at reducing costs and improving cancer care delivery. 3 Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and the fastest growing cause of cancer-related deaths in the United States. Although FC is associated with higher health care costs, inferior quality of patient care, and unnecessary procedures and treatments, it is unclear whether this translates into worse downstream outcomes, including time to treatment (TTT) and overall survival (OS).…”

Prevalence and characteristics of cancer patients receiving care from single vs. multiple institutions

“…To our knowledge, only two prior studies have quantified the percentage of cancer patients seen at two or more institutions, and these also suggest a substantial prevalence of this phenomenon [10,11]. When the records of breast cancer patients seen at a community hospital were linked with those of a nearby academic institution, 16% of patients were found to have been seen at both institutions [10].…”

“…For breast cancer patients, our population-based results confirm associations of multiple facility use with younger age and stage II/III, but not with race or neighborhood SES. Among Medicare recipients with stage III colorectal cancer, 37% received surgery and oncology services from different hospitals [11]. Rural patients were more likely to be seen at multiple hospitals, and although there were no associations with cancer specific survival, costs were noted to be higher for patients seen at multiple hospitals [11].…”

“…Among Medicare recipients with stage III colorectal cancer, 37% received surgery and oncology services from different hospitals [11]. Rural patients were more likely to be seen at multiple hospitals, and although there were no associations with cancer specific survival, costs were noted to be higher for patients seen at multiple hospitals [11]. In non-oncology settings, a study of Massachusetts patients seeking acute care found that 31% visited at least two hospitals over a five-year period [12] and a team building electronic medical record-based algorithms to identify patients with type 2 diabetes reported substantial data fragmentation across institutions, such that using data from two institutions greatly improved the predictive value of their search over using data from only one institution [13].…”