Fragmentation in specialist care and stage III colon cancer

Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States

PURPOSE

The Commission on Cancer (CoC) establishes standards to support multidisciplinary, comprehensive cancer care. CoC-accredited cancer programs diagnose and/or treat 73% of patients in the United States. However, rural patients may experience diminished access to CoC-accredited cancer programs. Our study evaluated distance to hospitals by CoC accreditation status, rurality, and Census Division.

METHODS

All US hospitals were identified from public-use Homeland Infrastructure Foundation-Level Data, then merged with CoC-accreditation data. Rural-Urban Continuum Codes (RUCC) were used to categorize counties as metro (RUCC 1-3), large rural (RUCC 4-6), or small rural (RUCC 7-9). Distance from each county centroid to the nearest CoC and non-CoC hospital was calculated using the Great Circle Distance method in ArcGIS.

FINDINGS

Of 1,382 CoC-accredited hospitals, 89% were in metro counties. Small rural counties contained a total of 30 CoC and 794 non-CoC hospitals. CoC hospitals were located 4.0, 10.1, and 11.5 times farther away than non-CoC hospitals for residents of metro, large rural, and small rural counties, respectively, while the average distance to non-CoC hospitals was similar across groups (9.4-13.6 miles). Distance to CoC-accredited facilities was greatest west of the Mississippi River, in particular the Mountain Division (99.2 miles).

CONCLUSIONS

Despite similar proximity to non-CoC hospitals across groups, CoC hospitals are located farther from large and small rural counties than metro counties, suggesting rural patients have diminished access to multidisciplinary, comprehensive cancer care afforded by CoC-accredited hospitals. Addressing distance-based access barriers to high-quality, comprehensive cancer treatment in rural US communities will require a multisectoral approach.

Relationship between patient outcomes and patterns of fragmented cancer care in older adults with gastric cancer: A nationwide cohort study in South Korea

INTRODUCTION

Fragmented cancer care, defined as receipt of care from multiple hospitals, has been shown to be associated with poor patient outcomes and high expense. However, evidence regarding the effects of hospital choice by patients with cancer on overall survival are lacking. Thus, we investigated the relationship between patterns of fragmented care and five-year mortality in patients with gastric cancer.

MATERIALS AND METHODS

Using the Korean National Health Insurance senior cohort of adults aged ≥60 years, we identified patients with gastric cancer who underwent gastrectomy during 2007-2014. We examined the distribution of the study population by five-year mortality, and used Kaplan-Meier survival curves/log-rank test and Cox proportional hazard model to compare five-year mortality with fragmented cancer care.

RESULTS

Among the participants, 19.5% died within five years. There were more deaths among patients who received fragmented care, especially those who transferred to smaller hospitals (46.6%) than to larger ones (40.0%). The likelihood of five-year mortality was higher in patients who received fragmented cancer care upon moving from large to small hospitals than those who did not transfer hospitals (hazard ratio, 1.28; 95% confidence interval, 1.10-1.48, P = .001). Moreover, mortality was higher among patients treated in large hospitals or in the capital area for initial treatment, and this association was greater for patients from rural areas.

DISCUSSION

Fragmentation of cancer care was associated with reduced survival, and the risk of mortality was higher among patients who moved from large to small hospitals.

Fragmentation of Care in Patients with Peritoneal Metastases Undergoing Cytoreductive Surgery

BACKGROUND

The delivery of multimodal treatment at a high-volume center is known to optimize the outcomes of gastrointestinal malignancies. However, patients undergoing cytoreductive surgery (CRS) for peritoneal metastases often must 'fragment' their surgical and systemic therapeutic care between different institutions. We hypothesized that this adversely affects outcomes.

PATIENTS AND METHODS

Adults undergoing CRS for colorectal or appendiceal adenocarcinoma at our institution between 2016 and 2022 were identified retrospectively and grouped by care network: 'coordinated care' patients received exclusively in-network systemic therapy, while 'fragmented care' patients received some systemic therapy from outside-network providers. Factors associated with fragmented care were also ascertained. Overall survival (OS) from CRS and systemic therapy-related serious adverse events (SAEs) were compared across the groups.

RESULTS

Among 85 (80%) patients, 47 (55%) had colorectal primaries and 51 (60%) received fragmented care. Greater travel distance [OR 1.01 (CI 1.00-1.02), p = 0.02] and educational status [OR 1.04 (CI 1.01-1.07), p = 0.01] were associated with receiving fragmented care. OS was comparable between patients who received fragmented and coordinated care in the colorectal [32.5 months versus 40.8 months, HR 0.95 (CI 0.43-2.10), p = 0.89] and appendiceal [31.0 months versus 27.4 months, HR 1.17 (CI 0.37-3.74), p = 0.55] subgroups. The frequency of SAEs (7.8% versus 17.6%, p = 0.19) was also similar.

CONCLUSIONS

There were no significant differences in survival or SAEs based on the networks of systemic therapy delivery. This suggests that patients undergoing CRS at a high-volume center may safely receive systemic therapy at outside-network facilities with comparable outcomes.

The effect of fragmented cancer care and change in nurse staffing grade on cancer patient mortality

BACKGROUND

Continuity of patient care ensures timely and appropriate care and is associated with better patient outcomes among cancer patients. However, the impact of nurse staffing grade changes on patient outcomes remains unknown.

AIMS

This retrospective cohort study aimed to evaluate the effect of fragmented care and changes in nurse staffing grade on the survival of colorectal cancer patients who underwent surgery.

METHODS

This study included 2228 newly diagnosed colorectal cancer patients. Fragmented care was defined as the receipt of treatment in multiple hospitals and was divided into three categories based on changes in nurse staffing grade. Five-year survival rates were used to evaluate the effect of fragmented care and nurse staffing grade on outcomes of cancer patients. Survival analysis was performed by adjusting for covariates using the Cox proportional hazards model for 5-year mortality.

RESULTS

Approximately 18.5% of patients died within 5 years; the mortality rate during cancer treatment was higher in patients who received fragmented care, especially in those transferred to hospitals with fewer nurses. Patients who received fragmented care had shorter survival times, and those transferred to hospitals with fewer nurses had higher risks of 5-year mortality (hazard ratio: 1.625; 95% CI: [1.095, 2.412]). Transfers to hospitals with fewer nurses were associated with increased mortality rates in low-income patients, hospitals located in metropolitan and rural areas, and high-severity groups.

LINKING EVIDENCE TO ACTION

Receipt of fragmented care and change in nurse staffing grade due to patients' transfer to different hospitals were associated with increased mortality rates in cancer patients, thus underlining the importance of ensuring continuity and quality of care. Patients from rural areas, from low-income families, and with high disease severity may have better outcomes if they receive treatment in well-staffed hospitals.

Pancreatic Adenocarcinoma: Real World Evidence of Care Delivery in AccessHope Data

BACKGROUND

Pancreatic adenocarcinoma is an aggressive disease and the delivery of comprehensive care to individuals with this cancer is critical to achieve appropriate outcomes. The identification of gaps in care delivery facilitates the design of interventions to optimize care delivery and improve outcomes in this population.

METHODS

AccessHope™ is a growing organization that connects oncology subspecialists with treating providers through contracts with self-insured employers. Data from 94 pancreatic adenocarcinoma cases (August 2019-December 2022) in the AccessHope dataset were used to describe gaps in care delivery.

RESULTS

In all but 6% of cases, the subspecialist provided guideline-concordant recommendations anticipated to improve outcomes. Gaps in care were more pronounced in patients with non-metastatic pancreatic cancer. There was a significant deficiency in germline testing regardless of the stage, with only 59% of cases having completed testing. Only 20% of cases were receiving palliative care or other allied support services. There was no difference in observed care gaps between patients receiving care in the community setting vs. those receiving care in the academic setting.

CONCLUSIONS

There are significant gaps in the care delivered to patients with pancreatic adenocarcinoma. A concurrent subspecialist review has the opportunity to identify and address these gaps in a timely manner.

Is Fragmented Cancer Care Associated With Medical Expenditure? Nationwide Evidence From Patients With Lung Cancer Using National Insurance Claim Data

Objectives: We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data. Methods: We identified National Health Insurance beneficiaries diagnosed with lung cancer in South Korea from 2010 to 2014. We included 1,364 lung cancer patients with reduced immortal time bias and heterogeneity. We performed multiple regression analysis using a generalized estimate equation with a gamma distribution for medical expenditures. Results: Among the 1,364 patients with lung cancer, 12.8% had fragmented cancer care. Healthcare costs were higher in fragmented cancer care for both during diagnosis to 365 days and diagnosis to 1,825 days. Linear regression results showed that fragmented cancer care was associated with 1.162 times higher costs during the period from diagnosis to 365 days and 1.163 times the cost for the period from diagnosis to 1,825 days. Conclusion: We found fragmented cancer care is associated with higher medical expenditure. Future health policy should consider the limitation of patients' free will when opting for fragmented cancer care, as there are currently no control mechanisms.

Readmission outcomes following infectious hospitalization: same-care unit performed better than different-care unit

BACKGROUND

Previous studies showed that same-hospital readmission is associated with better outcomes than different-hospital readmission. However, little is known about whether readmission to the same care unit (same-care unit readmission) after infectious hospitalization performs better than readmission to a different care unit at the same hospital (different-care unit readmission).

METHODS

This retrospective study screened patients rehospitalized within 30 days following admission to two acute medical wards for infectious diseases from 2013 to 2015 and included only those readmitted for unplanned medical reasons. Outcomes of interest included hospital mortality and length of stay of readmitted patients.

RESULTS

Three hundred and fifteen patients were included; of those, 149(47%) and 166(53%) were classified as same-care unit and different-care unit readmissions, respectively. Same-care unit patients were more likely to be older(76 years vs. 70 years; P = 0.001), have comorbid chronic kidney disease(20% vs. 9%; P = 0.008), and have a shorter time to readmission(13 days vs. 16 days; P = 0.020) than different-care unit patients. Univariate analysis showed that same-care unit patients had a shorter length of stay than different-care unit patients(13 days vs. 18 days; P = 0.001), but had similar hospital mortality(20% vs. 24%; P = 0.385). The multivariable linear regression model indicated that same-care unit readmission was associated with a 5-day shorter hospital stay than different-care unit readmission(P = 0.002).

CONCLUSION

Among patients readmitted within 30 days after hospitalization for infectious diseases, same-care unit readmission was associated with a shorter length of hospital stay than different-care unit readmission. Whenever feasible, it is encouraged to allocate a readmitted patient to the same care unit in hope of pursuing continuity and quality of care.

Multi-institutional Care in Clinical Stage II and III Esophageal Cancer

BACKGROUND

Management of clinical stage II or III esophageal cancer requires multidisciplinary care. Multi-institutional care has been associated with worse survival in other malignant diseases. This study aimed to determine the impact of multi-institutional care on survival in patients with stage II or III esophageal cancer.

METHODS

The 2004 to 2016 National Cancer Database was queried for patients with clinical stage II or III esophageal cancer who received neoadjuvant chemotherapy with or without radiation therapy followed by surgical resection. Patients were stratified into 2 groups: multi-institutional or single-institution care. Survival between groups was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. Multivariable logistic regression was performed to identify factors associated with multi-institutional care.

RESULTS

Overall, 11 399 patients met study criteria: 6569 (57.6%) received multi-institutional care and 4,830 (42.4%) received care at a single institution. In a multivariable analysis, factors associated with multi-institutional care were later year of diagnosis, greater distance from treating facility, residence in an urban or rural setting (vs metro), and residence in states without Medicaid expansion. Care at a single institution was associated with Black race, lack of insurance, and treatment at higher-volume or academic centers. Despite these differences, patients who received multi-institutional care had survival comparable to that in patients who received care at a single institution (HR, 0.97; 95% CI, 0.92-1.03; P = .30).

CONCLUSIONS

In this National Cancer Database analysis, multi-institutional care was not associated with inferior overall survival. As complex cancer care becomes more regionalized, patients may consider receiving part of their cancer care closer to home, whereas traveling to surgical centers of excellence should be encouraged.

Does fragmented cancer care affect survival? Analysis of gastric cancer patients using national insurance claim data

BACKGROUND

We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data.

METHODS

From a nationwide sampled cohort database, we identified National Health Insurance beneficiaries diagnosed with gastric cancer (ICD-10: C16) in South Korea during 2005-2013. We analyzed the results of a multiple logistic regression analysis using the generalized estimated equation model to investigate which patient and institution characteristics affected fragmented cancer care during the first year after diagnosis. Then, survival analysis using the Cox proportional hazard model was conducted to investigate the association between fragmented cancer care and five-year mortality.

RESULTS

Of 2879 gastric cancer patients, 11.9% received fragmented cancer care by changing their most visited medical institution during the first year after diagnosis. We found that patients with fragmented cancer care had a higher risk of five-year mortality (HR: 1.310, 95% CI: 1.023-1.677). This association was evident among patients who only received chemotherapy or radiotherapy (HR: 1.633, 95% CI: 1.005-2.654).

CONCLUSIONS

Fragmented cancer care was associated with increased risk of five-year mortality. Additionally, changes in the most visited medical institution occurred more frequently in either patients with severe conditions or patients who mainly visited smaller medical institutions. Further study is warranted to confirm these findings and examine a causal relationship between fragmented cancer care and survival.

Fragmentation of Care in Pancreatic Cancer: Effects on Receipt of Care and Survival

BACKGROUND

The impact of fragmentation of care (FC), i.e., receipt of care at > 1 institution, on treatment of pancreatic cancer is unknown. The purpose of this study was to determine factors associated with FC in curative-intent treatment of pancreatic cancer (PDAC) patients and evaluate how FC affects survival outcomes.

METHODS

Using the National Cancer Database (NCDB), data on stage I-III PDAC patients diagnosed 2006-2016 were extracted. Multiple logistic regression analyses were performed to identify factors predictive of FC and survival.

RESULTS

Of the 20,013 patients identified, 24.1% had FC. Factors predictive of FC were stage-III tumors (odds ratio [OR] 1.36; p = 0.014), higher median-income [third quartile (OR 1.38; p = 0.006) and highest-quartile (OR 1.50; p = 0.003)], care at high-volume facility (OR 1.47; p < 0.001), and receipt of multi-modal therapy (OR 1.69; p < 0.001). In contrast, age > 80 years (OR 0.82; p = 0.018), Black (OR 0.85; p = 0.013) or Asian race (OR 0.76; p = 0.033), Charlson comorbidity-index 2 (OR 0.85; p = 0.033), treatment at non-academic facility (OR 0.87; p = 0.041), and non-private insurance were negatively predictive of FC. FC independently predicted decreased 30-day [OR 0.57; p < 0.001] and 90-day mortality [OR 0.61; p < 0.001] and improved overall survival [hazard ratio 0.91; p < 0.001].

DISCUSSION

Sociodemographic factors are significantly associated with FC in curative-intent treatment of PDAC patients. FC was found to predict improved 30-day, 90-day, and overall survival outcomes.

Care Fragmentation in Patients with Differentiated Thyroid Cancer

BACKGROUND

Among surgical patients, care fragmentation (CF) is associated with worse outcomes. However, oncologic literature documents an association between high surgical volume and improved outcomes, favoring centralized cancer-surgery centers and thus predisposing to CF in patients with surgically treated tumors. We aimed to identify features associated with CF and ascertain differences in overall survival (OS) among patients with differentiated thyroid cancer (DTC).

METHODS

The National Cancer Database was queried for DTC patients diagnosed from 2009 to 2017. Patients experienced CF if part of their treatment was performed outside of the reporting facility or an associated office. A multivariable logistic regression analysis identified independent features associated with CF. A Cox multivariable regression analysis assessed the impact of CF on OS. A Kaplan-Meier analysis compared survival differences between patients experiencing CF or unified care (UC).

RESULTS

A total of 131,620 patients were included. Among them, 70,204 (53.3%) experienced CF and 61,416 (46.7%) experienced UC. Age < 55, residing in high-income areas, and stage 3 and 4 tumors were features independently associated with CF, whereas uninsured patients were less likely to experience CF than the privately insured. The features most strongly associated with CF were treatment at highest thyroid cancer-surgery volume institutions and traveling in the top distance quartile. While patients with CF experienced minor delays in time from diagnosis to surgery, 5-year OS was improved among patients with CF compared to UC for those with Stage 1-3 disease.

CONCLUSIONS

Among patients with DTC, CF is associated with treatment at a highest thyroid cancer surgery volume facility and improved OS in a setting of minor treatment delays.

Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer

BACKGROUND

Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival.

METHODS

The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods.

RESULTS

Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05).

CONCLUSIONS

For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.

Clinical Research Professional Providing Care Coordination Support: A Study of Hawaii Minority/Underserved NCORP Community Site Trial Participants

PURPOSE

Although effective care coordination (CC) is recognized as a vital component of a patient-centered, high-quality cancer care delivery system, CC experiences of patients who enroll and receive treatment through clinical trials (CTs) are relatively unknown. Using mixed methods, we examined perceptions of CC among patients enrolled onto therapeutic CTs through the Hawaii Minority/Underserved National Cancer Institute Community Oncology Research Program.

METHODS

The Care Coordination Instrument, a validated instrument, was used to measure patients' perceptions of CC among CT participants (n = 45) and matched controls (n = 45). Paired t-tests were used to compare overall and three CC domain scores (Communication, Navigation, and Operational) between the groups. Semistructured focus group interviews were conducted virtually with 14 CT participants in 2020/2021.

RESULTS

CT participants reported significantly higher total CC scores than non-CT participants (P = .0008). Similar trends were found for Navigation and Operational domain scores (P = .007 and .001, respectively). Twenty-nine percent of CT participants reported receiving high-intensity CC assistance from their clinical research professionals (CRPs). Content analysis of focus group discussions revealed that nearly half of the focus group discussions centered on CRPs (47%), including CC support provided by CRPs (26%). Other key themes included general CT experiences (22%) and CRP involvement as an additional benefit to CT participation (15%).

CONCLUSION

Our results show that patients on CTs in this study had a more positive CC experience. This may be attributable in part to CC support provided by CRPs. These findings highlight both the improved experience of treatment for patients participating in a trial and the generally unrecognized yet integral role of CRPs as part of a cancer CT care team.

Fragmentation of care and colorectal cancer survival in South Korea: comparisons according to treatment at multiple hospitals

PURPOSE

Fragmented cancer care (FC) means that patients visit multiple providers for treatment, which is common in cancer care. While FC is associated with poor health outcomes in patients with colorectal cancer (CRC) worldwide, there is still a lack of evidence in South Korea. We investigated the association between FC and 5-year morality in patients with CRC using population-based claims data.

METHODS

The study population was followed up from 2002 to 2015. Data were collected from Korea National Health Insurance claims. Participants comprised patients with CRC diagnosed with International Classification of Diseases (ICD)-10 (C18.x-C20.x) and a special claim code for cancer (V193). Data were analyzed using the Kaplan-Meier curve with a log-rank test and Cox proportional hazard model. The effect of FC on patients' 5-year survival was examined.

RESULTS

Of 3467 patients with CRC, 20.0% had experienced FC. FC was significantly associated with an increased risk of 5-year mortality (hazard ratio 1.516, 95% confidence interval 1.274-1.804). FC was prevalent in those who had a low income level, underwent chemotherapy, did not undergo radiation therapy, and did not visit a tertiary hospital for their first treatment.

CONCLUSION

Efforts to decrease FC and integrate complex cancer care within appropriate healthcare delivery systems may improve survivorship among patients with CRC.

Impact of care fragmentation on the outcomes of patients receiving neoadjuvant and adjuvant therapy for pancreatic adenocarcinoma

INTRODUCTION

Neoadjuvant therapy (NT) is increasingly used for localized pancreatic ductal adenocarcinoma (PDAC). The impact of care fragmentation during NT on the outcomes of patients with PDAC is unknown.

METHODS

Adult patients with Stage I-III PDAC who received NT and patients who underwent surgery first followed by adjuvant therapy (AT) between 2004 and 2016 were queried from the National Cancer Database. Short- and long-term outcomes were compared between patients who received fragmented care (FC; care provided at >1 hospital) versus integrated care (IC; care at a single institution).

RESULTS

Among 6522 patients who underwent NT before pancreatectomy, 3755 (57.6%) received FC and 2767 (42.4%) received IC. While patients who received FC had a longer time to initiation of treatment (33.2 vs. 29.7 days, p < 0.001), there was no difference in median overall survival (OS) (26.7 vs. 26.5 months, p = 0.6). Among patients who underwent upfront surgery followed by AT (n = 15 291), patients who received FC had a longer time from diagnosis to undergoing surgery but less time from surgery to AT and no difference in OS (24.0 vs. 24.0 months, p = 0.910).

CONCLUSION

Although care fragmentation was associated with slightly longer times to initiate and complete treatment among patients with localized PDAC, long-term survival outcomes were similar.

Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non-Index Hospitals

OBJECTIVE

To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease.

METHODS

All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively.

RESULTS

Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non-index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p <0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode-based costs were higher in the non-index setting, with a mean difference of $783 (Non-index: $13,672, 95% CI $13,292 - $14,053; Index: $12,889, 95% CI $12,677 - $13,102; p < 0.001).

CONCLUSIONS

Re-presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode-related health encounters, longer time to definitive surgery, and increased costs.

Non-inferiority of fragmented care for high-risk pediatric neuroblastoma patients: a single institution analysis

Pediatric neuroblastoma (NB) patients receive multi-modal therapy and may experience care fragmented among multiple institutions with a significant travel burden, which has been associated with poor outcomes for some adult cancers. We hypothesized that fragmented care for pediatric NB patients is associated with inferior outcomes compared to treatment consolidated at one location. We reviewed paper and electronic records for pediatric NB patients who received ≥1 hematopoietic stem cell transplant (HSCT) at Duke from 1990-2017. Fragmented care was defined by treatment at >1 institution and grouped by 2 institutions vs. 3+ institutions. Distances were calculated using Google Maps. To compare all care groups, we used Fisher's Exact and Kruskal-Wallis tests for demographic and treatment characteristics, Kaplan-Meier for unadjusted overall survival (OS), and Cox proportional hazards for factors associated with OS. Of 127 eligible patients, 102 (80.3%) patients experienced fragmented care, with 17 treated at 3+ facilities. Kaplan-Meier analysis did not associate fragmented care with increased mortality (log-rank p = 0.13). With multivariate analysis, only earlier diagnostic decade and greater distance to HSCT remained significantly associated with worsened OS. In this single institutional study, we found fragmented care did not impact overall survival. Worsened overall survival was associated with increased travel distance for HSCT and further research should aim to improve supportive processes for patients undergoing HSCT for high-risk neuroblastoma.

The growing trend for no primary surgery in colorectal cancer

AIM

In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery.

METHOD

We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management.

RESULTS

A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival.

CONCLUSION

A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.

Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

PURPOSE

Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation.

MATERIALS AND METHODS

We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation.

RESULTS

Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05).

CONCLUSION

The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

Fragmentation of surgery and chemotherapy in the initial phase of ovarian cancer care and its association with overall survival

BACKGROUND

Fragmentation occurs when a patient receives care at more than one hospital, and the long-term effects in ovarian cancer are unknown. We examined the association between fragmentation of primary debulking surgery (PDS) and adjuvant chemotherapy (AC) and overall survival (OS).

METHODS

The National Cancer Database was used to identify women with stage II-IV epithelial ovarian cancer between 2004 and 2016 who underwent PDS followed by AC. Fragmentation was defined as receipt of AC at a different institution than where PDS was performed. After propensity score weighting, proportional hazard models were developed to estimate the association between fragmented care and OS.

RESULTS

Of the 36,300 patients identified, 13,347 (36.8%) had fragmented care. Patient factors associated with fragmentation included older age, higher income, and longer travel distance for PDS; hospital factors included PDS performed at a community center or a facility with lower annual surgical volume (P < 0.05, all). Fragmentation was associated with a 15% risk of 30-day delay to AC (aRR 1.15, 95% CI 1.09-1.22). In a propensity scoring weighted analysis, mortality was reduced when AC was fragmented (HR 0.95, 95% CI 0.92-0.97). Sensitivity analyses indicated fragmentation was associated with improved survival in metropolitan residents. Stratified analyses indicated patients who traveled 50 miles or more with PDS and AC at the same institution had the worst OS.

CONCLUSION

Fragmentation of PDS and AC has no adverse effects on long-term survival. Survival outcomes were worst for those who received care at the same institution 50 miles or more away.

Does Fragmentation of Care in Locally Advanced Rectal Cancer Increase Patient Mortality?

OBJECTIVE

To evaluate health care fragmentation in patients with stage II and III rectal cancers.

BACKGROUND

Fragmentation of care among multiple hospitals may worsen outcomes for cancer patients.

METHODS

National Cancer Database was queried for adult patients who underwent radiation and surgery for locally advanced (stage II-III) rectal adenocarcinoma from 2006 to 2015. Fragmented care was defined as receiving radiation at a different hospital from surgery. Descriptive statistics characterized patients, and survival probability was plotted using the Kaplan-Meier method and a Cox proportional hazards model.

RESULTS

A total of 37,081 patients underwent surgery and radiation for stage II-III rectal cancer from 2006 to 2015 (24,102 integrated care vs. 12,979 fragmented care). Patients who received fragmented care (hazard ratio [HR] 1.105; 95% CI 1.045-1.169) had a higher risk of mortality. Patients who received at least surgery (HR 0.84; 95% CI 0.77-0.92) at academic hospitals had a lower risk of mortality. Academic hospitals had a higher proportion of patients with fragmented care (38.0 vs. comprehensive community 32.8% vs. community 33.8%, p < 0.001). Within academic hospitals, fragmented care portended worse survival (integrated academic 80.0% vs. fragmented academic 76.7%, p = 0.0002). Fragmented care at academic hospitals had increased survival over integrated care at community hospitals (fragmented academic 76.7 vs. integrated community 72.2%, p = 0.00039).

CONCLUSIONS

In patients with stage II-III rectal cancer, patients who have integrated care at academic hospitals or at least surgery at academic centers had better survival. All efforts should be made to reduce care fragmentation and surgery at academic centers should be prioritized.

Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers

Background

Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described.

Objective

To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes.

Research design

We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers.

Subjects

Adult patients with 4 or more inpatient stays in 1 year.

Measures

Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer.

Results

Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer.

Conclusions

Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06323-5.

Examining Health Care Mobility of Transgender Veterans Across the Veterans Health Administration

Purpose: Transgender veterans are overrepresented in the Veterans Health Administration (VHA) compared with in the general population. Utilization of multiple different health care systems, or health care mobility, can affect care coordination and potentially affect outcomes, either positively or negatively. This study examines whether transgender veterans are more or less health care mobile than nontransgender veterans and compares the patterns of geographic mobility in these groups. Methods: Using an established cohort (n = 5,414,109), we identified 2890 transgender veterans from VHA electronic health records from 2000 to 2012. We compared transgender and nontransgender veterans on sociodemographic, clinical, and health care system-level measures and conducted conditional logistic regression models of mobility. Results: Transgender veterans were more likely to be younger, White, homeless, have depressive disorders, post-traumatic stress disorder (PTSD), and hepatitis C. Transgender veterans were more likely to have been health care mobile (9.9%) than nontransgender veterans (5.2%) (unadjusted odds ratio = 2.02, 95% confidence interval = 1.73-2.36). In a multivariable model, transgender status, being separated/divorced, receiving care in less-complex facilities, and diagnoses of depression, PTSD, or hepatitis C were associated with more mobility, whereas older age was associated with less mobility. For the top three health care systems utilized, a larger proportion of transgender veterans visited a second health care system in a different state (56.2%) than nontransgender veterans (37.5%). Conclusions: Transgender veterans were more likely to be health care mobile and more likely to travel out of state for health care services. They were also more likely to have complex chronic health conditions that require multidisciplinary care.

Impact of Treatment Coordination on Overall Survival in Rectal Cancer

BACKGROUND

Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer.

METHODS

A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models.

RESULTS

A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P< .001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P< .001) but not for stage IV (P= .474).

CONCLUSION

Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.

Outcomes after readmission at the index or nonindex hospital following acute myocardial infarction complicated by cardiogenic shock

Little is known about the prevalence and outcomes of readmission to nonindex hospitals after an admission for acute myocardial infarction complicated by cardiogenic shock (AMI‐CS). We aimed to determine the rate of nonindex readmissions following AMI‐CS and to evaluate its association with clinical factors, hospitalization cost, length of stay (LOS), and in‐hospital mortality rates.

Hypothesis

Nonindex readmission may lead to worse in‐hospital outcomes.

Methods

We reviewed the data of inpatients with AMI‐CS between 2010 and 2017 using the National Readmission Database. The survey analytical methods recommended by the Healthcare Cost and Utilization Project were used for national estimates. Multiple regression models were used to evaluate the predictors of nonindex readmission, and its association with hospitalization cost, LOS, and in‐hospital mortality rates.

Results

Of 238 349 patients with AMI‐CS, 28028 (11.76%) had an unplanned readmission within 30 days. Of these patients, 7423 (26.48%) were readmitted to nonindex hospitals. Compared with index readmission, nonindex readmission was associated with higher hospitalization costs (p < .0001), longer LOS (p < .0001), and increased in‐hospital mortality rates (p = .0016). Patients who had a history of percutaneous coronary intervention, received intubation/mechanical ventilation, or left against medical advice during the initial admission had greater odds of a nonindex readmission.

Conclusions

Over one‐fourth of readmissions following AMI‐CS were to nonindex hospitals. These admissions were associated with higher hospitalization costs, longer LOS, and higher in‐hospital mortality rates. Further studies are needed to evaluate whether a continuity of care plan in the acute hospital setting can improve outcomes after AMI‐CS.

Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy

BACKGROUND

The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care.

STUDY DESIGN

A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution.

RESULTS

From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival.

CONCLUSIONS

This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.

Does multicenter care impact the outcomes of surgical patients with gastrointestinal malignancies requiring complex multimodality therapy?

BACKGROUND

Regionalization of oncologic care has increased, but less is known whether patient outcomes are influenced by receipt of multimodality care through multicenter care (MCC) or single-center care (SCC).

METHODS

Patients from 2004 to 2015 National Cancer Data Base diagnosed with stage II-III esophageal (EA), stage II-III pancreatic (PA), and stage II-IV rectal (RA) adenocarcinoma who underwent resection at a high volume center (HVC) and required radiation and/or chemotherapy were included. MCC (care at 2+ facilities) and SCC patients were propensity-score matched 1:2 and Cox proportional hazards regression used to analyze survival.

RESULTS

On multivariable regression analysis, MCC in RA patients (N = 325/2097, 15.5%) was more associated with residing ≥40 miles from the HVC (odds ratio [OR] = 2.37; P = .044) and receipt of neoadjuvant chemotherapy (1.42, P = .040). In PA patients (N = 75/380, 19.7%), residing ≥40 miles from the HVC (OR = 3.22; P = .001), and in EA patients (N = 88/534, 16.5%), younger patients (<50 years: OR = 2.96; P = .011) were associated with MCC. Following propensity score matching, EA (N = 147), PA (N = 133), and RA (N = 661) patients had no difference in 1-year and 3-year overall survival when comparing MCC to SCC.

CONCLUSIONS

The use of MCC appears safe without a difference in survival and may offer significant advantages in convenience to patients as they undergo their complex oncologic care.

Frequency of Care Fragmentation and Its Impact on Outcomes in Acute and Chronic Pancreatitis in a Nationally Representative Sample

OBJECTIVES

Hospitalized patients with acute and chronic pancreatitis (AP and CP) are prone to frequent readmissions to different hospitals. The rate of care fragmentation and its impact on important outcomes are unknown. The aims of this study were to evaluate the rate and predictors of care fragmentation in patients hospitalized with AP and CP using a nationally representative sample, and to analyze the impact of care fragmentation on mortality, cost, and hospital readmissions.

METHODS

We identified all adult hospitalizations with a primary diagnosis of AP or CP in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We calculated 30- and 90-day readmission and care fragmentation rates. Readmission to a nonindex hospital was considered care fragmentation. Logistic regression was used to determine hospital and patient factors independently associated with 30-day care fragmentation. Patients readmitted within 30 days were followed for 60 days postdischarge from the first readmission. Mortality during the first readmission, hospitalization costs, and rates of 60-day readmission were compared between those with and without care fragmentation.

RESULTS

There were 479,427 admissions with AP and 25,513 with CP. The rates of 30- and 90-day readmissions were 13.5% and 22.9% for AP and 26.9% and 44.7%% for CP. The rates of 30- and 90-day care fragmentation were 28% and 32% for AP and 33% and 38% for CP. Younger age (younger than 45 y), male patients, length of stay <5 days, ≥4 Elixhauser comorbidities, and self-pay or Medicaid insurance were associated with increased risk of 30-day care fragmentation. Large hospital size, routine discharge, and metropolitan location were associated with lower risk. Patients who had the first readmission to a nonindex hospital had a higher mortality (2% vs 1.6%, P = 0.005), length of stay (6.5 vs 5.6 days, P < 0.0001), mean hospitalization cost ($16,731 vs $13,368, P < 0.0001), and 60-day readmission (48.4% vs 42.9%) compared with those readmitted to the index hospital.

CONCLUSIONS

In patients with AP and CP, one-third of 90-day readmissions occur at a nonindex hospital. Care fragmentation is associated with increased mortality, readmissions, and cost of care.

Differences in ambulatory care fragmentation between cancer survivors and noncancer controls

BACKGROUND

Patients with chronic conditions are treated by many providers, which can increase the risk of communication gaps across providers and potential harm to patients. However, to the authors' knowledge, the extent of fragmented care among this population is unknown. In the current study, the authors sought to determine whether cancer survivors have more fragmented care than noncancer controls and to quantify the extent of fragmentation.

METHODS

Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study linked to Medicare claims were used. The authors included beneficiaries with continuous Part A and B coverage for 12 months at the time of their baseline REGARDS survey. The primary outcome of the current study was claims-based fragmentation over 12 months, which was calculated using the reversed Bice-Boxerman Index so a higher score reflected greater fragmentation. Unadjusted differences in fragmentation were compared between cancer survivors and controls. Beta regression models were used to estimate associations between cancer status and fragmentation, adjusting for potential confounders.

RESULTS

The authors included 4922 participants aged ≥65 years at baseline. Of these patients, approximately 21% were cancer survivors. Survivors had a median of 11 visits (interquartile range, 7-15 visits) with 5 providers compared with controls, who had a median of 9 visits (interquartile range, 6-14 visits) with 4 providers (P < .0001). Cancer survivors had significantly more fragmented care compared with controls (median reversed Bice-Boxerman Index, 0.80 vs 0.76; P < .0001). After adjusting for confounders, cancer survivors had an increased odds of having fragmented care (odds ratio, 1.08; 95% CI, 1.02-1.14).

CONCLUSIONS

Care fragmentation is more prevalent among cancer survivors compared with those without a history of cancer. Future studies should examine whether fragmentation puts survivors at risk of worse outcomes.

Development and psychometric evaluation of a questionnaire to measure cancer patients' perception of care coordination

BACKGROUND

Although the importance of care coordination (CC) is well-recognized, cancer patients often receive poorly coordinated care across varied care settings and different oncology providers. Efforts to improve cancer care are hampered by lack of adequate measures. In this two-part, mixed-method study, we describe the development, refinement, and validation of a new care coordination instrument (CCI) designed to assess cancer patients' perception of CC.

METHODS

In Study 1, an initial CCI was developed incorporating questions based on literature review. The items were then modified following four field tests conducted in a large academic hospital with oncology nurses (n = 20) and cancer patients (n = 120). This modified instrument was used to determine whether the CCI was able to distinguish CC between two practices (30 GI and 30 myeloma patients) within the same hospital setting. In Study 2, 68 patients receiving community-based care participated in seven focus groups. Based on these discussions, the CCI items were again refined, and psychometric evaluation was conducted to assess the quality of the instrument.

RESULTS

Based on field tests, 3 domains of the CCI, Communication, Navigation, and Operational, were defined as critical components of CC. The Operational domain evaluates efficiency of care and is unique to this CCI. The field test demonstrated that GI patients reported significantly better CC Overall and for the Communication and Navigation domains (all p < .05). In Study 2, patients expressed concordance with the CCI items and their CC experiences, establishing validity of the CCI. Qualitative analysis of the focus group discussions indicated that the items with the highest frequencies of participants' comments were related to the concepts of Navigator, Team, Survey, and Communication. Quantitative analysis identified items with a limited response range or high rates of "neutral" responses; accordingly, those items were removed. The final CCI survey is a 29 item, multiple-choice questionnaire with excellent reliability, Cronbach's α = .922.

CONCLUSIONS

We developed a novel, patient-centered tool with excellent psychometric properties that can be utilized across varied practice settings to assess patients' perception of cancer care coordination.

TRIAL REGISTRATION

Not required; retrospectively registered ClinicalTrials.gov NCT03594006 20 July 2018.

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

BACKGROUND

Fragmented cancer care (FC), or care received from multiple institutions, increases systemic health care costs and potentiates cancer care disparities. There is a paucity of data on mechanisms contributing to FC and the resulting effect on patient outcomes. This study characterized patient- and hospital-level factors associated with FC, time to treatment (TTT), and overall survival (OS) in patients with hepatocellular carcinoma (HCC).

METHODS

Patients newly diagnosed with HCC from 2004 to 2015 and receiving treatment were identified in the Texas Cancer Registry. Patient- and hospital-level factors were compared across 2 cohorts: an FC treatment group and a nonfragmented cancer care (NFC) treatment group. Covariate-adjusted treatment use and OS were compared between the 2 treatment groups.

RESULTS

Among 4329 patients with HCC, 1185 (27.4%) received FC, and 3144 (72.6%) received NFC. Compared with NFC patients, FC patients had larger tumors (median size ≥4 cm, 52.6% vs 35.2%; P < .001), and a higher proportion had a regional/metastatic stage (35.9% vs 26.7%; P < .001). Among patients with localized disease, FC was associated with decreased odds of curative therapy (odds ratio, 0.83; 95% confidence interval [CI], 0.7-0.9). FC was associated with worse OS (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24) and increased TTT (HR, 0.76; 95% CI, 0.7-0.8). In the subset of patients with localized-stage HCC who received curative therapy, FC was associated with worse OS (median survival, 67 vs 43 months; HR, 1.2; 95% CI, 1.0-1.4) and increased TTT (HR, 0.74; 95% CI, 0.7-0.8).

CONCLUSIONS

FC patients were less likely to undergo curative therapy when they were diagnosed at an early stage. After covariate adjustment, newly diagnosed patients with HCC receiving FC had worse OS and increased TTT.

Same- vs Different-Hospital Readmissions in Patients With Cirrhosis After Hospital Discharge

INTRODUCTION

There is a lack of data on the impact of readmission to the same vs a different hospital following an index hospital discharge in cirrhosis patients.

METHODS

We sought to describe rates and predictors of different-hospital readmissions (DHRs) among patients with cirrhosis and also determine the impact on cirrhosis outcomes including all-cause inpatient mortality and hospital costs. Using the national readmissions database, we identified cirrhosis hospitalizations in 2013. Regression analysis was used to determine the predictors of DHRs. A time-to-event analysis was performed to assess the impact on subsequent readmissions and all-cause inpatient mortality.

RESULTS

In 2013, there were 109,039 cirrhosis readmissions with 67% of these being same-hospital readmissions and 33% being DHRs (P < 0.001). Two percent of readmitted patients were treated at ≥4 different hospitals. The 30-day readmission rate was 29.1%. Predictors of DHR included Medicaid payer (adjusted odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.01-1.14), age (OR 0.98, 95% CI 0.978-0.982), elective admission (OR 1.09, 95% CI 1.01-1.17), hepatic encephalopathy (OR 1.20, 95% CI 1.16-1.25), hepatorenal syndrome (OR 1.09, 95% CI 1.03-1.16), and low socioeconomic status (OR 1.15, 95% CI 1.06-1.25). No difference was observed in 30-day readmission risk following a DHR (adjusted hazard ratio 1.044, 95% CI 0.975-1.118). In addition, there was no increased risk of inpatient death observed during a DHR within 30 days (adjusted hazard ratio 1.08, 95% CI 0.94-1.23). However, patients with DHR had significantly higher hospital costs and length of stay.

CONCLUSIONS

Majority of cirrhosis readmissions are same-hospital readmissions. Different-hospital readmissions do not increase the risk of 30-day readmissions and inpatient mortality but are associated with higher hospital costs.

Cancer care coordination: opportunities for healthcare delivery research

In this commentary, we discuss opportunities to explore issues related to care coordination at three points on the cancer care continuum: (1) screening, particularly coordinating follow-up for abnormal findings, (2) active treatment, particularly challenges for patients with multiple chronic conditions, and (3) survivorship, particularly issues related to facilitating shared care between oncology and primary care. For each point on the continuum, we briefly summarize some of the important coordination issues and discuss potential avenues for future research in the context of existing evidence.

Factors Associated with Emergency Department Utilization and Admission in Patients with Colorectal Cancer

PURPOSE

We assessed emergency department (ED) utilization in patients with colorectal cancer to identify factors associated with ED visits and subsequent admission, as well as identify a high-risk subset of patients that could be targeted to reduce ED visits.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was retrospectively analyzed to identify patients with colorectal cancer from 2008 to 2014. Multivariable logistic regression was used to identify factors associated with ED visits and ED "super-users" (3+ visits). Repeated measures analysis was used to model ED visits resulting in hospitalization as a logistic regression based on treatments 30 days prior to ED visit.

RESULTS

Of 13,466 patients with colorectal cancer, 7440 (55.2%) had at least one ED visit within 12 months of diagnosis. Factors associated with having an ED visit included non-white race, advancing age, increased comorbidities, and receipt of chemotherapy or radiation. 69.2% of patients who visited the ED were admitted to the hospital. A group of 1834 "super-users" comprised 13.6% of our population yet accounted for 52.1% of the total number of ED visits and 32.3% of admissions.

CONCLUSIONS

Over half of privately insured patients undergoing treatment for colorectal cancer will visit the ED within 12 months of diagnosis. Within this group, we identify common factors for a high-risk subset of patients with three or more ED visits who account for over half of all ED visits and a third of all admissions. These patients could potentially be targeted with alternative management strategies in the outpatient setting.

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

INTRODUCTION

Patients may receive cancer care from multiple institutions. However, at the population level, such patterns of cancer care are poorly described, complicating clinical research. To determine the population-based prevalence and characteristics of patients seen by multiple institutions, we used operations data from a state-mandated cancer registry.

METHODS AND MATERIALS

59,672 invasive cancers diagnosed in 1/1/2010-12/31/2011 in the Greater Bay Area of northern California were categorized as having been reported to the cancer registry within 365days of diagnosis by: 1) ≥1 institution within an integrated health system (IHS); 2) IHS institution(s) and ≥1 non-IHS institution (e.g., private hospital); 3) 1 non-IHS institution; or 4) ≥2 non-IHS institutions. Multivariable logistic regression was used to characterize patients reported by multiple vs. single institutions.

RESULTS

Overall in this region, 17% of cancers were reported by multiple institutions. Of the 33% reported by an IHS, 8% were also reported by a non-IHS. Of non-IHS patients, 21% were reported by multiple institutions, with 28% for breast and 27% for pancreatic cancer, but 19%% for lung and 18% for prostate cancer. Generally, patients more likely to be seen by multiple institutions were younger or had more severe disease at diagnosis.

CONCLUSIONS

Population-based data show that one in six newly diagnosed cancer patients received care from multiple institutions, and differed from patients seen only at a single institution. Cancer care data from single institutions may be incomplete and possibly biased.

The Value of Continuity between Primary Care and Surgical Care in Colon Cancer

BACKGROUND

Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs.

METHODS

Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider's main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models.

RESULTS

Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746-$14,577), a 20% reduction in total median cost of care at 12 months.

CONCLUSIONS

Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.