Abstract
Care fragmentation refers to receipt of health care services through multiple institutions. Although care fragmentation has been linked to inferior oncologic outcomes, it also captures "upgrades" to specialized centers. Herein, we investigate the association between care fragmentation and hepatocellular carcinoma survival in California. Hepatocellular carcinoma cases occurring between January 1, 2007, and December 31, 2017, were retrospectively identified through a maintained, statewide database. Care fragmentation was measured (1) as a binary classification of fragmented or nonfragmented care, (2) by the number of facilities visited, and (3) in terms of care directionality through which care fragmentation occurred between Network of Comprehensive Cancer/National Cancer Institute-designated and -nondesignated centers, within 2years of diagnosis. Multivariable time-varying covariate Cox regression analyses were used to model the impact of care fragmentation on overall survival. Of 10,825 patients with hepatocellular carcinoma, 5,778 patients (53.4%) received fragmented care. Compared with nonfragmented care, fragmented care was associated with worse overall survival (hazard ratio, 1.81; 95% confidence interval, 1.72-1.91, P < .001) by our analyses. The quantity of centers visited also corresponded to a greater mortality (2 facilities: hazard ratio, 1.65; 95% confidence interval, 1.56-1.75, P<.001; 3 facilities: hazard ratio, 2.21; 95% confidence interval, 2.02-2.41, P<.001; 4+ facilities: hazard ratio, 2.66; 95% confidence interval, 2.35-3.02, P<.001). Compared with nonfragmented-designated, all other care fragmentation directionality patterns, including fragmented-designated and nondesignated care, decreased overall survival (hazard ratio, 1.74; 95% confidence interval, 1.55-1.95, P<.001). Care fragmentation in surgical patients showed a similar trend for the fragmented-designated and nondesignated pattern (hazard ratio, 1.67; 95% confidence interval, 1.30-2.14, P<.001). In hepatocellular carcinoma, fragmented care is associated with worse survival. Although fragmented-designated and nondesignated care was expected to mitigate such effect, this was not observed. Additional mechanisms driving such findings warrant further investigation.
Published Version
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