The Impact of Care Fragmentation on Pancreatic Cancer Care: More Complex Than It Seems

Abstract

Introduction: Fragmentation of care (FC)—care at >1 facility—has been associated with increased cost, delayed treatment, and worse survival for gastrointestinal cancers. We assessed the impact of FC on pancreatic cancer care in California. Methods: Using the California Cancer Registry, linked with ambulatory surgery, emergency visits and discharge records from the Office of Statewide Health Planning Database, patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) from 2007-2017 were identified. FC was determined by the number of unique facilities where patients received cancer care over the initial 12 months. We evaluated the association between FC and all-cause mortality using multivariable-adjusted Cox regression. Results: Among 9,464 PDAC patients, 4,545 patients received care at 1 facility (48.0%), 3,571 (37.7%) at 2, and 1,348 (14.2%) at >3. After adjusting for patient, tumor and hospital characteristics, female sex (HR=0.93 [0.89-0.97], p=0.001), high socioeconomic status (highest vs lowest quintile: HR=0.75 [0.70-0.82], p=<0.001) and cancer-hospital designations (all HR<1, p<0.001; see table) were associated with lower mortality. Mortality was lower for patients treated at 2 facilities compared to those treated at 1 facility (HR=0.95 [0.90-0.99], p=0.02), but was similar for patients treated at >3 vs 1 facility (HR=1.01 [0.94-1.07], p=0.87). Conclusions: Although prior data suggested that FC at >1 facility compromised cancer outcomes, in this large population-based cohort, PDAC patients treated at 2 facilities had better survival. FC is more complex than previously hypothesized. Our ongoing research is directed at better understanding “positive fragmentation” (e.g., seeking higher level of care) versus disjointed care (previously ascribed to fragmentation).