Fragmented care, Commission on Cancer Accreditation and Overall Survival in Patients Receiving Surgery and Chemotherapy for Lung Cancer.

Abstract

Background: Patients may receive their adjuvant therapy at a facility different than where they had their lung cancer operation. Whether this fragmentation of care affects outcomes is unclear.

Methods: We used the National Cancer Database to identify lung cancer patients undergoing resection and adjuvant chemotherapy from 2006-2020. We stratified patients into those receiving fragmented care or not, and further divided fragmented care patients by the Commission on Cancer (CoC) accreditation status of the hospital. Fragmented care refers to patients receiving surgery and chemotherapy at different institutions. These institutions can be either CoC accredited or not. The main outcome was overall survival. We used Kaplan-Meier analysis to estimate survival and multivariable and Cox proportional models to identify associations.

Results: Of 65,369 patients, 32,494(49.7%) had fragmented care, with the majority(70.4%) receiving their chemotherapy at a non-CoC accredited facility. Factors associated with fragmented care were white(adjusted odds ratio(aOR)=1.34;p<0.001), lower comorbidity index(aOR=1.11;p<0.001), having a private insurance(aOR=1.11;p<0.001), and a higher median income(aOR=1.24;p<0.001). Fragmented care was associated with worse overall survival(Median survival=60vs65 months;p<0.001) compared to single center care. When care was fragmented, receiving adjuvant chemotherapy at CoC accredited centers had higher 5-year overall survival rates compared to those fragmented care at non-CoC centers(Median survival=71vs55 months;p<0.001).

Conclusions: The majority of lung cancer patients have their care fragmented to non-CoC accredited centers and this is associated with worse outcomes. Regionalization, achieving CoC accreditation, or improved patient access may be necessary to allow select patients to receive closer care while maintaining outcomes.