Association of care fragmentation and hospital cancer designation with survival in gastroesophageal junction cancer: a statewide study

Background

Fragmentation of care (FC) refers to healthcare provided by different providers and facilities. FC has been associated with inferior outcomes. However, it improves access to specialized cancer care. This study aimed to identify the association between fragmented gastroesophageal junction (GEJ) cancer care and survival.

Methods

In this retrospective cohort study, adults diagnosed with primary GEJ cancer between January 1, 2007, and December 31, 2017, were identified in the California Cancer Registry (patient data) and merged with the California Department of Healthcare Access and Information database (facility-level data for each patient encounter). FC was measured by quantity, defined as the number of facilities a patient visited within 1 year after diagnosis, and FC directionality, defined by how patients transitioned across different healthcare facilities (with/without cancer center designation). Multivariate time-varying Cox regression models were used to determine the association between FC and survival, which was expressed as hazard ratios (HRs).

Results

Overall, 6025 patients were identified. Of the 2919 patients (48.4%) who experienced FC, 1979 (67.8%) were observed at 2 facilities. Time-varying Cox regression for FC quantity showed that FC quantity was associated with higher mortality (2 facilities: HR, 1.21; 95% CI, 1.12–1.31; P <.001, 3 facilities: HR, 1.47; 95% CI, 1.31–1.65; P <.001; ≥4 facilities: HR, 2.34; 95% CI, 1.93–2.82; P <.001). Upgrading care received from a non-designated center to a designated center was associated with a higher survival than patients who received unfragmented non-designated care (HR: 1.40 [95% CI, 1.16–1.70; P=.001] vs 1.48 [95% CI, 1.29–1.70; P <.001] respectively).

Conclusion

Fragmented GEJ cancer care was associated with decreased survival rates. However, upgrading care from a nondesignated cancer facility to a designated cancer facility could mitigate the deleterious association between FC and decreased survival rates.