Understanding fragmentation of prostate cancer survivorship care: implications for cost and quality

Abstract

Background: Cancer survivors are particularly prone to the effects of a fragmented health care delivery system. The implications of fragmented cancer care across providers likely include greater spending and worse quality of care. For this reason, the authors measured relations between increasing fragmentation of cancer care, expenditures, and quality of care among prostate cancer survivors.

Methods: A total of 67,736 patients diagnosed with prostate cancer between 1992 and 2005 were identified using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Using the Herfindahl-Hirschman Index and a measure of the average number of prostate cancer providers over time, patients were sorted into 3 fragmentation groups (low, intermediate, and high). The authors then examined annual per capita survivorship expenditures and a measure of quality (ie, repetitive prostate-specific antigen [PSA] testing within 30 days) according to their fragmentation exposure using multinomial logistic regression.

Results: Patients with highly fragmented cancer care tended to be younger, white, and of higher socioeconomic status (all P < .001). Prostate cancer survivorship interventions were most common among patients with the highest fragmentation of care across providers (P < .001). After adjustment for clinical characteristics and prostate cancer survivorship interventions, higher degrees of fragmentation continued to be associated with repetitive PSA testing (13.6% for high vs 7.0% for low fragmentation; P < .001) and greater spending, particularly among patients not treated with androgen deprivation therapy.

Conclusions: Fragmented prostate cancer survivorship care is expensive and associated with potentially unnecessary services. Efforts to improve care coordination via current policy initiatives, electronic medical records, and the implementation of cancer survivorship tools may help to decrease fragmentation of care and mitigate downstream consequences for prostate cancer survivors.

Figure 1

Various examples of fragmentation and prostate cancer survivorship care are shown. In Example 1, a single urologist is responsible for all prostate cancer-related claims during the survivorship period. This would represent the least fragmented care and the average number of providers would equal 1. In contrast, Example 4 represents a patient with multiple providers involved in his prostate cancer care for the entire survivorship period. This situation might represent the greatest potential for the consequences of fragmented cancer care (average number of providers: 4).

Figure 2

Relationship between degree of fragmentation, (A) survivorship spending, stratified by whether patients underwent androgen deprivation injection therapy (ADT), and (B) repetitive prostate-specific antigen (PSA) testing. Patients with higher fragmentation of care were more likely to undergo repetitive PSA testing within 30 days, independent of clinical characteristics and prostate cancer survivorship interventions (P < .05 for all comparison groups). In addition, patients with higher fragmentation of care who were not treated with ADT were more likely to have greater annual spending. For example, among those not receiving ADT, 5.5% of survivors with the highest degree of fragmented care would be in the highest spending group compared with 2.3% in the least fragmented group (adjusted for age, race, comorbidity, socioeconomic status, rural status, tumor grade, tumor stage, initial treatment, and prostate cancer survivorship interventions).