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Association of Care Fragmentation and Hospital Cancer Designation with Survival in Gastroesophageal Junction Cancer: A State-Wide Study.
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Association of Care Fragmentation and Hospital Cancer Designation with Survival in Gastroesophageal Junction Cancer: A State-Wide Study. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Ngongoni, R. F., Timmerhuis, H. C., Li, A. Y., Day, H., Harrison, J., Visser, B. C. 2025: 101962Abstract
BACKGROUND: Fragmentation of care (FC) is healthcare provided by different providers and/or facilities. FC has been associated with inferior outcomes, yet it improves access to specialized cancer care. We aim to identify the association of fragmented gastroesophageal junction cancer (GEJ) care with 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 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 1year post-diagnosis, and FC directionality, defined by how patients transitioned across different healthcare facilities (with/without cancer center designation). Multivariable time-varying Cox regression models were performed to determine the association of FC with survival which were expressed as hazard ratios (HR).RESULTS: A total of 6025 patients were identified. Of the 2919 (48.4%) patients who experienced FC, 1979 (67.8%) were seen at two facilities. Time-varying Cox regression for FC quantity showed that FC quantity was associated with higher mortality (2 facilities: HR:1.21, (1.12-1.31), p<0.001, 3 facilities: HR:1.47, (1.31-1.65), p<0.001, 4+ facilities: HR:2.34, (1.93-2.82), p<0.001). Compared to unfragmented designated care, upgrading from a non-designated to designated center had higher survival than unfragmented non-designated care (HR:1.40, (1.16-1.70), p=0.001 versus HR:1.48, (1.29-1.70), p<0.001).CONCLUSION: Fragmented GEJ cancer care is associated with decreased survival. However, upgrading care to a designated cancer facility could mitigate the deleterious association of fragmentation with decreased survival.
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