Association of healthcare fragmentation and the survival of patients with colorectal cancer in Colombia

Abstract

Background Healthcare fragmentation is a phenomenon in which patients experience a discontinuity in healthcare. Patients with colorectal cancer are more likely to experience fragmented care because they require specialized treatment by multidisciplinary teams. The objective of this study was to identify the association between healthcare fragmentation and 3-year survival for patients with colorectal cancer in Colombia. Methods A retrospective cohort study was performed using administrative databases, with an electronic algorithm to identify patients with colorectal cancer based on codes. The patients were recruited between January 1, 2013 and December 31, 2016. The exposure variable was fragmentation, which was measured based on the number of different providers that treated a patient during the first year after diagnosis. Three-year mortality rates and incidence rate ratios (IRRs) were estimated for quartiles of fragmentation. A cut-off point was determined that divided the population between exposure to higher fragmentation versus lower fragmentation. Matching was performed using propensity scores to control for confounding, and the hazard ratio for exposure to higher fragmentation was calculated for the matched sample. Results A total of 5,036 patients with colorectal cancer was identified, 2,525 (49.88%) of whom were women. The mean number of network providers for the total sample was 5.71 (SD 1.98). The patients in the quartile with higher fragmentation had the highest mortality rate, 35.67 (95%CI; 33.63–38.06) per 100 patients. The comparison of higher and lower quartiles of fragmentation resulted in an IRR of 1.23 (95%CI; 1.04–1.45; p 0.02). Of the 5,036 patients, 422 (8.38%) were classified as the exposed cohort (higher fragmentation). The total matched sample consisted of 844 subjects, and an HR of 1.35 (95%CI; 1.14–1.61) was estimated. Conclusions Exposure to more highly fragmented healthcare networks decreases overall 3-year survival for patients with colorectal cancer in Colombia.