title: 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.
authors.affiliation: Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan 48109-5330, USA. tskolar@med.umich.edu
authors.forename: Ted A
authors.initials: TA
authors.lastname: Skolarus
authors.forename: Yun
authors.initials: Y
authors.lastname: Zhang
authors.forename: Brent K
authors.initials: BK
authors.lastname: Hollenbeck
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care / Q000191:economics*; D005102:Health Expenditures; D006300:Health Services Misuse / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011471:Prostatic Neoplasms / Q000628:therapy*; D011787:Quality of Health Care / Q000191:economics*; D017741:Survivors; D014481:United States