title: Fragmentation in specialist care and stage III colon cancer.
abstract: BACKGROUND
  Patients with cancer frequently transition between different types of specialists and across care settings. This study explored how frequently the surgical and medical oncology care of stage III colon cancer patients occurred across more than 1 hospital and whether this was associated with mortality and costs.
  
  
  METHODS
  This was a retrospective Surveillance, Epidemiology, and End Results-Medicare cohort study of 9075 stage III colon cancer patients diagnosed between 2000 and 2009 who had received both surgical and medical oncology care within 1 year of their diagnosis. Patients were assigned to the hospital at which they had undergone their cancer surgery and to their oncologist's primary hospital, and then they were characterized according to whether these hospitals were the same or different. Outcomes included all-cause mortality, subhazards for colon cancer-specific mortality, and costs of care at 12 months.
  
  
  RESULTS
  Thirty-seven percent of the patients received their surgical and medical oncology care from different hospitals. Rural patients were less likely than urban patients to receive medical oncology care from the same hospital (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). Care from the same hospital was not associated with reduced all-cause or colon cancer-specific mortality but resulted in lower costs (8% of the median cost) at 12 months (dollars saved, $5493; 95% confidence interval, $1799-$9525).
  
  
  CONCLUSIONS
  The delivery of surgical and medical oncology care at the same hospital was associated with lower costs; however, reforms seeking to improve outcomes and lower costs through the integration of complex care will need to address the significant proportion of patients receiving care at more than 1 hospital.
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Tanvir
authors.initials: T
authors.lastname: Hussain
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Hsien-Yen
authors.initials: HY
authors.lastname: Chang
authors.affiliation: University of Michigan Health System, Ann Arbor, Michigan.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Veenstra
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland.|Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Craig Evan
authors.initials: CE
authors.lastname: Pollack
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003110:Colonic Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008495:Medical Oncology / Q000706:statistics & numerical data; D009367:Neoplasm Staging; D012189:Retrospective Studies; D018426:SEER Program; D014481:United States
keywords: colon cancer; delivery of health care; health care costs; integrated health care systems; mortality; patient care management