title: Care fragmentation, quality, and costs among chronically ill patients.
abstract: OBJECTIVE
  To assess the relationship between care fragmentation and both quality and costs of care for commercially insured, chronically ill patients.
  
  
  METHODS
  We used claims data from 2004 to 2008 for 506,376 chronically ill, privately insured enrollees of a large commercial insurance company to construct measures of fragmentation. We included patients in the sample if they had chronic conditions in any of the following categories: cardiovascular disease, diabetes, asthma, arthritis, or migraine.
  
  
  METHODS
  We assigned each patient a fragmentation index based on the patterns of care of their primary care provider (PCP), with care patterns spread across a higher number of providers considered to be more fragmented. We used regression analysis to examine the relationship between fragmentation and both quality and cost outcomes.
  
  
  RESULTS
  Patients of PCPs in the highest quartile of fragmentation had a higher chance of having a departure from clinical best practice (32.8%, vs 25.9% among patients of PCPs in the lowest quartile of fragmentation; P < .001). Similarly, patients of PCPs with high fragmentation had higher rates of preventable hospitalizations (9.1% in highest quartile vs 7.1% in lowest quartile; P < .001). High fragmentation was associated with $4542 higher healthcare spending ($10,396 in the highest quartile vs $5854 in the lowest quartile; P < .001). We found similar or larger effects on quality and costs among patients when we examined the most frequently occurring disease groups individually.
  
  
  CONCLUSIONS
  Chronically ill patients whose primary care providers offer highly fragmented care more often experience lapses in care quality and incur greater healthcare costs.
authors.forename: Brigham R
authors.initials: BR
authors.lastname: Frandsen
authors.forename: Karen E
authors.initials: KE
authors.lastname: Joynt
authors.forename: James B
authors.initials: JB
authors.lastname: Rebitzer
authors.affiliation: Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115. E-mail: ajha@hsph.harvard.edu.
authors.forename: Ashish K
authors.initials: AK
authors.lastname: Jha
mesh_terms: D000367:Age Factors; D002908:Chronic Disease / Q000191:economics / Q000628:therapy*; D003266:Continuity of Patient Care / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data; D008297:Male; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012720:Severity of Illness Index; D012737:Sex Factors