Daniel Aryeh Metzger MD , Haley Harris BA , Isabelle Tan BA , Andrea Mesiti MD , Ying Li MS , Julianna Brouwer MPH , Dawn Chirko MD , Alessio Pigazzi MD, PhD , Steven Chao MD , Heather Yeo MD, MHS, MBA, MS
{"title":"护理碎片化对局部晚期直肠癌患者生存的影响:识别弱势群体","authors":"Daniel Aryeh Metzger MD , Haley Harris BA , Isabelle Tan BA , Andrea Mesiti MD , Ying Li MS , Julianna Brouwer MPH , Dawn Chirko MD , Alessio Pigazzi MD, PhD , Steven Chao MD , Heather Yeo MD, MHS, MBA, MS","doi":"10.1016/j.surg.2025.109471","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>Treatment for locally advanced rectal cancer requires multidisciplinary coordination. Studies examining care fragmentation, in which a patient receives cancer treatment at multiple facilities, are limited. This study aimed to determine the demographic, clinical, and hospital subgroups impacted by care fragmentation.</div></div><div><h3>Methods</h3><div>Patients with stage II-III rectal cancer treated with surgery, chemotherapy, and radiation (2009–2019) were selected from the National Cancer Database and divided into fragmented care and unified care groups. Overall survival was compared. Demographic, disease characteristic, and hospital type subgroups were analyzed to determine differential impact of care fragmentation.</div></div><div><h3>Results</h3><div>In total, 63,299 patients were included, of whom 41,978 (66.3%) received fragmented care and 21,321 (33.7%) received unified care. Median age was 60 years (interquartile range, 51–68 years), and 62.2% were male. Overall, fragmented care was associated with shorter survival (<em>P</em> = .0017), increased treatment delays (13.7% vs 12.4% in unified care; <em>P</em> < .001) and decreased neoadjuvant therapies (<em>P</em> < .001). Fragmented care was significantly associated with decreased survival in 5 subgroups: female patients (adjusted hazard ratio, 1.152, <em>P</em> < .001), patients with clinical Stage III disease (adjusted hazard ratio, 1.094, <em>P</em> = .001), patients with Medicaid (adjusted hazard ratio, 1.212, <em>P</em> = .006), patients ≥100 miles from the hospital (adjusted hazard ratio, 1.377, <em>P</em> = .013), and patients treated at academic centers (adjusted hazard ratio, 1.225, <em>P</em> < .001). Unified care at academic centers was associated with significantly improved overall survival compared to fragmented care at academic centers and treatment at nonacademic centers (<em>P</em> < .001).</div></div><div><h3>Conclusions</h3><div>Care fragmentation is associated with worse survival outcomes in patients with locoregional rectal cancer, with certain subgroups being particularly vulnerable. Addressing the socioeconomic and logistical barriers that contribute to care fragmentation will be crucial in improving patient outcomes.</div></div>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":"184 ","pages":"Article 109471"},"PeriodicalIF":2.7000,"publicationDate":"2025-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Impact of care fragmentation on survival in locally advanced rectal cancer: Identifying vulnerable populations\",\"authors\":\"Daniel Aryeh Metzger MD , Haley Harris BA , Isabelle Tan BA , Andrea Mesiti MD , Ying Li MS , Julianna Brouwer MPH , Dawn Chirko MD , Alessio Pigazzi MD, PhD , Steven Chao MD , Heather Yeo MD, MHS, MBA, MS\",\"doi\":\"10.1016/j.surg.2025.109471\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Background</h3><div>Treatment for locally advanced rectal cancer requires multidisciplinary coordination. Studies examining care fragmentation, in which a patient receives cancer treatment at multiple facilities, are limited. This study aimed to determine the demographic, clinical, and hospital subgroups impacted by care fragmentation.</div></div><div><h3>Methods</h3><div>Patients with stage II-III rectal cancer treated with surgery, chemotherapy, and radiation (2009–2019) were selected from the National Cancer Database and divided into fragmented care and unified care groups. Overall survival was compared. Demographic, disease characteristic, and hospital type subgroups were analyzed to determine differential impact of care fragmentation.</div></div><div><h3>Results</h3><div>In total, 63,299 patients were included, of whom 41,978 (66.3%) received fragmented care and 21,321 (33.7%) received unified care. Median age was 60 years (interquartile range, 51–68 years), and 62.2% were male. Overall, fragmented care was associated with shorter survival (<em>P</em> = .0017), increased treatment delays (13.7% vs 12.4% in unified care; <em>P</em> < .001) and decreased neoadjuvant therapies (<em>P</em> < .001). Fragmented care was significantly associated with decreased survival in 5 subgroups: female patients (adjusted hazard ratio, 1.152, <em>P</em> < .001), patients with clinical Stage III disease (adjusted hazard ratio, 1.094, <em>P</em> = .001), patients with Medicaid (adjusted hazard ratio, 1.212, <em>P</em> = .006), patients ≥100 miles from the hospital (adjusted hazard ratio, 1.377, <em>P</em> = .013), and patients treated at academic centers (adjusted hazard ratio, 1.225, <em>P</em> < .001). Unified care at academic centers was associated with significantly improved overall survival compared to fragmented care at academic centers and treatment at nonacademic centers (<em>P</em> < .001).</div></div><div><h3>Conclusions</h3><div>Care fragmentation is associated with worse survival outcomes in patients with locoregional rectal cancer, with certain subgroups being particularly vulnerable. Addressing the socioeconomic and logistical barriers that contribute to care fragmentation will be crucial in improving patient outcomes.</div></div>\",\"PeriodicalId\":22152,\"journal\":{\"name\":\"Surgery\",\"volume\":\"184 \",\"pages\":\"Article 109471\"},\"PeriodicalIF\":2.7000,\"publicationDate\":\"2025-06-09\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Surgery\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://www.sciencedirect.com/science/article/pii/S003960602500323X\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"SURGERY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Surgery","FirstCategoryId":"3","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S003960602500323X","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"SURGERY","Score":null,"Total":0}
Impact of care fragmentation on survival in locally advanced rectal cancer: Identifying vulnerable populations
Background
Treatment for locally advanced rectal cancer requires multidisciplinary coordination. Studies examining care fragmentation, in which a patient receives cancer treatment at multiple facilities, are limited. This study aimed to determine the demographic, clinical, and hospital subgroups impacted by care fragmentation.
Methods
Patients with stage II-III rectal cancer treated with surgery, chemotherapy, and radiation (2009–2019) were selected from the National Cancer Database and divided into fragmented care and unified care groups. Overall survival was compared. Demographic, disease characteristic, and hospital type subgroups were analyzed to determine differential impact of care fragmentation.
Results
In total, 63,299 patients were included, of whom 41,978 (66.3%) received fragmented care and 21,321 (33.7%) received unified care. Median age was 60 years (interquartile range, 51–68 years), and 62.2% were male. Overall, fragmented care was associated with shorter survival (P = .0017), increased treatment delays (13.7% vs 12.4% in unified care; P < .001) and decreased neoadjuvant therapies (P < .001). Fragmented care was significantly associated with decreased survival in 5 subgroups: female patients (adjusted hazard ratio, 1.152, P < .001), patients with clinical Stage III disease (adjusted hazard ratio, 1.094, P = .001), patients with Medicaid (adjusted hazard ratio, 1.212, P = .006), patients ≥100 miles from the hospital (adjusted hazard ratio, 1.377, P = .013), and patients treated at academic centers (adjusted hazard ratio, 1.225, P < .001). Unified care at academic centers was associated with significantly improved overall survival compared to fragmented care at academic centers and treatment at nonacademic centers (P < .001).
Conclusions
Care fragmentation is associated with worse survival outcomes in patients with locoregional rectal cancer, with certain subgroups being particularly vulnerable. Addressing the socioeconomic and logistical barriers that contribute to care fragmentation will be crucial in improving patient outcomes.
期刊介绍:
For 66 years, Surgery has published practical, authoritative information about procedures, clinical advances, and major trends shaping general surgery. Each issue features original scientific contributions and clinical reports. Peer-reviewed articles cover topics in oncology, trauma, gastrointestinal, vascular, and transplantation surgery. The journal also publishes papers from the meetings of its sponsoring societies, the Society of University Surgeons, the Central Surgical Association, and the American Association of Endocrine Surgeons.