A measure of care coordination?

Identifying opioid agonist treatment prescriber networks from health administrative data: A validation study

BACKGROUND

Given the growth of collaborative care strategies for people with opioid use disorder and the changing composition of the illicit drug supply, there is a need to identify and analyze clinic-level outcomes for centers prescribing opioid agonist treatment (OAT). We aimed to determine and validate whether prescriber networks, constructed with administrative data, can successfully identify distinct clinical practice facilities in Ontario, Canada.

METHODS

We executed a retrospective population-based cohort study using OAT prescription records from the Canadian Addiction Treatment Centres in Ontario, Canada between 01/01/2013 and 12/31/2020. Social network analysis was utilized to create networks with connections between physicians based on their shared OAT clients. We defined connections two different ways, by including the number of clients shared or a relative threshold on the percentage of shared OAT clients per physician. Clinics were identified using modularity maximization, with sensitivity analyses applying Louvain, Walktrap, and Label Propagation algorithms. Concordance between network-identified facilities and the (gold standard) de-identified facility-level IDs was assessed using overall, positive and negative agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

From 144 physicians at 105 clinics with 32,842 OAT clients, we assessed 250 different versions of the created networks. The three different detection algorithms had wide variation in concordance, with ranges on sensitivity from 0.02 to 0.88 and PPV from 0.06 to 0.97. The optimal result, derived from the modularity maximization method, achieved high specificity (0.98, 95% CI: 0.98, 0.98) and NPV (0.98, 95% CI: 0.97, 0.98) and moderate PPV (0.54, 95% CI: 0.52, 0.57) and sensitivity (0.45, 95% CI: 0.43, 0.47). This scenario had an overall agreement of 0.96, negative agreement of 0.98, and positive agreement of 0.49.

CONCLUSIONS

Social network analysis can be used to identify clinics prescribing OAT in the absence of clinic-level identifiers, thus facilitating construction and comparison of clinic-level caseloads and treatment outcomes.

Promoting Intensive Transitions for Children and Youth with Medical Complexity from Paediatric to Adult Care: the PITCare study-protocol for a randomised controlled trial

INTRODUCTION

Children with medical complexity (CMC) have chronic, intensive care needs managed by many healthcare practitioners. Medical advances have enabled CMC to survive well into adulthood. However, the availability of supports as CMC transition into the adult care system remain suboptimal, contributing to poor care coordination, and discontinuity. Promoting Intensive Transitions for Children and Youth with Medical Complexity from Paediatric to Adult Care (PITCare) aims to assess whether intensive patient and caregiver-oriented transition support beyond age 18 will improve continuity of care for CMC compared with usual care.

METHODS AND ANALYSIS

This is a pragmatic superiority randomised controlled trial in a parallel group, two-arm design with an embedded qualitative component. CMC turning 17.5 years old will be recruited (n=154), along with their primary caregiver. Participants randomised to the intervention arm will be provided with access to a multidisciplinary transition team who will support patients and caregivers in care planning, integration with an adult primary care provider (PCP), adult subspecialty facilitation and facilitation of resource supports for 2 years. Outcomes will be measured at baseline, 12 and 24 months. The primary outcome measure is successful transfer completion, defined as continuous care in the 2 years after age 18 years old. Secondary outcomes include satisfaction with transitional care, self-management, care coordination, healthcare service use, caregiver fatigue, family distress, utility and cost-effectiveness. Qualitative interviews will be conducted to explore the experiences of patients, caregivers, the transition team, and healthcare providers with the PITCare intervention.

ETHICS AND DISSEMINATION

Institutional approval was obtained from the Hospital for Sick Children Research Ethics Board. Our findings and resources will be shared with child health policymakers and transitions advocacy groups provincially, nationally, and internationally.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, US National Library of Medicine, National Institutes of Health, #NCT06093386.

Avaliação da coordenação do cuidado na atenção primária à saúde: comparando o PMAQ-AB (Brasil) e referências internacionais

Resumo: O objetivo deste estudo foi comparar os resultados obtidos para a coordenação do cuidado a partir do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), com os parâmetros adotados pelo Atlas de Medidas de Coordenação do Cuidado e pelo Observatório Europeu de Políticas e Sistemas de Saúde. Foi realizado estudo transversal, com base no banco de dados do 3º ciclo do PMAQ-AB. Foram criadas três tipologias de coordenação do cuidado: PMAQ-AB, Atlas e Observatório. O teste qui-quadrado foi aplicado para comparar as proporções; os testes de Kruskal-Wallis e de Nemenyi para verificar e identificar eventuais diferenças entre as tipologias. O nível de significância foi de 5%. Foram avaliadas 35.350 equipes que realizaram alguma atividade de coordenação do cuidado. Observou-se diferença significativa (p < 0,001), entre os níveis de coordenação, com maior percentual entre o nível alto e médio nos três instrumentos, PMAQ-AB (56,07% e 38,35%), Atlas (52,63% e 40,66%) e o Observatório (44,82% e 43,98%). Na comparação dos indicadores, houve diferença significativa (p < 0,001) entre as tipologias. Para o Brasil, na tipologia PMAQ-AB, todos os estratos exibiram maior percentual entre o nível alto e médio; no Atlas, o estrato 1 destacou-se no nível médio (43,81%) e, no Observatório, predominou o nível alto. Na comparação dos indicadores por estratos, pelo menos um estrato diferiu dos demais (p < 0,001). O 6 se distinguiu dos demais (p < 0,001), e o 1 diferiu de todos (p < 0,001), exceto do 2 (p > 0,05). Os níveis de coordenação do cuidado diferenciaram-se entre os instrumentos utilizados. Altos e médios níveis foram identificados, demonstrando a necessidade de estudos adicionais.

Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review

BACKGROUND

In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care.

OBJECTIVES

We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes.

RESEARCH DESIGN

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review.

RESULTS

Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery.

CONCLUSIONS

This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.

Veteran Perspectives on Care Coordination Between Veterans Affairs and Community Providers: A Qualitative Analysis

OBJECTIVE

To investigate veteran perspectives on challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers in rural areas.

METHODS

We completed qualitative interviews with a geographically diverse sample of 51 veterans who had used both VA and community health care services. Interviews were audio-recorded and transcribed verbatim. We used directed content analysis (informed by previous work with VA and community staff) to elucidate findings, while remaining attentive to emergent themes.

RESULTS

We report results in 5 key domains related to interorganizational care coordination: organizational mechanisms, organizational culture, relational practices, contextual factors, and the role of the Third-Party Administrators responsible for scheduling and payment for community services. Veterans described successes and challenges in interorganizational coordination across these domains, while also reporting a variety of workarounds and mitigation strategies.

CONCLUSIONS

Veterans living in rural areas face myriad challenges when using health care services both within and outside of VA. In the absence of strong mechanisms for ensuring coordination and communication between health care providers at different institutions, veterans themselves may carry the primary burden for coordinating their care. Our results suggest the utility of both structural and relational approaches to enhancing interorganizational care coordination in these settings.

Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease

IMPORTANCE

Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation.

OBJECTIVE

To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020.

EXPOSURES

Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation.

MAIN OUTCOMES AND MEASURES

A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention).

RESULTS

Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07).

CONCLUSIONS AND RELEVANCE

Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.

Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis

OBJECTIVE

To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans.

METHODS

We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses.

RESULTS

Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges.

CONCLUSIONS

Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.

[Coordination of care and quality of healthcare for women and children in the PMAQ]

The study aimed to identify the association between coordination of care and quality of healthcare for women and children in primary healthcare in Brazil. A cross-sectional study was performed with data from 30,523 teams that participated in the Program for Improvement in Access and Quality of Basic Care (PMAQ) in 2013. Logistic regression was performed, in which the dependent variable was quality of healthcare for women and children and the independent variable was level of coordination of care. The multivariate analysis included variables that presented p < 0.05. The model's fit was assessed with the Hosmer-Lemeshow test. The study assessed the results of 28,056 teams that conducted activities in coordination and healthcare for women and children simultaneously. In Brazil, the largest percentage of teams displayed low levels of coordination (68.5%). The highest levels of coordination were found in stratum 6 (57.2%) and the lowest in stratum 1 (78.5%). Among the major geographic regions, the North of Brazil showed the highest percentage of teams with low coordination (89.1%), while the Southeast had the most teams with high coordination (37.6%). More than two-thirds (70.5%) of the teams showed low quality of care in women's health, while 63.5% showed high level of care in children's health. High level of coordination is associated with high quality of care both in women's health (OR = 11.85) and children's health (OR = 8.79). The predominance of low levels of coordination of care in Brazil and low quality of healthcare for women reflect the need for coordinated action in this area.

Evaluation of Physician Network-Based Measures of Care Coordination Using Medicare Patient-Reported Experience Measures

BACKGROUND

There is significant promise in analyzing physician patient-sharing networks to indirectly measure care coordination, yet it is unknown whether these measures reflect patients' perceptions of care coordination.

OBJECTIVE

To evaluate the associations between network-based measures of care coordination and patient-reported experience measures.

DESIGN

We analyzed patient-sharing physician networks within group practices using data made available by the Centers for Medicare and Medicaid Services.

SUBJECTS

Medicare beneficiaries who provided responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey in 2016 (data aggregated by physician group practice made available through the Physician Compare 2016 Group Public Reporting).

MAIN MEASURES

The outcomes of interest were patient-reported experience measures reflecting aspects of care coordination (CAHPS). The predictor variables of interests were physician group practice density (the number of physician pairs who share patients adjusting for the total number of physician pairs) and clustering (the extent to which sets of three physicians share patients).

KEY RESULTS

Four hundred seventy-six groups had patient-reported measures available. Patients' perception of "Clinicians working together for your care" was significantly positively associated with both physician group practice density (Est (95 % CI) = 5.07(0.83, 9.33), p = 0.02) and clustering (Est (95 % CI) = 3.73(1.01, 6.44), p = 0.007). Physician group practice clustering was also significantly positively associated with "Getting timely care, appointments, and information" (Est (95 % CI) = 4.63(0.21, 9.06), p = 0.04).

CONCLUSIONS

This work suggests that network-based measures of care coordination are associated with some patient-reported experience measures. Evaluating and intervening on patient-sharing networks may provide novel strategies for initiatives aimed at improving quality of care and the patient experience.

The Role of Organizational Affiliations in Physician Patient-Sharing Relationships

Provider consolidation may enable improved care coordination, but raises concerns about lack of competition. Physician patient-sharing relationships play a key role in constructing patient care teams, but it is unknown how organization affiliations affect these. We use the Massachusetts All Payer Claims Database to examine whether patient-sharing relationships are associated with sharing a practice site, medical group, and/or physician contracting network. Physicians were 17 percentage points more likely to have a patient-sharing relationship if they shared a practice site and 4 percentage points more likely if they shared a medical group, as compared with sharing no affiliation. However, there was no detectable increased probability of a patient-sharing relationship within the same physician contracting network. Our finding that physician patient-sharing relationships are concentrated within organizational boundaries at practice site and medical group levels helps illuminate referral incentives and provide insight into the role of organizational affiliations in patient care team construction.

Optimizing the Care Coordinator Role in Primary Care: A Qualitative Case Study

BACKGROUND

Care coordinators (CCs) are increasingly employed in primary care as a means to improve health care quality, but little research examines the process by which CCs are integrated into practices. This case study provides an in-depth examination of this process and efforts to optimize the role.

METHODS

Two CCs' work was observed and assessed, and attempts were made to optimize the role using workflow modeling and "Plan-Do-Study-Act" cycles. Rolling qualitative analyses of field notes from key informant interviews and team meetings were conducted using iterative cycles of "immersion/crystallization" to identify emerging themes.

RESULTS

Expected roles of CCs included case management of high-risk patients, transitions of care, and population management. Case management was the least difficult to implement; transition management required more effort; and population management met with individual and institutional obstacles and was difficult to address.

CONCLUSIONS

The process by which CCs are integrated into primary care is not well understood and will require more attention to optimally use this role to improve health care quality. Understanding aspects of CCs' roles that are the least and most difficult to integrate may provide a starting place for developing best practices for implementation of this emerging role.

The Impact of Provider Networks on the Co-Prescriptions of Interacting Drugs: A Claims-Based Analysis

INTRODUCTION

Multiple provider prescribing of interacting drugs is a preventable cause of morbidity and mortality, and fragmented care is a major contributing factor. We applied social network analysis to examine the impact of provider patient-sharing networks on the risk of multiple provider prescribing of interacting drugs.

METHODS

We performed a retrospective analysis of commercial healthcare claims (years 2008-2011), including all non-elderly adult beneficiaries (n = 88,494) and their constellation of care providers. Patient-sharing networks were derived based on shared patients, and care constellation cohesion was quantified using care density, defined as the ratio between the total number of patients shared by provider pairs and the total number of provider pairs within the care constellation around each patient.

RESULTS

In our study, 2% (n = 1796) of patients were co-prescribed interacting drugs by multiple providers. Multiple provider prescribing of interacting drugs was associated with care density (odds ratio per unit increase in the natural logarithm of the value for care density 0.78; 95% confidence interval 0.74-0.83; p < 0.0001). The effect of care density was more pronounced with increasing constellation size: when constellation size exceeded ten providers, the risk of multiple provider prescribing of interacting drugs decreased by nearly 37% with each unit increase in the natural logarithm of care density (p < 0.0001). Other predictors included increasing age of patients, increasing number of providers, and greater morbidity.

CONCLUSION

Improved care cohesion may mitigate unsafe prescribing practices, especially in larger care constellations. There is further potential to leverage network analytics to implement large-scale surveillance applications for monitoring prescribing safety.

Provider Connectedness to Other Providers Reduces Risk of Readmission After Hospitalization for Heart Failure

Provider interactions other than explicit care coordination, which is challenging to measure, may influence practice and outcomes. We performed a network analysis using claims data from a commercial payor. Networks were identified based on provider pairs billing outpatient care for the same patient. We compared network variables among patients who had and did not have a 30-day readmission after hospitalization for heart failure. After adjusting for comorbidities, high median provider connectedness-normalized degree, which for each provider is the number of connections to other providers normalized to the number of providers in the region-was the network variable associated with reduced odds of readmission after heart failure hospitalization (odds ratio = 0.55; 95% confidence interval [0.35, 0.86]). We conclude that heart failure patients with high provider connectedness are less likely to require readmission. The structure and importance of provider relationships using claims data merits further study.

ESTRATÉGIAS PARA CONSOLIDAÇÃO DA COORDENAÇÃO DO CUIDADO PELA ATENÇÃO BÁSICA

Resumo O estudo aqui apresentado analisou a coordenação do cuidado por meio de dados do Programa Nacional para a Melhoria da Qualidade e do Acesso da Atenção Básica. Tratou-se de estudo descritivo com base em questionários aplicados a 1.313 usuários e 324 equipes de atenção básica no município do Rio de Janeiro em 2012. Avaliaram-se dimensões como organização da porta de entrada, resolutividade e continuidade do cuidado, integração horizontal, organização dos fluxos e acesso à rede de referência, continuidade informacional e comunicação entre profissionais. Os resultados indicaram que a atenção primária em saúde se consolidou como porta de entrada preferencial. Os usuários relataram que as equipes de atenção básica buscavam resolver seus problemas de saúde, o prontuário eletrônico estava disponível, embora não fosse integrado aos demais níveis, e os profissionais indicaram realizar reuniões semanais e receber apoio matricial. Entretanto, o tempo de espera para atendimento especializado era alto e a comunicação entre os profissionais insuficiente, o que dificultava o percurso do usuário na busca pelo cuidado e desvelava as fragilidades do trabalho em rede. Foram identificados avanços no fortalecimento da atenção primária e desafios para a constituição da Rede de Atenção à Saúde que minimizavam as possibilidades de coordenação do cuidado pelas equipes de atenção básica.

Regional health network in the Amazonian context: the case in Manaus, Entorno and Alto Rio Negro

Abstract Objectives: to analyze the dimensions of policy, structure and organization in the construction of Redes de Atenção à Saúde (RAS) (healthcare networks) in the health region of Manaus, Entorno and Alto Rio Negro, focusing on Atenção Primária à Saúde (APS) (primary healthcare) and Rede de Urgência e Emergência (RUE) (urgency and emergency network). Methods: a case study with multidimensional analysis using quantitative and qualitative approach carried out in the first semester of 2016. Results: 37 interviewed key informants, such as managers (States, Cities and Regionals), providers and civil society. The reality was marked by the difficulties in the implementation of RAS's with centralized decision-making powers of State level. Perception of insufficient human resources of limited installed capacity, particularly in the APS, with insufficient priority given to this level of care. Concentration of services in Manaus, priority for urgency and emergency actions expressed in the greatest investment in human resources and mate-rials allocated at this level of care, lack of proposals for promoting equity. Conclusions: the Region was unable to implement RAS to respond to the health demands in the region. The necessity to overcome the dependency relation with the cities and the State and to strengthen its protagonism and fulfillits roles in management network, instituting a plan capable of strengthening APS to be committed in reducing iniquities and with adequate responses in health needs.

Primary Health Care: care coordinator in regionalized networks?

OBJECTIVE

To analyze the breadth of care coordination by Primary Health Care in three health regions.

METHODS

This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia.

RESULTS

Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network.

CONCLUSIONS

Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries.

Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines

BACKGROUND

Prescription benzodiazepine overdose continues to cause significant morbidity and mortality in the US. Multiple-provider prescribing, due to either fragmented care or "doctor-shopping," contributes to the problem.

OBJECTIVE

To elucidate the effect of provider professional relationships on multiple-provider prescribing of benzodiazepines, using social network analytics.

DESIGN

A retrospective analysis of commercial healthcare claims spanning the years 2008 through 2011. Provider patient-sharing networks were modelled using social network analytics. Care team cohesion was measured using care density, defined as the ratio between the total number of patients shared by provider pairs within a patient's care team and the total number of provider pairs in the care team. Relationships within provider pairs were further quantified using a range of network metrics, including the number and proportion of patients or collaborators shared.

MAIN MEASURES

The relationship between patient-sharing network metrics and the likelihood of multiple prescribing of benzodiazepines.

PARTICIPANTS

Patients between the ages of 18 and 64 years who received two or more benzodiazepine prescriptions from multiple providers, with overlapping coverage of more than 14 days.

RESULTS

A total of 5659 patients and 1448 provider pairs were included in our study. Among these, 1028 patients (18.2 %) received multiple prescriptions of benzodiazepines, involving 445 provider pairs (30.7 %). Patients whose providers rarely shared patients had a higher risk of being prescribed overlapping benzodiazepines; the median care density was 8.1 for patients who were prescribed overlapping benzodiazepines and 10.1 for those who were not (p < 0.0001). Provider pairs who shared a greater number of patients and collaborators were less likely to co-prescribe overlapping benzodiazepines.

CONCLUSIONS

Our findings demonstrate the importance of care team cohesion in addressing multiple-provider prescribing of controlled substances. Furthermore, we illustrate the potential of the provider network as a surveillance tool to detect and prevent adverse events that could arise due to fragmentation of care.

It's who you know: patient-sharing, quality, and costs of cancer survivorship care

PURPOSE

Cancer survivors frequently receive care from a large number of physicians, creating challenges for coordination. We sought to explore whether cancer survivors whose providers have more patients in common (e.g., shared patients) tend to have higher quality and lower cost care.

METHODS

We performed a retrospective cohort study of 8,661 patients diagnosed with loco-regional breast, prostate, or colorectal cancer. We examined survivorship care from days 366 to 1,095 following their cancer diagnosis. Our primary independent variable was "care density," a novel metric of the extent to which a patient's providers share patients with one another. Our outcome measures were health care utilization, quality metrics, and costs.

RESULTS

In adjusted analyses, we found that patients with high care density--indicating high levels of patient-sharing among their providers--had significantly lower rates of hospitalization (OR 0.87, 95% CI 0.75-1.00) and higher odds of an eye examination for diabetes (OR 1.31, 95% CI 1.03-1.66) compared to patients with low care density. High care density was not associated with emergency department visits, avoidable outcomes, lipid profile following an angina diagnosis, or odds of glycosylated hemoglobin testing for diabetes. Patients with high care density had significantly lower total costs of care over 24 months (beta coefficient -$2,116, 95% CI -$3,107 to -$1,125) along with lower inpatient and outpatient costs.

CONCLUSION

Cancer survivors treated by physicians who share more patients with one another tend to have some higher aspects of quality and lower cost care.

IMPLICATIONS OF CANCER SURVIVORS

If validated, care density may be a useful indicator for monitoring care coordination among cancer survivors and potentially targeting interventions that seek to improve care delivery.