Lost in Transition and Losing Money, but perhaps too Hasty?

Abstract

Cancer survivors represent a burgeoning patient population at risk for recurrence and co-morbidity. Their needs are great and we must find ways to deliver care that optimizes health, while not “breaking-the-bank.” Fragmentation of care contributes to higher health care costs. Strategies that reduce redundancy while preserving care quality are essential.

In a recent report, “Understanding Fragmentation of Prostate Cancer Survivorship Care,” Skolarus, Zhang and Hollenbeck relayed results of a study on 66,736 Medicare patients diagnosed with prostate cancer.¹ Their defined purpose was to quantify the degree of fragmentation of care in this patient population, and to assess the degree to which increased fragmentation led to greater health care costs and poorer quality of care. This work is important since prostate cancer survivors represent the second largest segment of cancer survivors in the U.S. (surpassed only by breast cancer survivors), and currently number over 2 million.² Health care needs are great among men with prostate cancer, and so are the associated costs, which total nearly $7 billion annually.³

In this large sample of men who were tracked from 1992–2005, Skolarus et al.¹ defined “survivorship” as the period extending 1-year post-diagnosis to 2005, or to the year prior to death. This period was chosen based on the assumption that by 1-year post-diagnosis, treatment should be complete and patterns of care stabile. Researchers characterized fragmentation of care using a composite measure which factored-in the average number of health care providers and intensity of care across providers, ultimately grouping men into three categories: low; intermediate; or high fragmentation. Primary findings were that fragmentation of care was highest among younger, white men of higher socio-economic status. Furthermore, as compared to low fragmentation, high fragmentation of care was associated with significantly greater annual per capita health care expenditures, i.e., $142 vs. $453 (2005 US dollars), respectively. Men who were classified as having high fragmentation of care also had significantly lower quality of care (defined as redundant prostate specific antigen [PSA] testing within a 30-day period). Redundant testing was performed on 14.7% of men in the high fragmented care group as compared to 5.7% in the low fragmented care group. Costs were lower among men who received androgen deprivation therapy (ADT), as compared to other treatment.

Indeed, the fragmentation of care is a source of concern that was addressed over a decade ago by the Institute of Medicine (IOM) Committee on Quality of Health Care in America,⁴ which called for “care based on continuous healing relationships,” “continuous decrease in waste,” and “cooperation among clinicians.” Given that cancer survivors often have 5 or more treating physicians and the risk of fragmentation is great,⁵ these tenets were reiterated in the 2005 IOM report, “From Cancer Patient to Cancer Survivor: Lost in Transition.⁶” This hallmark document also chronicled the late and long-term effects of cancer and its treatment, as well as the high rates of co-morbidity in this patient population.⁵

Prostate cancer poses a particular challenge in evaluating the quality of survivorship care, and the fact that Skolarus et al.¹ chose this cancer to chronicle fragmentation is indeed ambitious. First, there exists a variety of acceptable treatment options that range from active surveillance to active treatments, such as surgery or radiotherapy. Each of these options is likely to be delivered by a different provider. Moreover, men may choose active surveillance for the balance of life or only until their anxiety with PSA monitoring exceeds their distaste for more definitive treatment--a process that can take years, and can perpetuate fragmentation of care long-term. In addition, many treatments can cause urinary and bowel-related issues, as well as erectile dysfunction. Depending on the treatment, some side-effects can occur immediately, while others may be significantly delayed. Treatments for many side-effects are typically not “quick fixes,” and may involve extended consultation to address all of the contributing issues--both physiologic and psychologic--all of which contribute to the fragmentation of care long-term. Finally, increased fragmentation occurs because prostate cancer is a disease of older men who often have comorbidities that pose a more urgent threat to their health than prostate cancer, and therefore require multiple subspecialists and primary care physicians. Therfore, it is not surprising that Skolarus et al.¹ found that 63.4% of prostate cancer survivors receive care that is either intermediate or highly fragmented. Another predictable finding is that younger men receive more costly and more fragmented care--likely because they are apt to receive more aggressive treatments, thereby resulting in more side effects. Also unsurprising is that men treated with primary ADT have less fragmented care--likely because of the absence of locoregional treatment and attendant side effects. Therefore, although the data that Skolarus et al.¹ provide regarding fragmentation of care and cost for prostate cancer survivors is informative and logical, it is not necessarily actionable.

Skolarus et al. appear to place particular value on a “one patient-one physician” model to reduce fragmentation. However, as discussed, prostate cancer is complex, as are its treatment and attendant side-effects and late effects. Thus, although fragmentation of care could be reduced by restricting the number of involved physicians, this may not be possible nor desirable, particularly for managing lingering effects of treatment that require specialized care. Certainly, as time elapses from diagnosis, prostate cancer patients should be guided more to the responsibility of primary care physicians who may best address overall health care needs.⁵ This is most applicable to men with loco-regional disease who are far more likely to die of causes other than prostate cancer. However, the premise that fragmentation of care can be solved by reducing the number of providers after a given point in time post-diagnosis is likely untenable.

Indeed, it is through improved communication that we are most likely to optimize care while reducing fragmentation and waste. Granted, substantial infrastructural challenges stand in the way, such as the inconsistent utilization of electronic medical records and the incompatibility of computer systems.⁸ Furthermore, there are social hurdles such as attitudinal barriers, the lack of willingness to share amongst providers,⁹ and the lack of consensus regarding care.⁷ There also is incongruence in the expectations for care between patients and providers.¹⁰ Such barriers likely contributed to the redundant PSA testing observed by Skolarus et al.¹ in the current study; a finding that may be further exacerbated by varying assays used in differing labs, and patients’ desire for reassurance regarding their disease status.⁷ Thus, there is a need to not only increase communication among various members of the health care team, but to also intimately include the patient. Because the patient also is likely to be keenly interested in coverage of health care, any restrictions regarding duplicate testing with denial of benefit could provide a powerful impetus to reduce redundant PSA testing and its associated costs.

In summary, the article provided by Skolarus et al.¹ provides solid, but expected information regarding the fragmentation of care among prostate cancer survivors. While some fragmentation can be lessened by encouraging survivors to seek a majority of their long-term care through their primary care physicians, open lines of communication between all providers, entities that provide coverage, and the patient, holds the best chance of optimizing care while reducing fragmentation.

Biographies

Author Biographies

Wendy Demark-Wahnefried, PhD, RD is Associate Director for Cancer Prevention and Control at the UAB Comprehensive Cancer Center, and Professor and Webb Endowed Chair of Nutrition Sciences. A designated Komen Professor of Cancer Survivorship, she has led several NIH-funded trials to improve the health and health-related behaviors of this population. Dr. Demark-Wahnefried serves on the American Cancer Society’s Guidelines Panel for Nutrition and Physical Activity, the American College of Sports Medicine Guidelines Panel for Physical Activity in Cancer Survivors, the American Society of Clinical Oncology Committee on Cancer Survivorship, and the National Cancer Policy Forum of the Institute of Medicine.

Joseph Erik Busby, MD is Associate Professor of the Division of Urology in the Department of Surgery specializing in urologic surgical oncology. As an Associate Scientist of the UAB Comprehensive Cancer Center, he is involved in multiple NIH-funded studies and clinical protocols involving prostate cancer. Dr. Busby also is a contributing member of both the NCCN Guideline panels for Early Detection of Prostate Cancer and Treatment of Prostate Cancer. He also is active in the National Chemoprevention Consortium in prostate cancer.