Association Between Fragmentation of Care and Delivery of Adjuvant Chemotherapy in Patients Traveling to High-Volume Hospitals for Pancreatic Adenocarcinoma.

Abstract

Surgical care for pancreatic ductal adenocarcinoma (PDAC) is increasingly centralized to high-volume hospitals (HVHs), prompting many patients to travel farther for resection. While surgery is centralized, adjuvant chemotherapy is often delivered locally, resulting in care fragmentation. The implications of this separation on chemotherapy receipt and survival are unclear. This study evaluated associations between travel distance, care fragmentation, and receipt of adjuvant chemotherapy in patients undergoing upfront PDAC resection at HVHs and assessed how these factors influenced overall survival. Patients with non-metastatic PDAC who underwent upfront resection at HVHs (≥20 pancreatectomies/year) were identified from the National Cancer Database (2007-2021). The cohort was stratified by adjuvant chemotherapy receipt, travel distance (deciles D1-D10), and care fragmentation. Multivariable logistic regression assessed factors associated with chemotherapy receipt; Cox proportional hazards models evaluated survival. Among 17,807 patients treated at 97 HVHs, 10,200 (57%) received adjuvant chemotherapy. Patients traveling ≥14 miles (≥D4) were less likely to receive adjuvant chemotherapy (D4 odds ratio [OR] 0.85; 95% confidence interval [CI] 0.73-0.99; P=0.04). Patients experiencing care fragmentation were more likely to receive adjuvant therapy (64.3% vs. 54.4%, OR 1.51; 95% CI 1.35-1.69; P<0.001). Travel ≥20 miles (≥D5) was associated with higher mortality (hazards ratio [HR] 1.12; 95% CI 1.02-1.23; P=0.01). Conversely, receipt of adjuvant chemotherapy (HR 0.77; 95% CI 0.73-0.81; P<0.001) and fragmented care (HR 0.89; 95% CI 0.84-0.93; P<0.001) were associated with improved survival. Longer travel distance was associated with lower chemotherapy receipt and worse survival. Care fragmentation was linked to improved treatment access and survival, underscoring the need for coordinated cross-institutional care.