Background
Cervical cancer remains a major cause of morbidity and mortality in Colombian women. Despite broad insurance coverage, care fragmentation and delays in treatment initiation persist. This study assesses healthcare fragmentation in cervical cancer care and its impact on five-year overall survival (OS).
Objetives
The primary objective of this study is to determine the association between exposure to healthcare fragmentation and five-year overall survival (OS) among cervical cancer patients enrolled in Colombia's contributory health insurance system, and to evaluate their five-year mortality rates. It also describes the sociodemographic and clinical characteristics of the cohort and the extent of healthcare fragmentation they experienced.
Methods
A retrospective cohort study of women diagnosed with cervical cancer between 2012 and 2014, with a five-year follow-up. 2913 patients were identified using an algorithm applied to national administrative databases. The number of healthcare providers and the Herfindahl-Hirschman Index (HHI) were used to measure fragmentation during the first year of care. Five-year OS was analyzed using Kaplan-Meier estimates and Cox regression models.
Results
The median number of providers during the first year was six (IQR 4-8), and the median HHI was 33 (IQR 25-46). The departments with the highest median number of providers were Amazonas, Chocó, and Atlántico, whereas those with the lowest median HHI were Huila, Guaviare, and Amazonas. The 5-year mortality rate was 69.38 (95% CI 64.71-74.30) per 1000 patient-years for the entire cohort, being higher among patients with more than 8 providers (97.83 per 1000 patient-years; 95% CI 85.79- 111.1). A higher mortality risk was observed for patients attended by more than 8 providers (HR 1.93; 95% CI 1.55-2.40) and for the group with the highest fragmentation in a combined measure (HR 1.60; 95% CI 1.33-1.93).
Conclusions
Higher fragmentation in the care of cervical cancer is associated with lower five-year OS. The combination of the number of providers and HHI is useful for its assessment. These findings highlight the need for health system–level policies that promote care coordination, continuity, and integrated service delivery, as well as for the development of monitoring tools to identify and reduce fragmentation and improve clinical outcomes. Strategies are needed to reduce healthcare fragmentation and improve clinical outcomes as well as to explore other ways of measuring fragmentation. 

Kaplan-Meier survival curves and results of Log-rank test for five-year mortality for cervical cancer