• Lisa M Kern, Mangala Rajan, Joanna Bryan Ringel, Lisandro D Colantonio, Paul M Muntner, Lawrence P Casalino, Michael Pesko, Evgeniya Reshetnyak, Laura C Pinheiro, and Monika M Safford.
• Weill Cornell Medicine , New York, NY, USA. lmk2003@med.cornell.edu.
• J Gen Intern Med. 2021 Feb 1; 36 (2): 422-429.

BackgroundHighly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear.ObjectiveTo determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health.Design And ParticipantsWe conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556).Main MeasuresWe measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period.Key ResultsThe mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health.ConclusionHigh fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.

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