Does continuity of care improve patient outcomes?

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Applied Evidence

Does continuity of care improve patient outcomes?

J Fam Pract. 2004 December;53(12):974-980

By

Michael D. Cabana, MD, MPH

Sandra H. Jee, MD, MPH

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References

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Practice recommendations

Sustained continuity of care (SCOC) improves quality of care, by decreasing hospitalizations, decreasing emergency department use, and improving receipt of preventive services (SOR: B, based primarily on cohort studies).
SCOC has been consistently documented to improve quality of care for patients with chronic conditions such as asthma and diabetes (SOR: B, primarily on cohort studies).

Abstract

Objective Continuity of care is a cornerstone of primary care that has been promoted by recent trends in medical education and in the way health care delivery is organized. We sought to determine the effect of sustained continuity of care (SCOC) on the quality of patient care.

Data sources We conducted a systematic review of all articles in Medline (January, 1966 to January, 2002), Educational Resources Information Center (ERIC), and PSYCH INFO using the terms “continuity of care” or “continuity of patient care.” We identified additional titles of candidate articles by reviewing the bibliographies of articles from our original MEDLINE search, contacting experts in primary care, health care management, and health services research, and by reviewing bibliographies of textbooks of primary care and public health.

Study selection and data extraction Two investigators (MDC, SHJ) independently reviewed the full text to exclude articles that did not fulfill search criteria. Articles excluded were those that focused on physicians-in-training, on SCOC in a non–primary care setting, such as an inpatient ward, or on transitions from inpatient to the outpatient setting. We also excluded articles that did not correlate SCOC to a quality of care measure.

Data synthesis From 5070 candidate titles, we examined the full text of 260 articles and found 18 (12 cross-sectional studies, 5 cohort studies and 1 randomized controlled trial) that fulfilled our criteria. Five studies focused on patients with chronic illness (eg, asthma, diabetes).

Results No studies documented negative effects of increased SCOC on quality of care. SCOC is associated with patient satisfaction (4 studies), decreased hospitalizations and emergency department visits (7 studies), and improved receipt of preventive services (5 studies).

Conclusions SCOC improves quality of care, and this association is consistently documented for patients with chronic conditions. Programs to promote SCOC may best maximize impact by focusing on populations with chronic conditions.

Continuity of care (COC) has been promoted recently by such trends as the concept of the “medical home” for patients, use of gatekeepers in managed care organizations (MCOs), and “continuity clinics” for residency training.^1-4 In assessing quality of care provided by MCOs, COC is indirectly measured through physician turnover rate.⁵In addition, many states have enacted laws to guarantee patients’ rights to continue seeing their physician, when a physician’s contract with a MCO has been terminated.⁶

Continuity refers to “care over time by a single individual or team of health care professionals and to effective and timely communication of health information.”⁷ Previous work distinguishes continuity from longitudinality. Continuity refers to whether a patient sees the same clinician from one visit to the next. Longitudinality refers to whether the patient has an established, long-term relationship with a clinician.⁸ The term continuity is often used when actually describing longitudinality.

In this analysis, we distinguish between the 2 concepts and focus on the sustained continuity of care between a patient and a health care provider through a relationship over time. Since this focus most closely resembles the concept of longitudinality, we will distinguish this from COC as sustained continuity of care (SCOC).

SCOC may encourage communication between physician and patient throughout the course of a long-term relationship. As health care providers gain familiarity with a patient’s history, they may more effectively manage chronic conditions or monitor long-term development.

The advantage of SCOC lessens, however, as electronic medical information becomes more prevalent, allowing different providers to stay up to date on long-term issues. There are tradeoffs, too, with SCOC, such as not being able to see the next available provider in an urgent situation.⁹ Also, one provider voices one perspective or opinion; access to multiple perspectives can serve as a “check” for avoiding incorrect or delayed diagnoses.¹⁰ Providers with different expertise¹¹may be able to complement others’ skills and thus provide better services overall.¹² Furthermore, SCOC could decrease communication if physicians or patients assume they know (or are known by) the other so well that new issues are not introduced or discussed.

Given these tradeoffs, it is not surprising that different studies suggest conflicting results regarding SCOC and quality.^{13, 15}Although Dietrich et al previously reviewed this topic, the following analysis incorporates new studies published since the previous analysis.¹⁶