Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review

Continuity of care and consultation mode in general practice: a cross-sectional and longitudinal study using patient-level and practice-level data from before and during the COVID-19 pandemic in England

OBJECTIVES

Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics.

DESIGN

Retrospective cross-sectional and longitudinal observational studies.

SETTING

Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England.

PARTICIPANTS

In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP.

RESULTS

Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity.

CONCLUSIONS

We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.

Physician home visits to rostered patients during their last year of life: a retrospective cohort study

BACKGROUND

Physician home visits are associated with better health outcomes, yet most patients near the end of life never receive such a visit. Our objectives were to describe the receipt of physician home visits during the last year of life after a referral to home care - an indication that the patient can no longer live independently - and to measure associations between patient characteristics and receipt of a home visit.

METHODS

We conducted a retrospective cohort study using linked population-based health administrative databases housed at ICES. We identified adult (aged ≥ 18 yr) decedents in Ontario who died between Mar. 31, 2013, and Mar. 31, 2018, who were receiving primary care and were referred to publicly funded home care services. We described the provision of physician home visits, office visits and telephone management. We used multinomial logistic regression to calculate the odds of receiving home visits from a rostered primary care physician, controlling for referral during the last year of life, age, sex, income quintile, rurality, recent immigrant status, referral by rostered physician, referral during hospital stay, number of chronic conditions and disease trajectory based on the cause of death.

RESULTS

Of the 58 753 decedents referred in their last year of life, 3125 (5.3%) received a home visit from their family physician. Patient characteristics associated with higher odds of receiving home visits compared to office-based or telephone-based care were being female (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.21-1.35), being 85 years of age or older (adjusted OR 2.42, 95% CI 1.80-3.26) and living in a rural area (adjusted OR 1.09, 95% CI 1.00-1.18). Increased odds were associated with home care referrals by the patient's primary care physician (adjusted OR 1.49, 95% CI 1.39-1.58) and referrals occurring during a hospital stay (adjusted OR 1.20, 95% CI 1.13-1.28).

INTERPRETATION

A small proportion of patients near the end of life received home-based physician care, and patient characteristics did not explain the low visit rates. Future work on system- and provider-level factors may be critical to improve access to home-based end-of-life primary care.

Study on the application effect of the family doctor contract service mode of 'basic package+personalised package' in elderly hypertension management in Chengdu, China: a retrospective observational study

OBJECTIVES

We conducted this study to assess the application effect of the family doctor contract service mode of 'basic package+personalised package' in the management of hypertension patients.

DESIGN

Observational study.

SETTING

The study was conducted at a community health centre in Southwest China. Data were collected from 1 January 2018 to 31 December 2020.

PARTICIPANTS

From 1 January 2018 to 31 December 2020, hypertensive patients (age ≥65 years) who participated in the contract services of family doctors at a community health service centre in Chengdu, Southwest China, were selected as the study subjects.

MAIN OUTCOME MEASURES

The primary outcomes included mean blood pressure (systolic, diastolic) and the rate of blood pressure control, secondary outcomes included the level of cardiovascular disease risk and self-management ability. Assessments of baseline and 6 months after signing up were conducted on all outcomes. The major statistical analysis methods included two independent sample t-tests, paired t-tests, Pearson's χ² test, McNemar's test, two independent sample Mann-Whitney U tests and paired sample marginal homogeneity tests.

RESULTS

Of the 10 970 patients screened for eligibility, 968 (8.8%) were separated into an observation group (receiving 'basic package+personalised package (hypertension)' service) (n=403) and a control group (receiving 'basic package' service) (n=565) according to the type of service package they received. In comparison to the control group, the observation group had lower mean systolic blood pressure (p=0.023), higher blood pressure control rate (p<0.001), lower cardiovascular disease risk level (p<0.001) and higher self-management ability level (p<0.001) at 6 months after signing up. The mean diastolic blood pressure of the two groups was not significantly different (p=0.735).

CONCLUSIONS

The family doctor contract service model of 'basic package+personalised package (hypertension)' has a good application effect in the management of elderly hypertension, which can improve the average blood pressure, the rate of blood pressure control, the level of cardiovascular disease risk and self-management ability of the elderly with hypertension.

Efforts of a Mobile Geriatric Team from a Next-of-Kin Perspective: A Phenomenographic Study

Many older adults with complex illnesses are today cared for by their next of kin in their own homes and are often sent between different caregivers in public healthcare. Mobile Geriatric Teams (MGTs) are a healthcare initiative for older adults with extensive care needs living at home, coordinated between hospital, primary, and municipal care. The study aims to describe how next of kin experience care efforts from an MGT for their older adult family members. The study has a descriptive qualitative design and uses a phenomenographic approach. Fourteen next of kin to older adult family members who receive efforts from an MGT were interviewed. Two descriptive categories reflecting their experiences emerged: Professional care and No longer having the main responsibility. The study shows that the participants valued that the staff was very competent, that the physician made home visits and could make quick decisions, and that treatments were given at home. They feel that they receive support and experience security and that a burden is lifted from them. Our study shows that through the MGT, next of kin become involved in the care and are relieved of the burden of responsibility of caring for their older family member.

The effects of information platform-based nursing on preventing venous thromboembolism in patients with hip fractures

PURPOSE

Venous thromboembolism (VTE) is a major health issue among hip fracture patients. This study aimed to develop an information platform based on a mobile application and then evaluate whether information platform-based nursing could improve patient's drug compliance and reduce the incidence of VTE in hip fracture patients.

METHODS

This study retrospectively analyzed hip fracture patients who were treated with conventional prevention and intervention methods for VTE (control group) between January 2008 and November 2012, and prospectively analyzed hip fracture patients who were treated with nursing intervention based on the information platform (study group) between January 2016 and September 2017. All the patients included in the both groups were hip fracture patients who had an age over 50 years, treated with surgery, and hospitalized ≥ 48 h. Patients were excluded if they admitted to hospital due to old fractures, had a severe bleeding after 72 h of admission, diagnosed with any type of VTE, or refused to participate in the study. The information platform was divided into medical, nursing, and patient interface. Based on the information platform, medical practitioners and nurses could perform risk assessments, monitoring management and early warnings, preventions and treatments, health educations, follow-up, and other aspects of nursing interventions for patients. This study compared essential characteristics, drug compliance, VTE occurrence, and mean length of hospitalization between the two groups. Besides, a subgroup analysis was performed in the study group according to different drug compliances. SPSS 18.0 software (IBM Corp., NY, and USA) was used for statistical analysis.

RESULTS

Altogether 1177 patients were included in the control group, and 491 patients in the study group. Regarding baseline data, patients in the study group had more morbidities than those in the control group (p < 0.05). The difference of drug compliance between the two groups was statistically significant (p < 0.001): 761 (64.7%) of the patients in the control group and only 30 (6.1%) patients in the study group had poor drug compliance. In terms of VTE, 10.7% patients (126/1177) in the control group had VTE, and the rate in the study group was 7.1% (35/491), showing a statistically significant difference (p = 0.02). Moreover, the average length of hospitalization in the study group was also significantly lower than that in the control group (10.4 days vs. 13.7 days, p < 0.001). Subgroup analyses of the study group showed that the incidence of VTE in patients with poor, partial, and good compliances were 56.7% (17/30), 5.8% (10/171), and 2.8% (8/290), respectively, revealing a significantly huge difference (p < 0.001).

CONCLUSIONS

Poor drug compliance leads to higher VTE occurrence. The information platform-based nursing can effectively improve the compliance of hip fracture patients and thus considerably reduce the incidence of VTE. The mobile application may be an effective tool to prevent VTE in hip fracture patients.

The effect of family-centered empowerment model on the quality of life of adults with chronic diseases: An updated systematic review and meta-analysis

BACKGROUND

Family-centered empowerment model (FCEM) is a concept that strengthens the family to help a chronic patient to obtain a better quality of life (QoL). The effects of FCEM on QoL of chronic patients are still inconclusive. Therefore, this meta-analysis was conducted to evaluate the effect of FCEM on QoL of adult patients with chronic diseases.

METHODS

Following an online search PubMed/MEDLINE, Scopus, Web of Science, ProQuest, OVID, EMBASE, EBSCO, PsycINFO and Persian databases (Irandoc, IranMedex, SID and MagIran), all studies that tested the impact of FCEM on QoL of patients with chronic diseases were included. Cochrane Risk of Bias Tool was used to assessment the quality of included randomized clinical trials (RCTs) and before/after studies. Analyses were conducted by STATA16.

RESULTS

Six hundred and ninety-seven studies were identified for screening. After screening process, 11 eligible studies were included in this meta-analysis. There were significant intervention effects in all QoL dimensions, physical and mental subscales and QoL total score (All P < 0.05). The minimum lower bound for SMD was 0.61 (95%CI: 0.96 to 1.66), indicating an increasing effect of the intervention on all QOL dimensions. The results showed substantial heterogeneity between the studies for all QoL dimensions, physical and mental subscales and QoL total scores (P < 0.001).

CONCLUSION

FCEM is an appropriate model with a simple and effective application for families with a patient suffering from a chronic illness. Nursing education planners and healthcare providers could benefit from this model for improving the nursing education curriculum and accrediting programs.

Chronic disease care integration into primary care services in sub-Saharan Africa: a 'best fit' framework synthesis and new conceptual model

OBJECTIVE

To examine the relevance of existing chronic care models to the integration of chronic disease care into primary care services in sub-Saharan Africa and determine whether additional context-specific model elements should be considered.

DESIGN

'Best fit' framework synthesis comprising two systematic reviews. First systematic review of existing chronic care conceptual models with construction of a priori framework. Second systematic review of literature on integrated HIV and diabetes care at a primary care level in sub-Saharan Africa, with thematic analysis carried out against the a priori framework. New conceptual model constructed from a priori themes and new themes. Risk of bias of included studies was assessed using CASP and MMAT.

ELIGIBILITY CRITERIA

Conceptual models eligible for inclusion in construction of a priori framework if developed for a primary care context and described a framework for long-term management of chronic disease care. Articles eligible for inclusion in second systematic review described implementation and evaluation of an intervention or programme to integrate HIV and diabetes care into primary care services in SSA.

INFORMATION SOURCES

PubMed, Embase, CINAHL Plus, Global Health and Global Index Medicus databases searched in April 2020 and September 2022.

RESULTS

Two conceptual models of chronic disease care, comprising six themes, were used to develop the a priori framework. The systematic review of primary research identified 16 articles, within which all 6 of the a priori framework themes, along with 5 new themes: Improving patient access, stigma and confidentiality, patient-provider partnerships, task-shifting, and clinical mentoring. A new conceptual model was constructed from the a priori and new themes.

CONCLUSION

The a priori framework themes confirm a need for co-ordinated, longitudinal chronic disease care integration into primary care services in sub-Saharan Africa. Analysis of the primary research suggests integrated care for HIV and diabetes at a primary care level is feasible and new themes identified a need for a contextualised chronic disease care model for sub-Saharan Africa.

What is needed for continuity of care and how can we achieve it? - Perceptions among multiprofessionals on the chronic care trajectory

Background

Continuity of care (CoC) implies delivery of services in a coherent, logical and timely fashion. Continuity is conceptualized as multidimensional, encompassing three specific domains – relational, management and informational continuity – with emphasis placed on their interrelations, i.e., how they affect and are affected by each other. This study sought to investigate professionals’ perceptions of the prerequisites of CoC within and between organizations and how CoC can be realized for people with complex care needs.

Methods

This study had a qualitative design using individual, paired and focus group interviews with a purposeful sample of professionals involved in the chain of care for patients with chronic conditions across healthcare and social care services from three different geographical areas in Sweden, covering both urban and rural areas. Transcripts from interviews with 34 informants were analysed using conventional content analysis.

Results

CoC was found to be dependent on professional and cross-disciplinary cooperation at the micro, meso and macro system levels. Continuity is dependent on long-term and person-centred relationships (micro level), dynamic stability in organizational structures (meso level) and joint responsibility for cohesive care and enabling of uniform solutions for knowledge and information exchange (macro level).

Conclusions

Achieving CoC that creates coherent and long-term person-centred care requires knowledge- and information-sharing that transcends disciplinary and organizational boundaries. Collaborative accountability is needed both horizontally and vertically across micro, meso and macro system levels, rather than a focus on personal responsibility and relationships at the micro level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08023-0.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study

PURPOSE

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs.

METHODS

We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression.

RESULTS

Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin.

CONCLUSIONS

Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data

Objective

To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data.

Methods

We used data on 240′000 insured individuals aged 50+ for the period 2015–2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities.

Results

The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex (“high-cost high-need”) individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence.

Conclusions

Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers.

•

We investigated the relationship between multimorbidity and COC, using claims-based data.

•

We applied three approaches of expressing multimorbidity in claims data: simple counts, expert-based and data-driven.

•

Association between COC and multimorbidity expressed in simple counts was modest, while expert-based approach showed larger heterogeneity.

•

Data-driven approach revealed that most complex individuals tended to have higher COC.

Association of Continuity of General Practitioner Care with Utilisation of General Practitioner and Specialist Services in China: A Mixed-Method Study

Background: Continuity of general practitioner (GP) care, widely known as the core value of high-quality patient care, has a positive association with health outcomes. Evidence about the relationship between continuity and health service utilisation has so far been lacking in China. This study aimed to analyse the association of continuity of GP care with utilisation of general practitioner and specialist services in China. Method: A cross-sectional mixed methods study was conducted in 10 urban communities in Hangzhou. Quantitative data were collected from a random sample of 624 residents adopting the self-developed questionnaire. Measurement of continuity of GP care included informational continuity (IC), managerial continuity (MC) and relational continuity (RC). With adjustment for characteristics of residents, multivariate regression models were established to examine the association of continuity of GP care with the intention to visit GP, frequency of GP and specialist visitations. Qualitative data were collected from 26 respondents using an in-depth interview, and thematic content analysis for qualitative data was conducted. Results: Quantitative analysis showed that the IC was positively associated with the intention to visit GP and frequency of GP visitations. Those people who gave a high rating for RC also used GP services more frequently than their counterparts. MC was negatively associated with frequency of specialist visitations. Qualitative analysis indicated that service capabilities, doctor-patient interaction and time provision were regarded as three important reasons why patients chose GPs or specialists. Conclusions: Overall, high IC and RC are independently associated with more GP service utilisation, but a high MC might reduce specialist visitations. Continuity of GP care should be highlighted in designing a Chinese GP system.

Derivation and validation of predictors of oral anticoagulant-related adverse events in seniors transitioning from hospital to home

INTRODUCTION

Oral anticoagulant (OAC)-related adverse events are high post-hospitalization. We planned to develop and validate a prediction model for OAC-related harm within 30 days of hospitalization.

METHODS

We undertook a population-based study of adults aged ≥66 years who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome was a composite of time to first hospitalization or emergency department visit for a hemorrhagic or thromboembolic event, or mortality within 30 days of hospital discharge. Cox proportional hazards regression was used to build the model.

RESULTS

We included 120,721 patients of which 5423 experienced the outcome. Most patients were aged ≥75 years (59.5%) and were female (55.6%). Sixty percent of the cohort had a follow-up visit with a healthcare provider within 7 days of discharge. Patients discharged on a direct acting OAC versus warfarin (apixaban: Hazard Ratio [HR] 0.82, 95% confidence interval [CI] 0.71-0.94; dabigatran: HR 0.73, 95% CI 0.63-0.84; rivaroxaban: HR 0.79, 95% CI 0.71-0.88), were prevalent users of the dispensed OAC versus incident users (HR 0.82, 95% CI 0.69-0.96), had a joint replacement in the past 35 days (HR 0.40, 95% CI 0.33-0.50) or major surgery during index hospital stay (HR 0.69, 95% CI 0.60-0.80) had a lower risk for the outcome. The Cox model was stable with acceptable discrimination but poor goodness-of-fit.

CONCLUSIONS

A model for OAC-related harm in the early post-discharge period was developed. External validation studies are required to understand the model's poor calibration.

Transitioning From Hospital to Palliative Care at Home: Patient and Caregiver Perceptions of Continuity of Care

CONTEXT

Continuity of care is important at improving the patient experience and reducing unnecessary hospitalizations when transitioning across care settings, especially at the end of life.

OBJECTIVE

To explore patient and caregiver understanding and valuation of "continuity of care" while transitioning from an in-hospital to a home-based palliative care team.

METHODS

Longitudinal qualitative design using semistructured interviews conducted with patients and their caregivers before and after transitioning from hospital to palliative care at home. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis within a postpositivist framework. Thirty-nine participants (18 patients, seven caregivers, and seven patient-caregiver dyads) were recruited from two acute care hospitals, wherein they received care from an inpatient palliative care consultation team and transitioned to home-based palliative care.

RESULTS

Patients had a mean age of 68 years, 60% were female and 60% had a diagnosis of cancer. Caregivers had a mean age of 62 years and 50% were female. Participants perceived continuity of care to occur in three ways, depending on which stage they were at in their hospital-to-home transition. In hospital, continuity of care was experienced, as consistency of information exchanged between providers. During the transition from hospital to home, continuity of care was experienced as consistency of treatments. When receiving home-based palliative care, continuity of care was experienced as having consistent providers.

CONCLUSION

Patients' and their caregivers' valuation of continuity of care was dependent on their stage of the hospital-to-home transition. Optimizing continuity of care requires an integrated network of providers with reliable information transfer and communication.

Continuity of Care in Chronic Diseases: A Concept Analysis by Literature Review

PURPOSE

This study aimed to utilize concept analysis to obtain a better understanding of the concept of "continuity of care" in chronic diseases.

METHODS

The concept of continuity of care was analyzed using the Walker and Avant method. Covering literature in English from 1930 to 2018, the data sources included CINAHL Complete, Academic Search Complete, MEDLINE, PsyARTICLES, Health Source: Nursing/Academic Edition, Google Scholar, Science Direct, and the Cochrane Library.

RESULTS

A comprehensive definition of concept of continuity of care was developed based on a systematic search and synthesis. The key defining attributes were identified as (a) care over time, (b) the relationship between an individual patient and a care team, (c) information transfer, (d) coordination, and (e) meeting changing needs. The antecedents of continuity of care were having a chronic disease, inexperienced with disease management, a poorly coordinated healthcare system, and medical care limitations. The consequences of continuity of care were decreasing hospital admissions, reducing costs, reducing emergency room visits, improving the quality of life, improving patient satisfaction, and delivering good healthcare.

CONCLUSION

The thorough concept analysis provides insight into the nature of "continuity of care" in chronic diseases and also helps ground the concept in healthcare.

Dealing with Discontinuity in Cancer Care Trajectories: Patients' Solutions

Introduction

Patients with cancer require specialized care from different care providers, challenging continuity of care in terms of information, relationships, and/or management. The recognition of discontinuity of care has led to different initiatives by the healthcare system over the years. Yet, making use of the theory on boundary objects and brokers, this research explores the active role of patients themselves in resolving discontinuity along their care trajectories.

Methods

Semi-structured interviews were conducted with 33 patients to unravel the discontinuities that they experience and their attempts to resolve these. Interview data were analyzed using directed-content analysis informed by concepts from boundary crossing literature (i.e., data were searched for potential boundary objects and brokers).

Results

To re-establish continuity of care, patients actively use the objects and people provided by the healthcare system when these meet their needs. Patients also introduce own objects and people into the care trajectory. As such, information and management discontinuity can typically be resolved. Relational continuity appears to be more difficult to resolve, in some cases leaving patients to take drastic measures, such as changing care providers.

Discussion

The use of boundary crossing theory in improving care from a patient perspective is relatively novel. When patients and providers together address the objects and people that support establishing continuity of care, a continuous care process may be encouraged. We advocate an integrated approach, rather than provider or healthcare system initiatives exclusively, to patient care and continuity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00535-x.

Documented diabetes care among older people receiving home care services: a cross-sectional study

BACKGROUND

Home care services plays an important role in diabetes management, and to enable older adults remain home-dwellers. Adequate follow-up and systematic nursing documentation are necessary elements in high quality diabetes care. Therefore, the purpose of this study was to examine the diabetes treatment and management for older persons with diabetes receiving home care services.

METHODS

A cross-sectional study was used to assess the diabetes treatment and management in a Norwegian municipality. Demographic (age, sex, living situation) and clinical data (diabetes diagnose, type of glucose lowering treatment, diabetes-related comorbidities, functional status) were collected from electronic home care records. Also, information on diabetes management; i.e. follow-up routines on glycated haemoglobin (HbA_1c), self-monitoring of blood glucose, insulin administration and risk factors (blood pressure, body mass index and nutritional status) were registered. HbA_1c was measured upon inclusion. Descriptive and inferential statistics were applied in the data analysis.

RESULTS

A total of 92 home care records from older home-dwelling persons with diabetes, aged 66-99 years were assessed. Only 52 (57 %) of the individuals had the diabetes diagnosis documented in the home care record. A routine for self-monitoring of blood glucose was documented for 27 (29 %) of the individuals. Only 2 (2 %) had individual target for HbA_1c documented and only 3 (3 %) had a documented routine for measuring HbA_1c as recommended in international guidelines. Among 30 insulin treated older individuals, a description of the insulin regimen lacked in 4 (13 %) of the home care records. Also, documentation on who performed self-monitoring of blood glucose was unclear or lacking for 5 (17 %) individuals.

CONCLUSIONS

The study demonstrates lack of documentation in home care records with respect to diagnosis, treatment goals and routines for monitoring of blood glucose, as well as insufficient documentation on responsibilities of diabetes management among older home-dwelling adults living with diabetes. This indicates that home care services may be suboptimal and a potential threat to patient safety.

Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City

BACKGROUND

Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home.

PURPOSE

Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems.

METHODS

Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems.

RESULTS

Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017.

CONCLUSION

As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.

"There are still a lot of things that I need": a qualitative study exploring opportunities to improve the health services of First Nations People with arthritis seen at an on-reserve outreach rheumatology clinic

Background

Arthritis is a highly prevalent disease and leading cause of disability in the Indigenous population. A novel model of care consisting of a rheumatology outreach clinic in an on-reserve primary healthcare center has provided service to an Indigenous community in Southern Alberta since 2010. Despite quality assessments suggesting this model of care improves accessibility and is effective in meeting treatment targets, substantial improvements in patient-reported outcomes have not been realized. Therefore, the objective of this study was to explore the experiences of Indigenous persons with arthritis and healthcare providers involved in this model of care to inform the development of health service improvements that enhance patient outcomes.

Methods

This was a narrative-based qualitative study involving a purposeful sample of 32 individuals involved in the Indigenous rheumatology model of care. In-depth interviews were conducted to elicit experiences with the existing model of care and to encourage reflections on opportunities to improve it. A two-stage analysis was conducted. The first stage aimed to produce a narrative synthesis of concepts through a dialogical method comparing people with arthritis and health providers’ narratives. The second stage involved a collective effort to synthesize concepts and propose specific recommendations to improve the quality of the current model of care. Triangulation, through participant checking and discussion among researchers, was used to increase the validity of the final recommendations.

Results

Ten Indigenous people with arthritis lived experience, 14 health providers and 8 administrative staff were interviewed. One main overarching theme was identified, which reflected the need to provide services that improve people’s physical and mental functioning. Further, the following specific recommendations were identified: 1) enhancing patient-provider communication, 2) improving the continuity of the healthcare service, 3) increasing community awareness about the presence and negative impact of arthritis, and 4) increasing peer connections and support among people living with arthritis.

Conclusions

Improving the quality of the current Indigenous rheumatology model of care requires implementing strategies that improve functioning, patient-provider communication, continuity of care, community awareness and peer support. A community-based provider who supports people while navigating health services could facilitate the implementation of these strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05909-9.

Association of continuity of care with readmission, mortality and suicide after hospital discharge among psychiatric patients

Objectives

The objective of this study was to identify the association between continuity of ambulatory psychiatric care after hospital discharge among psychiatric patients and readmission, mortality and suicide.

Design

Nationwide nested case-control study.

Settings

South Korea.

Participants

Psychiatric inpatients.

Interventions

Continuity of psychiatric outpatient care was measured from the time of hospital discharge until readmission or death occurred, using the continuity of care index.

Main Outcome Measures

Readmission, all-cause mortality and suicides within 1-year post-discharge.

Results

Of 18 702 psychiatric inpatients in the study, 8022 (42.9%) were readmitted, 355 (1.9%) died, and 108 (0.6%) died by suicide within 1 year after discharge. Compared with the psychiatric inpatients with a high continuity-of-care score, a significant increase in the readmission risk within 1 year after discharge was found in those with medium and low continuity of care scores. An increased risk of all-cause mortality within 1 year after hospital discharge was shown in the patients in the low continuity group, relative to those in the high-continuity group. The risk of suicide within 1 year after hospital discharge was higher in those with medium and low continuity of care than those with high continuity of care.

Conclusion

The results of this study provide empirical evidence of the importance of continuity of care when designing policies to improve the quality of mental health care, such as increasing patient awareness of the importance of continuity and implementation of policies to promote continuity.

Dietitians' Perspectives on the Impact of Multidisciplinary Teams and Electronic Medical Records on Dietetic Practice for Weight Management

Purpose: To understand the perception of dietitians regarding the effects of multidisciplinary settings and Electronic Health Records (EHRs) on their dietetic practice for weight management. Methods: Individual semi-structured interviews were conducted with 14 dietitians working in multidisciplinary settings in Ontario. All interviews were audio recorded and transcribed verbatim. Two researchers coded the data independently using a thematic analysis approach. All themes emerged inductively and were refined iteratively. Results: Most dietitians believed that working in a multidisciplinary setting allowed for interprofessional collaboration and time-effective referrals. Multidisciplinary clinics were perceived to improve patient care due to convenient scheduling, consistent messaging, and ongoing support. However, some dietitians reported instances of conflicting approaches and beliefs regarding weight management across health professionals. Dietitians suggested ways to address these conflicting approaches through clinical meetings and education. EHRs were perceived to allow for collaboration through facilitated communication and knowledge exchange; however, lack of interoperability between EHR platforms across different types of health care settings was perceived to be a barrier for optimal care. Conclusions: Overall, multidisciplinary settings were perceived to positively impact dietitians' practices for weight management as they allow for interprofessional collaboration. Consistency in health messaging across health professionals should be emphasized through knowledge exchange.

Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study

BACKGROUND

Bipolar disorder if untreated, has severe consequences: severe role impairment, higher health care costs, mortality and morbidity. Although effective treatment is available, the delay in diagnosis might be as long as 10-15 years. In this study, we aim at documenting the length of the diagnostic delay in Hungary and identifying factors associated with it.

METHODS

Kaplan-Meier survival analysis and Cox proportional hazards model was employed to examine factors associated with the time to diagnosis of bipolar disorder measured from the date of the first presentation to any specialist mental healthcare institution. We investigated three types of factors associated with delays to diagnosis: demographic characteristics, clinical predictors and patient pathways (temporal sequence of key clinical milestones). Administrative data were retrieved from specialist care; the population-based cohort includes 8935 patients from Hungary.

RESULTS

In the sample, diagnostic delay was 6.46 years on average. The mean age of patients at the time of the first bipolar diagnosis was 43.59 years. 11.85% of patients were diagnosed with bipolar disorder without any delay, and slightly more than one-third of the patients (35.10%) were never hospitalized with mental health problems. 88.80% of the patients contacted psychiatric care for the first time in outpatient settings, while 11% in inpatient care. Diagnostic delay was shorter, if patients were diagnosed with bipolar disorder by non-specialist mental health professionals before. In contrast, diagnoses of many psychiatric disorders received after the first contact were coupled with a delayed bipolar diagnosis. We found empirical evidence that in both outpatient and inpatient care prior diagnoses of schizophrenia, unipolar depression without psychotic symptoms, and several disorders of adult personality were associated with increased diagnostic delay. Patient pathways played an important role as well: the hazard of delayed diagnosis increased if patients consulted mental healthcare specialists in outpatient care first or they were hospitalized.

CONCLUSIONS

We systematically described and analysed the diagnosis of bipolar patients in Hungary controlling for possible confounders. Our focus was more on clinical variables as opposed to factors controllable by policy-makers. To formulate policy-relevant recommendations, a more detailed analysis of care pathways and continuity is needed.

Reframing resilience: Strengthening continuity of patient care to improve the mental health of immigrants and refugees

Refugee and immigrant populations experience many pre- and post-migration risk factors and stressors that can negatively impact their mental health. This qualitative study aimed to explore the system-level issues that affect the access to, as well as quality and outcomes of mental health care for immigrants and refugees, with a particular focus on challenges in the continuity of patient care. A multidisciplinary group of health providers, including nurses, identified six themes including (i) perceived access to care; (ii) coordination amongst health care providers; (iii) patient connections with community organizations; (iv) coordinated care planning; (v) organizational protocols, policies and procedures and (vi) systemic and health care training needs. Although patient resilience is seen as a pivotal way for vulnerable populations to cope with hardship, there is a clear need for creating a resilient health care system that is able to anticipate and adapt to adverse situations. The findings from this study have implications for nurses, who are uniquely positioned to advocate for public health policy that improves the continuity of health care by creating systemic resilience.

Individual and community-level income and the risk of diabetes rehospitalization among women and men: a Canadian population-based cohort study

BACKGROUND

Marked disparities by socioeconomic status in the risk of potentially avoidable hospitalization for chronic illnesses have been observed in many contexts, including those with universal health coverage. Less well known is how gender mediates such differences. We conducted a population-based cohort study to describe associations between household and community-level income and rehospitalizations for types 1 and 2 diabetes mellitus among Canadian women and men.

METHODS

Our cohorts were drawn from respondents to the 2006 mandatory long-form census linked longitudinally to 3 years of nationally standardized hospital records. We included adults 30-69 years hospitalized with diabetes at least once during the study period. We used logistic regressions to estimate odds ratios for 12-month diabetes rehospitalization associated with indicators of household and community-level income, with separate models by gender, and controlling for a range of other sociodemographic characteristics. Since diabetes may not always be recognized as the main reason for hospitalization, we accounted for disease progression through consideration of admissions where diabetes was previously identified as a secondary diagnosis.

RESULTS

Among persons hospitalized at least once with diabetes (n = 41,290), 1.5% were readmitted within 12 months where the initial admission had diabetes as the primary diagnosis, and 1.8% were readmitted where the initial admission had diabetes as a secondary diagnosis. For men, being in the lowest household income quintile was associated with higher odds of rehospitalization in cases where the initial admission listed diabetes as either the primary diagnosis (OR = 2.21; 95% CI = 1.38-3.51) or a secondary diagnosis (OR = 1.51; 95% CI = 1.02-2.24). For women, we found no association with income and rehospitalization, but having less than university education was associated with higher odds of rehospitalization where diabetes was a secondary diagnosis of the initial admission (OR = 1.88; 95% CI = 1.21-2.92). We also found positive, but insignificant associations between community-level poverty and odds of rehospitalization.

CONCLUSIONS

Universal health coverage remains insufficient to eliminate socioeconomic inequalities in preventable diabetes-related hospitalizations, as illustrated in this Canadian context. Decision-makers should tread cautiously with gender-blind poverty reduction actions aiming to enhance population health that may inadequately respond to the different needs of disadvantaged women and men with chronic illness.

Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis

BACKGROUND

Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term.

OBJECTIVE

To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge.

DESIGN

Meta-analysis of randomized controlled trials.

DATA SOURCES

A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits.

REVIEW METHODS

RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model.

RESULTS

Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity.

CONCLUSIONS

Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.

A New Era in Pediatric Hospice Care for Military Families

: This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; https://advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

Background

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

Methods

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

Results

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

Conclusion

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Team Collaboration Networks and Multidisciplinarity in Diabetes Care: Implications for Patient Outcomes

Prevalence of type 2 diabetes mellitus (T2DM) has almost doubled in recent decades and commonly presents comorbidities and complications. T2DM is a multisystemic disease, requiring multidisciplinary treatment provided by teams working in a coordinated and collaborative manner. The application of social network analysis techniques in the healthcare domain has allowed researchers to analyze interaction between professionals and their roles inside care teams. We studied whether the structure of care teams, modeled as complex social networks, is associated with patient progression. For this, we illustrate a data-driven methodology and use existing social network analysis metrics and metrics proposed for this research. We analyzed appointment and HbA1c blood test result data from patients treated at three primary health care centers, representing six different practices. Patients with good metabolic control during the analyzed period were treated by teams that were more interactive, collaborative and multidisciplinary, whereas patients with worsening or unstable metabolic control were treated by teams with less collaboration and more continuity breakdowns. Results from the proposed metrics were consistent with the previous literature and reveal relevant aspects of collaboration and multidisciplinarity.

Association between Continuity of Care and the Onset of Thyroid Disorder among Diabetes Patients in Korea

Objectives: As the relationship between diabetes mellitus and thyroid dysfunction is well known, it is important to investigate the factors influencing this association. Continuity of care is associated with better quality of care and outcomes, such as reduced complications, among diabetes patients. Therefore, the purpose of this study was to investigate the association between continuity of care and the onset of thyroid dysfunction among diabetes patients. Methods: We used Korean National Health Insurance Service National Sample Cohort data from 2002 to 2013. Our final study population included 16,806 newly diagnosed diabetes patients who were older than 45 years of age. Continuity of care was measured using the Continuity of Care index. The dependent variable was the onset of thyroid disorder. Cox proportional hazard regression models were used for statistical analyses. Results: Diabetes patients with low continuity of care were at increased risk of the onset of thyroid disorder compared with those with high continuity of care (hazard ratio (HR): 1.28, 95% confidence interval (CI): 1.07–1.54). Subgroup analyses showed that this association was significant within patients with type 2 diabetes (HR: 1.24, 95% CI: 1.01–1.52) or whose main attending site was a local clinic (HR: 1.32, 95% CI: 1.07–1.64). Conclusions: Our results show that diabetes patients with low continuity of care are more likely to experience the onset of thyroid disorder. Therefore, improving continuity of care could be a reasonable method of preventing complications or comorbidities, including thyroid disorder, among diabetes patients.

Relationship between Continuity of Care in the Multidisciplinary Treatment of Patients with Diabetes and Their Clinical Results

Multidisciplinary treatment and continuity of care throughout treatment are important for ensuring metabolic control and avoiding complications in diabetic patients. This study examines the relationship between continuity of care of the treating disciplines and clinical evolution of patients. Data from 1836 adult patients experiencing type 2 diabetes mellitus were analyzed, in a period between 12 and 24 months. Continuity was measured by using four well known indices: Usual Provider Continuity (UPC), Continuity of Care Index (COCI), Herfindahl Index (HI), and Sequential Continuity (SECON). Patients were divided into five segments according to metabolic control: well-controlled, worsened, moderately decompensated, highly decompensated, and improved. Well-controlled patients had higher continuity by physicians according to UPC and HI indices (p-values 0.029 and <0.003), whereas highly decompensated patients had less continuity in HI (p-value 0.020). Continuity for nurses was similar, with a greater continuity among well-controlled patients (p-values 0.015 and 0.001 for UPC and HI indices), and less among highly decompensated patients (p-values 0.004 and <0.001 for UPC and HI indices). Improved patients had greater adherence to the protocol than those who worsened. The SECON index showed no significant differences across the disciplines. This study identified a relationship between physicians and nurse’s continuity of care and metabolic control in patients with diabetes, consistent with qualitative findings that highlight the role of nurses in treatment.

Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data

Background

Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran’s Health Administration (VHA) primary care patients with diabetes.

Methods

This patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a “home” VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations.

Results

Among VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75–0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07–0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69–0.97; reference least restrictive regulation).

Conclusions

ICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.

Continuity of care experiences following the transition from Early Intervention Teams to Primary, Community and Continuous Care Teams in Ireland: A multi-perspective case study exploring the views of caregivers’ of children with Autistic Spectrum Disorder and service providers

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Measurement tools and outcome measures used in transitional patient safety; a systematic review

BACKGROUND

Patients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed.

AIM AND METHODS

To identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection. First, publications about validation of measurement tools were appraised for quality following COSMIN criteria. Second, we inventoried all measurement tools and outcome measures found in our search that assessed current transitional patient safety or the effect of interventions targeting transitional patient safety.

RESULTS

The initial search yielded 8288 studies, of which 18 assessed validity of measurement tools of different aspects of transitional safety, and 191 assessed current transitional patient safety or effect of interventions. In the validated measurement tools, the overall quality of content and structural validity was acceptable; other COSMIN criteria, such as reliability, measurement error and responsiveness, were mostly poor or not reported. In our outcome inventory, the most frequently used validated outcome measure was the Care Transition Measure (n = 9). The most frequently used non-validated outcome measures were: medication discrepancies (n = 98), hospital readmissions (n = 55), adverse events (n = 34), emergency department visits (n = 33), (mental or physical) health status (n = 28), quality and timeliness of discharge summary, and patient satisfaction (n = 23).

CONCLUSIONS

Although no validated measures exist that assess all aspects of transitional patient safety, we found validated measurement tools on specific aspects. Reporting of validity of transitional measurement tools was incomplete. Numerous outcome measures with unknown measurement properties are used in current studies on safety of care transitions, which makes interpretation or comparison of their results uncertain.

Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system

Background

In the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain).

Methods

We conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data.

Results

Patients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship.

Conclusions

Consistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3042-9) contains supplementary material, which is available to authorized users.

Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil

Despite the fragmentation of healthcare provision being considered one of the main obstacles to attaining effective health care in Latin America, very little is known about patients' perceptions. This paper analyses the level of continuity of health care perceived by users and explores influencing factors in two municipalities of Colombia and Brazil, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had suffered at least one health problem within the previous three months (2163 in Colombia; 2167 in Brazil). An adapted and validated version of the CCAENA© (Questionnaire of care continuity across levels of health care) was applied. Logistic regression models were generated to assess the relationship between perceptions of the different types of health care continuity and sociodemographic characteristics, health needs, and organizational factors. The results show lower levels of continuity across care levels in information transfer and care coherence and higher levels for the ongoing patient-doctor relationship, albeit with differences between the two countries. They also show greater consistency of doctors in the Brazilian study areas, especially in primary care. Consistency of doctors was not only positively associated with the patient-doctor ongoing relationship in the study areas of both countries, but also with information transfer and care coherence across care levels. The study area and health needs (the latter negatively for patients with poor self-rated health and positively for those with at least one chronic condition) were associated with all types of continuity of care. The influence of the sex or income varied depending on the country. The influence of the insurance scheme in the Colombian sample was not statistically significant. Both countries should implement policies to improve coordination between care levels, especially regarding information transfer and job stability for primary care doctors, both key factors to guarantee quality of care.

Experiences of Living with Assisted Peritoneal Dialysis - A Qualitative Study

BACKGROUND

People's experiences of living with assisted peritoneal dialysis (aPD) have not been studied previously. Assisted PD is successfully used as renal replacement therapy for elderly and disabled patients with end-stage renal disease. To be treated with aPD implies being dependent on lifelong treatment at home. The aim of this study was to explore adults' experiences of living with aPD.

METHODS

In-depth interviews were conducted with 10 participants with aPD, median age 82.5 years. The text was analyzed using a phenomenological-hermeneutical method.

RESULTS

The participants experienced limitations and an uncertain future, but through different strategies and participation in healthcare, they could still enjoy what was important in life for them. The analysis of the text resulted in 4 main themes; 1) Facing new demands, 2) Managing daily life, 3) Partnership in care, and 4) Experiencing a meaningful life, leading to the comprehensive understanding: 'Striving for maintaining wellbeing'.

CONCLUSION

The participants expressed that they experienced a good quality of life despite being physically frail, severely ill, and in need of home-based lifesaving treatment. The findings suggest that aPD should be available everywhere where PD is offered. Integrating the model of person-centered care may greatly improve the care for persons living with aPD.

Process measures or patient reported experience measures (PREMs) for comparing performance across providers? A study of measures related to access and continuity in Swedish primary care

Aim To study (a) the covariation between patient reported experience measures (PREMs) and registered process measures of access and continuity when ranking providers in a primary care setting, and (b) whether registered process measures or PREMs provided more or less information about potential linkages between levels of access and continuity and explaining variables.

BACKGROUND

Access and continuity are important objectives in primary care. They can be measured through registered process measures or PREMs. These measures do not necessarily converge in terms of outcomes. Patient views are affected by factors not necessarily reflecting quality of services. Results from surveys are often uncertain due to low response rates, particularly in vulnerable groups. The quality of process measures, on the other hand, may be influenced by registration practices and are often more easy to manipulate. With increased transparency and use of quality measures for management and governance purposes, knowledge about the pros and cons of using different measures to assess the performance across providers are important.

METHODS

Four regression models were developed with registered process measures and PREMs of access and continuity as dependent variables. Independent variables were characteristics of providers as well as geographical location and degree of competition facing providers. Data were taken from two large Swedish county councils. Findings Although ranking of providers is sensitive to the measure used, the results suggest that providers performing well with respect to one measure also tended to perform well with respect to the other. As process measures are easier and quicker to collect they may be looked upon as the preferred option. PREMs were better than process measures when exploring factors that contributed to variation in performance across providers in our study; however, if the purpose of comparison is continuous learning and development of services, a combination of PREMs and registered measures may be the preferred option. Above all, our findings points towards the importance of a pre-analysis of the measures in use; to explore the pros and cons if measures are used for different purposes before they are put into practice.

Relationship preferences and experience of primary care patients in continuity of care: a case study in Beijing, China

Background

Continuity of care can bring a wide range of benefits to consumers, providers and health care systems. This study aimed to understand the relationship preferences of primary care patients and their associations with patient experience of continuity of care.

Methods

A questionnaire survey was conducted on 700 patients who sought medical care from a community health organisation in Beijing. The survey contained four items examining the relationship preferences of the respondents, and a modified Questionnaire of Continuity between Care Levels (CCAENA) measuring patient experience of continuity of care based on a three dimensional (relational, informational and managerial) model. The associations between the relationship preferences and the experience of respondents in continuity of care was tested using a linear regression model controlling for age, sex, education, medical insurance, personal income and servicing facilities.

Results

The respondents experienced relatively lower levels of informational and managerial continuity compared with relational continuity of care. More than 80% of respondents preferred free choice and a continuing relationship with doctors, compared with 59% who endorsed community facility control over hospital appointments. A preference for a continuing relationship with doctors was associated with all aspects of continuity of care. A preference in favour of community facility control over hospital appointments was a strong predictor of managerial continuity (β = 0.333, p < 0.001) and informational continuity (β = 0.256, p < 0.001). Patient preference for free choice of doctors was positively associated with relational continuity with specialists (p < 0.001), but not with primary care providers (p > 0.08). Perceived importance of information exchange was associated with relational and managerial continuity (p < 0.05), but not with informational continuity (p = 0.34).

Conclusions

Patients prefer a high level of freedom of choice and sustained individual relationship with doctors. Relationship preferences of patients are associated with their experience of continuity of care. But patient strong preference for free choice of doctors is not aligned with relational continuity with primary care, a desirable feature of cost-effective healthcare systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2536-1) contains supplementary material, which is available to authorized users.

Effect of Continuity of Care on Drug-Drug Interactions

BACKGROUND

Drug-drug interaction (DDI) is a critical concern in health care systems because it is directly associated with patient outcomes and is generally preventable. However, few studies have been conducted on whether poor continuity of care (COC) is a determinant of DDIs and whether this effect varies by level of comorbidity. Patients with higher comorbidity normally require more complex treatment regimens than other patients, and hence their COC is more critical for ensuring the accuracy of their medication information.

OBJECTIVE

This study investigated the association between COC and DDI, with COC being measured as physician and site COC. The effect of comorbidities on DDI events was also analyzed.

METHODS

The Taiwan National Health Insurance claims data of ∼1,000,000 randomly selected insurance beneficiaries were used. Each person was longitudinally followed from 2005 to 2013. Negative nominal regressions were estimated to determine the effect of COC on DDI.

RESULTS

Higher COC was found to decrease the risk of DDI, and this risk reduction was even greater with physician COC and a higher Charlson comorbidity index. In the 1-year observation interval, patients exhibited a 3% reduction in DDIs for every 0.1 increment in their COC index. The ability of COC to reduce DDIs increased with the level of comorbidity. Similar results were observed when the observation interval was increased.

CONCLUSIONS

Improving COC is critical for reducing DDIs. The effect of high-quality COC on the reduction of DDI is more significant for patients with higher levels of comorbidity; thus, they should be targeted to improve COC.

‘It’s not just the word care, it’s the meaning of the word…(they) actually care': caregivers’ perceptions of home-based primary care in Toronto, Ontario

The frail and homebound older adult populations currently experience difficulties accessing primary care in the medical office. Given this fundamental access to care problem, and the questionable care quality that arises when navigating a labyrinthine health-care system, these populations have typically been subject to inadequate primary care. To meet their needs better, growing research stresses the importance of providing comprehensive home-based primary care (HBPC), delivered by an inter-professional team of health-care providers. Family care-givers typically provide the majority of care within the home, yet their perceptions of HBPC remain under-researched. The purpose of this study was to explore unpaid care-givers' perceptions of and experiences with HBPC programmes in Toronto, Canada. We conducted qualitative inductive content analysis, using analytic procedures informed by grounded theory, to discover a number of themes regarding unpaid care-givers' understandings of HBPC. Findings suggest that, compared to the standard office-based care model, HBPC may better support unpaid care-givers, providing them assistance with system navigation and offering them the peace of mind that they are not alone, but have someone to call should the need arise. The implications of this research suggest that HBPC could be a model to help mitigate the discontinuities in care that patients with comorbid chronic conditions and their attendant unpaid care-givers experience when accessing fragmented health, home and social care systems.

Patients Negatively Impacted by Discontinuity of Nursing Care During Acute Hospitalization

BACKGROUND

Continuity of nursing care in hospitals remains poor and not prioritized, and we do not know whether discontinuous nursing care is negatively impacting patient outcomes.

OBJECTIVES

This study aims to examine nursing care discontinuity and its effect on patient clinical condition over the course of acute hospitalization.

RESEARCH DESIGN

Retrospective longitudinal analysis of electronic health records (EHR). Average point-in-time discontinuity was estimated from time of admission to discharge and compared with theoretical predictions for optimal continuity and random nurse assignment. Mixed-effects models estimated within-patient change in clinical condition following a discontinuity.

SUBJECTS

A total of 3892 adult medical-surgical inpatients were admitted to a tertiary academic medical center in the Eastern United States during July 1, 2011 and December 31, 2011.

MEASURES

Exposure: discontinuity of nursing care was measured at each nurse assessment entry into a patient's EHR as assignment of the patient to a nurse with no prior assignment to that patient.

OUTCOME

patient's clinical condition score (Rothman Index) continuously tracked in the EHR.

RESULTS

Discontinuity declined from nearly 100% in the first 24 hours to 70% at 36 hours, and to 50% by the 10th postadmission day. Discontinuity was higher than predicted for optimal continuity, but not random. Each instance of discontinuity lead to a 0.12-0.23 point decline in the Rothman Index score, with more pronounced effects for older and high-mortality risk patients.

CONCLUSIONS

Discontinuity in acute care nurse assignments was high and negatively impacted patient clinical condition. Improved continuity of provider-patient assignment should be advocated to improve patient outcomes in acute care.

Optimal Nutrition and Hydration Through the Surgical Treatment Trajectory

OBJECTIVES

To review oncology nurses role of informational continuity in regards to nutrition and hydration to ensure continuity of care from one care center to another.

DATA SOURCES

Peer-reviewed literature, PubMed, CINAHL, EMBASE, and web-based resources.

CONCLUSION

Optimal nutrition and hydration during cancer treatment and survivorship requires assessment and preplanning of needs. Oncology nurses play a vital role in preparing patients and caregivers for optimal nutrition during the surgical treatment trajectory.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses should emphasize nutrition planning during the surgical treatment trajectory to enhance survivorship and quality of life of the cancer patient. Educational resources exist for both nursing and cancer patients.

Continuity of clinical management and information across care levels: perceptions of users of different healthcare areas in the Catalan national health system

BACKGROUND

The integration of health care has become a priority in most health systems, as patients increasingly receive care from several professionals in various different settings and institutions, particularly those with chronic conditions and multi-morbidities. Continuity of care is defined as one patient experiencing care over time as connected and coherent with his or her health needs and personal circumstances. The objective is to analyse perceptions of continuity of clinical management and information across care levels and the factors influencing it, from the viewpoint of users of the Catalan national health system.

METHODS

A descriptive-interpretative qualitative study was conducted using a phenomenological approach. A two-stage theoretical sample was selected: (i) the study contexts: healthcare areas in Catalonia with different services management models; (ii) users ≥ 18 years of age who were attended to at both care levels for the same health problem. Data were collected by means of individual semi-structured interviews with patients (n = 49). All interviews were recorded and transcribed. A thematic content analysis was conducted segmented by study area, with a mixed generation of categories and triangulation of analysts.

RESULTS

Patients in all three areas generally perceived that continuity of clinical management across levels existed, on referring to consistent care (same diagnosis and treatment by doctors of both care levels, no incompatibilities of prescribed medications, referrals across levels when needed) and accessibility across levels (timeliness of appointments). In terms of continuity of information, patients in most areas mentioned the existence of information sharing via computer and its adequate usage. Only a few discontinuity elements were reported such as long waiting times for specific tests performed in secondary care or insufficient use of electronic medical records by locum doctors. Different factors influencing continuity were identified by patients, relating to the health system itself (clear distribution of roles between primary and secondary care), health services organizations (care coordination mechanisms, co-location, insufficient resources) and physicians (willingness to collaborate, commitment to patient care, the primary care physician's technical competence).

CONCLUSIONS

Care continuity across care levels is experienced by patients in the areas studied, with certain exceptions that highlight where there is room for improvement. Influencing factors offer valuable insights on where to direct coordination efforts.