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Kümpel L, Oslislo S, Resendiz Cantu R, Möckel M, Heintze C, Holzinger F. "I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care. BMC Health Serv Res 2024; 24:629. [PMID: 38750500 PMCID: PMC11097521 DOI: 10.1186/s12913-024-10977-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/10/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP. METHOD Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis. RESULTS Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity. CONCLUSION Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden. TRIAL REGISTRATION German Clinical Trials Register: DRKS00023480; date: 2020/11/27.
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Affiliation(s)
- Lisa Kümpel
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sarah Oslislo
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Rebecca Resendiz Cantu
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Martin Möckel
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Christoph Heintze
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Holzinger
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
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Lin MY, Hanchate AD, Frakt AB, Burgess JF, Carey K. Association between physician-hospital integration and inpatient care delivery in accountable care organizations: An instrumental variable analysis. Health Serv Res 2024. [PMID: 38654539 DOI: 10.1111/1475-6773.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE To investigate the relationship between physician-hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure. DATA SOURCES The primary data were Massachusetts All-Payer Claims Database (2009-2013). STUDY SETTING Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013. STUDY DESIGN Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician-hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital. The study sample comprised non-elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30-day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician-hospital integration was associated with a 10.6% reduction in 30-day expenditure (95% CI, -15.1% to -5.9%). Corresponding estimates for 45 and 60 days were - 9.7% (95%CI, -14.2% to -4.9%) and - 9.6% (95%CI, -14.3% to -4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, -22.6% to -8.2%) but unrelated to 30-day readmission rate. CONCLUSIONS Our instrumental variable analysis shows physician-hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.
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Affiliation(s)
- Meng-Yun Lin
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Austin B Frakt
- Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Kathleen Carey
- Boston University School of Public Health, Boston, Massachusetts, USA
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Hou Y, Trogdon JG, Freburger JK, Bushnell CD, Halladay JR, Duncan PW, Kucharska-Newton AM. Association of Continuity of Care With Health Care Utilization and Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack. Med Care 2024; 62:270-276. [PMID: 38447009 DOI: 10.1097/mlr.0000000000001983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
OBJECTIVES To examine the association of prestroke continuity of care (COC) with postdischarge health care utilization and expenditures. STUDY POPULATION The study population included 2233 patients with a diagnosis of stroke or a transient ischemic attack hospitalized in one of 41 hospitals in North Carolina between March 2016 and July 2019 and discharged directly home from acute care. METHODS COC was assessed from linked Centers for Medicare and Medicaid Services Medicare claims using the Modified, Modified Continuity Index. Logistic regressions and 2-part models were used to examine the association of prestroke primary care COC with postdischarge health care utilization and expenditures. RESULTS Relative to patients in the first (lowest) COC quartile, patients in the second and third COC quartiles were more likely [21% (95% CI: 8.5%, 33.5%) and 33% (95% CI: 20.5%, 46.1%), respectively] to have an ambulatory care visit within 14 days. Patients in the highest COC quartile were more likely to visit a primary care provider but less likely to see a stroke specialist. Highest as compared with lowest primary care COC quartile was associated with $45 lower (95% CI: $14, $76) average expenditure for ambulatory care visits within 30 days postdischarge. Patients in the highest, as compared with the lowest, primary care COC quartile were 36% less likely (95% CI: 8%, 64%) to be readmitted within 30 days postdischarge and spent $340 less (95% CI: $2, $678) on unplanned readmissions. CONCLUSIONS These findings underscore the importance of primary care COC received before stroke hospitalization to postdischarge care and expenditures.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Cheryl D Bushnell
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pamela W Duncan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
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Dufour E, Bolduc J, Leclerc-Loiselle J, Charette M, Dufour I, Roy D, Poirier AA, Duhoux A. Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review. BMC Prim Care 2023; 24:176. [PMID: 37661248 PMCID: PMC10476383 DOI: 10.1186/s12875-023-02089-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 06/22/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach. METHODS We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool. RESULTS Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components. CONCLUSIONS Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions. PROSPERO REGISTRATION CRD42021220004.
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Affiliation(s)
- Emilie Dufour
- Faculty of Nursing, Université de Montréal, Montréal, Canada.
| | - Jolianne Bolduc
- École de santé publique, Université de Montréal, Montréal, Canada
| | | | - Martin Charette
- School of Nursing, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabelle Dufour
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Denis Roy
- Commissaire à la santé et au bien-être, Gouvernement du Québec, Montréal, Canada
| | | | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, Canada
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Enckell A, Laine MK, Kautiainen H, Lehto MT, Pitkälä KH, Rahkonen O, Roitto HM, Kauppila T. Comparison of two GP service provider models in older adults: a register-based follow-up study. BJGP Open 2023; 7:BJGPO.2022.0101. [PMID: 37185139 PMCID: PMC10646206 DOI: 10.3399/bjgpo.2022.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/13/2022] [Accepted: 02/23/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND In Finland, there have been various strategies attempting to provide access to GPs. The 'restricted-List General Practitioner model' (rLGP) was launched in primary health care (PHC) in the city of Vantaa after the 'named General Practitioner model' (nGP) failed to provide sufficient access to GPs. This was done to improve access to GP appointments for those most needing care. AIM To evaluate the impact of the transition from nGP to rLGP on access to non-urgent scheduled appointments among patients aged ≥75 years. DESIGN & SETTING A register-based follow-up study in public PHC in Vantaa, Finland. METHOD The study focused on patients aged ≥75 years who used PHC from 2004-2008. It looked at the number of non-urgent and urgent scheduled appointments, patient contacts, home visits, PHC emergency department appointments, and cancelled appointments, which were recorded 7 years before and after the transition from nGP to rLGP in 2011 and adjusted to patient-years. Non-urgent appointments were booked to the patient's own nGP or rLGP in public PHC, whereas urgent appointments could be to any GP. RESULTS The number of non-urgent scheduled appointments to GPs was halved during the time of nGP, before launching the rLGP. Simultaneously, the number of urgent scheduled appointments more than tripled. The number of both started to plateau a year before the rLGP was launched. The number of both non-urgent and urgent scheduled appointments remained mainly at that level after rLGP was implemented. CONCLUSION The rLGP model was unsuccessful in improving access to non-urgent scheduled appointments to GPs.
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Affiliation(s)
- Aina Enckell
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- City of Espoo, Welfare and Health Sector, Espoo, Finland
| | - Merja K Laine
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
| | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Centre, Helsinki, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Mika T Lehto
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- City of Vantaa, Vantaa, Finland
| | - Kaisu H Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ossi Rahkonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Hanna-Maria Roitto
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
- Department of Geriatrics, Helsinki University Hospital, Helsinki, Finland
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Timo Kauppila
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Hjalmarsson L, Kaiser B, Bischof T. The impact of physician exits in primary care: A study of practice handovers. Health Policy 2023; 135:104867. [PMID: 37437479 DOI: 10.1016/j.healthpol.2023.104867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
Recent studies on physician exits suggest that general practitioners (GPs) have an important impact on health care utilization and costs, but the transmission channels - interpersonal dis- continuities of care, practice style differences and deterioration in access - are usually not clear. Our objective is to estimate the short-run and long-run impacts of switches in GPs on patients' health care utilization and costs, while all other factors of the health care setting remain the same. To do this, we collect data on handovers of primary care practices in Switzerland, occurring between 2007 and 2015. We link this data to rich insurance claims to construct a panel dataset of roughly 240,000 patients. Employing a difference-in-difference type framework, we find transitory increases in overall visits and costs, which are likely caused by the entering GP's initial re-assessment of patients' health care needs. Additionally, we find long-term increases in specialist health care utilization and ambulatory costs. The latter finding can be explained by changes in practice styles between the exiting GP and her successor, who is typically much younger and more likely to be female. In contrast to the literature on practice closures, we do not find evidence on reduced overall utilization rates. An important lesson for health policy is thus to preserve patients' access to care in the case of GP exits.
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Affiliation(s)
- Linn Hjalmarsson
- Department of Economics, University of Bern, Schanzeneckstrasse 1, 3001, Bern, Switzerland.
| | - Boris Kaiser
- BSS Volkswirtschaftliche Beratung, Aeschengraben 9, 4051 Basel, Switzerland
| | - Tamara Bischof
- Interface Politikstudien Forschung Beratung AG, Seidenhofstrasse 12, 6003, Lucerne, Switzerland
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Limón E, Riera N. [Longitudinality and continuity in home care]. Aten Primaria 2023; 55:102632. [PMID: 37169450 DOI: 10.1016/j.aprim.2023.102632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
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Kümpel L, Oslislo S, Resendiz Cantu R, Möckel M, Heintze C, Holzinger F. Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany. BMJ Open 2023; 13:e070054. [PMID: 37085303 PMCID: PMC10124305 DOI: 10.1136/bmjopen-2022-070054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment. DESIGN Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis. SETTING The study was carried out in three EDs in the city centre of Berlin, Germany. PARTICIPANTS Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years). INTERVENTION In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention. RESULTS Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently. CONCLUSIONS Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour. TRIAL REGISTRATION NUMBER DRKS00023480.
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Affiliation(s)
- Lisa Kümpel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, Berlin, Germany
| | - Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, Berlin, Germany
| | - Rebecca Resendiz Cantu
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice, Charitéplatz 1, Berlin, Germany
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Groot L, Te Winkel M, Schers H, Burgers J, Smalbrugge M, Uijen A, van der Horst H, Maarsingh O. Optimising personal continuity: a survey of GPs' and older patients' views. BJGP Open 2023:BJGPO.2022.0099. [PMID: 36720564 DOI: 10.3399/bjgpo.2022.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/16/2022] [Accepted: 12/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Personal continuity - having a GP who knows their patients and keeps track of them - is an important dimension of continuity of care and is associated with lower mortality rates, higher quality of life, and reduced healthcare costs. In recent decades it has become more challenging for GPs to provide personal continuity owing to changes in society and health care. AIM To investigate GPs' and older patients' views on personal continuity and how personal continuity can be improved. DESIGN & SETTING Cross sectional survey study in The Netherlands. METHOD A digital and postal survey was sent to 499 GPs and 1599 patients aged 65 years or older. Results were analysed using descriptive statistics for quantitative data and thematic analysis for open questions. RESULTS In total, 249 GPs and 582 patients completed the surveys. A large majority of GPs (92-99%) and patients (91-98%) felt it was important for patients to see their own GP for life events or psychosocial issues. GPs and patients provided suggestions on how personal continuity can be improved. The thematic analysis of these suggestions identified nine themes: 1) personal connection, 2) GP accessibility and availability, 3) communication about (dis)continuity, 4) GP responsibility, 5) triage, 6) time for the patient, 7) actions by third parties, 8) team continuity, and 9) GP vocational training. CONCLUSION Both GPs and older patients still place high value on personal continuity in the context of a changing society. GPs and patients provided a wide range of suggestions for improving personal continuity. The authors will use these suggestions to develop interventions for optimising personal continuity in general practice.
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Affiliation(s)
- Lex Groot
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Aging and Later Life, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marije Te Winkel
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Aging and Later Life, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Henk Schers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jako Burgers
- Maastricht University Medical Center+, Maastricht University, Department of General Practice, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Martin Smalbrugge
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medicine for Older People, Boelelaan, Amsterdam, The Netherlands
| | - Annemarie Uijen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Henriëtte van der Horst
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Aging and Later Life, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Otto Maarsingh
- Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Aging and Later Life, Amsterdam Public Health, Amsterdam, The Netherlands
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O'Brien EC, Ford CB, Sorenson C, Jutkowitz E, Shepherd-Banigan M, Van Houtven C. Continuity of care (COC) and amyloid-β PET scan: the CARE-IDEAS study. Alzheimers Res Ther 2023; 15:6. [PMID: 36611213 DOI: 10.1186/s13195-022-01126-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/18/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND High continuity of care (COC) is associated with better clinical outcomes among older adults. The impact of amyloid-β PET scan on COC among adults with mild cognitive impairment (MCI) or dementia of uncertain etiology is unknown. METHODS We linked data from the CARE-IDEAS study, which assessed the impact of amyloid-β PET scans on outcomes in Medicare beneficiaries with MCI or dementia of uncertain etiology and their care partners, to Medicare claims (2015-2018). We calculated a participant-level COC index using the Bice-Boxerman formula and claims from all ambulatory evaluation and management visits during the year prior to and following the amyloid-β PET scan. We compared baseline characteristics by scan result (elevated or non-elevated) using standardized differences. To evaluate changes in COC, we used multiple regression models adjusting for sociodemographics, cognitive function, general health status, and the Charlson Comorbidity Index. RESULTS Among the 1171 cohort members included in our analytic population, the mean age (SD) was 75.2 (5.4) years, 61.5% were male and 93.9% were non-Hispanic white. Over two-thirds (68.1%) had an elevated amyloid-β PET scan. Mean COC for all patients was 0.154 (SD = 0.102; range = 0-0.73) prior to the scan and 0.158 (SD = 0.105; range = 0-1.0) in the year following the scan. Following the scan, the mean COC index score increased (95% CI) by 0.005 (-0.008, 0.019) points more for elevated relative to not elevated scan recipients, but this change was not statistically significant. There was no association between scan result (elevated vs. not elevated) or any other patient covariates and changes in COC score after the scan. CONCLUSION COC did not meaningfully change following receipt of amyloid-β PET scan in a population of Medicare beneficiaries with MCI or dementia of uncertain etiology. Future work examining how care continuity varies across marginalized populations with cognitive impairment is needed.
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Sinsky CA, Shanafelt TD, Ristow AM. Radical Reorientation of the US Health Care System Around Relationships: Rebalancing the Transactional Model. Mayo Clin Proc 2022; 97:2194-2205. [PMID: 36207152 DOI: 10.1016/j.mayocp.2022.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/20/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
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Hung P, Cramer LD, Pollack CE, Gross CP, Wang S. Primary care physician continuity, survival, and end-of-life care intensity. Health Serv Res 2022; 57:853-862. [PMID: 34386976 PMCID: PMC9264461 DOI: 10.1111/1475-6773.13869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the associations of primary care physician (PCP) care continuity with cancer-specific survival and end-of-life care intensity. DATA SOURCES Surveillance, epidemiology, and end results linked to Medicare claims data from 2001 to 2015. STUDY DESIGN Cox proportional hazards models with mixed effects and hierarchical generalized logistic models were used to examine the associations of PCP care continuity with cancer-specific survival and end-of-life care intensity, respectively. PCP care continuity, defined as having visited the predominant PCP (who saw the patient most frequently before diagnosis) within 6 months of diagnosis. DATA EXTRACTION METHODS We identified Medicare patients diagnosed at age 66.5-94 years with stage-III or IV poor-prognosis cancer during 2001-2012 and followed them up until 2015. Patients who died within 6 months after diagnosis were excluded. PRINCIPAL FINDINGS Primary study cohort consisted of 85,467 patients (median survival 22 months), 71.7% of whom had PCP care continuity. Patients with PCP care continuity tended to be older, married, nonblack, non-Hispanic, and to have fewer comorbid conditions (p < 0.001 for all). Patients with PCP care continuity had lower cancer-specific mortality (adjusted hazard ratio: 0.93; 95% confidence interval [CI]: 0.91 to 0.95; p = 0.001) than did those without PCP care continuity. Findings of the 2001-2003 cohorts (nearly all of whom died by 2015) show no associations of overall end-of-life care intensity measures with PCP care continuity (adjusted marginal effects: 0.005; 95% CI: -0.016 to 0.026; p = 0.264). CONCLUSIONS Among Medicare beneficiaries with advanced poor-prognosis cancer, PCP continuity was associated with modestly improved survival without raising overall aggressive end-of-life care.
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Affiliation(s)
- Peiyin Hung
- Department of Health Services Policy and ManagementUniversity of South Carolina Arnold School of Public HealthColumbiaSouth CarolinaUSA
| | - Laura D. Cramer
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
| | - Craig E. Pollack
- Division of General Internal MedicineJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Departmental Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenConnecticutUSA
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Shi‐Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenConnecticutUSA
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13
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Kim SH, Kim H, Jeong SH, Jang SY, Park EC. Impact of continuity of care on risk for major osteoporotic fracture in patients with new onset rheumatoid arthritis. Sci Rep 2022; 12:10189. [PMID: 35715560 PMCID: PMC9205920 DOI: 10.1038/s41598-022-14368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/17/2022] [Indexed: 11/24/2022] Open
Abstract
There is a clear relationship between rheumatoid arthritis (RA) and major osteoporotic fracture (MOF), although there is limited evidence on the effect of continuity of care (COC) on MOF in these patients. We investigated the association between COC and risk of MOF, including fractures of the lumbar spine and pelvis, forearm, and hip, among newly diagnosed RA patients aged ≥ 60 years. A total of 8715 incident RA patients from 2004 to 2010 were included from the Korean National Health Insurance Service-Senior cohort database. Participants were categorized into a good and bad COC group according to the COC index. The cumulative incidence of MOF was higher in RA patients with bad than in those with good COC (p < 0.001). The incidence rates of MOF were 4439 and 3275 cases per 100,000 person-years in patients with bad and good COC, respectively. RA patients with bad COC had an increased incidence of overall MOF (adjusted hazard ratio, 1.32; 95% confidence interval, 1.14–1.53), with the highest increase in risk being that of forearm fracture. An increased MOF risk in patients with bad COC was predominantly observed in females. This study suggested that interventions that can improve COC in patients with RA should be considered.
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Affiliation(s)
- Seung Hoon Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Hyunkyu Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Jeong
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Suk-Yong Jang
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.
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14
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Añel Rodríguez RM, Astier Peña P. The longitudinal nature of Primary Care: a health protective factor. Rev Clín Med Fam 2022. [DOI: 10.55783/rcmf.150202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rosa M.ª Añel Rodríguez
- Especialista en Medicina Familiar y Comunitaria. CS Landako. Durango. Bizkaia (España). GdT de Seguridad del Paciente de la semFYC
| | - Pilar Astier Peña
- Especialista en Medicina Familiar y Comunitaria. CS de Universitas. Servicio Aragonés de Salud. Universidad de Zaragoza. GIBA-IIS-Aragón (España). Grupo de Trabajo de Seguridad del Paciente de semFYC. Miembro de la Junta Directiva de Wonca Mundial
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15
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Añel Rodríguez RM, Astier Peña P. Longitudinalidad en Atención Primaria: un factor protector de la salud. Rev Clín Med Fam 2022. [DOI: 10.55783/150202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Rosa María Añel Rodríguez
- Especialista en Medicina Familiar y Comunitaria. CS Landako. Durango. Bizkaia (España). GdT de Seguridad del Paciente de la semFYC
| | - Pilar Astier Peña
- Especialista en Medicina Familiar y Comunitaria. CS de Universitas. Servicio Aragonés de Salud. Universidad de Zaragoza. GIBA-IIS-Aragón (España). Grupo de Trabajo de Seguridad del Paciente de semFYC. Miembro de la Junta Directiva de Wonca Mundial
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16
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Jaramillo ET, Sommerfeld DH, Haozous EA, Brunner A, Willging CE. Causes and Consequences of Not Having a Personal Healthcare Provider Among American Indian Elders: A Mixed-Method Study. Front Public Health 2022; 10:832626. [PMID: 35309185 PMCID: PMC8926165 DOI: 10.3389/fpubh.2022.832626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/07/2022] [Indexed: 11/22/2022] Open
Abstract
Having a regular relationship with a healthcare provider contributes to better health outcomes and greater satisfaction with care for older adults. Although members of federally recognized American Indian tribes have a legal right to healthcare, American Indian Elders experience inequities in healthcare access that may compromise their ability to establish a relationship with a healthcare provider. This multi-year, community-driven, mixed-method study examines the potential causes and consequences of not having a personal healthcare provider among American Indian Elders. Quantitative surveys and qualitative interviews were conducted with 96 American Indian Elders (age 55 and over) in two states in the Southwestern United States. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. Findings confirmed that having a consistent healthcare provider correlated significantly with self-rated measures of health, confidence in getting needed care, access to overall healthcare, and satisfaction with care. Lack of a regular healthcare provider was related to interconnected experiences of self-reliance, bureaucratic and contextual barriers to care, and sentiments of fear and mistrust based in previous interactions with medical care. Increasing health equity for American Indian Elders will thus require tailored outreach and system change efforts to increase continuity of care and provider longevity within health systems and build Elders' trust and confidence in healthcare providers.
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Affiliation(s)
- Elise Trott Jaramillo
- Southwest Center, Pacific Institute for Research and Evaluation, Albuquerque, NM, United States
| | - David H Sommerfeld
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Emily A Haozous
- Southwest Center, Pacific Institute for Research and Evaluation, Albuquerque, NM, United States
| | - Amy Brunner
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Cathleen E Willging
- Southwest Center, Pacific Institute for Research and Evaluation, Albuquerque, NM, United States
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17
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Sinsky CA, Shanafelt TD, Dyrbye LN, Sabety AH, Carlasare LE, West CP. Health Care Expenditures Attributable to Primary Care Physician Overall and Burnout-Related Turnover: A Cross-sectional Analysis. Mayo Clin Proc 2022; 97:693-702. [PMID: 35227508 DOI: 10.1016/j.mayocp.2021.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/04/2021] [Accepted: 09/09/2021] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To estimate the excess health care expenditures due to US primary care physician (PCP) turnover, both overall and specific to burnout. METHODS We estimated the excess health care expenditures attributable to PCP turnover using published data for Medicare patients, calculated estimates for non-Medicare patients, and the American Medical Association Masterfile. We used published data from a cross-sectional survey of US physicians conducted between October 12, 2017, and March 15, 2018, of burnout and intention to leave one's current practice within 2 years by primary care specialty to estimate excess expenditures attributable to PCP turnover due to burnout. A conservative estimate from the literature was used for actual turnover based on intention to leave. Additional publicly available data were used to estimate the average PCP panel size and the composition of Medicare and non-Medicare patients within a PCP's panel. RESULTS Turnover of PCPs results in approximately $979 million in excess health care expenditures for public and private payers annually, with $260 million attributable to PCP burnout-related turnover. CONCLUSION Turnover of PCPs, including that due to burnout, is costly to public and private payers. Efforts to reduce physician burnout may be considered as one approach to decrease US health care expenditures.
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18
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McClellan SR, Trombley MJ, Marshall J, Kahvecioglu D, Kummet CM, LaRocca C, Dummit L, Hassol A. Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality. J Gen Intern Med 2022; 37:1052-9. [PMID: 34319560 DOI: 10.1007/s11606-021-06848-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care. OBJECTIVE To assess the association of BPCI with patient-reported functional status and care experiences. DESIGN We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes. PARTICIPANTS Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%). MAIN MEASURES Patient-reported functional status, care experiences, and overall satisfaction with recovery. KEY RESULTS Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures). CONCLUSIONS The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.
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19
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Rautiainen E, Ryynänen OP, Rautiainen P, Laatikainena T. How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups. Nordisk Alkohol Nark 2022; 38:450-465. [PMID: 35308819 PMCID: PMC8900183 DOI: 10.1177/14550725211018593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Aims: Alcohol use disorders (AUDs) are associated with high risk of comorbidities and excess use of social and healthcare services. We examined health service use (HSU) frequencies of patients with AUD in comparison to those with type 2 diabetes mellitus (T2DM). Design: A random sample of individuals with AUD (n = 396) were identified based on ICD-10 codes and HSU patterns, morbidity and mortality were compared with age- and gender-matched T2DM controls (n = 792) using logistic regression analysis. Six years (2011–2016) of electronic health record (EHR) data from the North Karelia district in Finland were used. Results: Similarities in comorbidity patterns existed, although mental health comorbidity (odds ratio [OR] 1.86) was more prevalent in the AUD group. The average annual HSU varied according to the groups: T2DM patients had more continuous contact with public health nurses in primary care, whereas AUD patients were more likely to experience somatic specialised care hospitalisations (OR 11.30) and have frequent somatic primary healthcare doctor visits (OR 3.30) and frequent emergency room doctor visits in specialised care (OR 8.89). Furthermore, patients with AUD had a 7.5 times higher risk of death compared with T2DM patients. Conclusions: This study identified rather similar comorbidity status for the AUD and T2DM patients, but their HSU patterns differed noticeably. AUD patients had higher frequencies of hospitalisation periods and emergency service use and were at a higher risk of death compared with T2DM patients, indicating greater challenges in the organisation of care for AUD patients compared with those having T2DM.
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Affiliation(s)
- Elina Rautiainen
- University of Eastern Finland, Kuopio, Finland; and National Institute for Health and Welfare, Helsinki, Finland
| | - Olli-Pekka Ryynänen
- University of Eastern Finland, Kuopio, Finland; and Kuopio University Hospital, Finland
| | - Päivi Rautiainen
- Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Tikkamäentie, Joensuu, Finland
| | - Tiina Laatikainena
- Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Tikkamäentie, Joensuu, Finland; and National Institute for Health and Welfare, Helsinki, Finland
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20
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François J, Fowler É. Continuity in the academic family medicine teaching environment: Exploring the potential of the CFPC's Patient's Medical Home. Can Fam Physician 2022; 68:74-76. [PMID: 35063986 PMCID: PMC9810062 DOI: 10.46747/cfp.680174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- José François
- Associate Professor in the Department of Family Medicine in the Max Rady College of Medicine at the University of Manitoba in Winnipeg.,Correspondence Dr José François; e-mail ,
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21
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François J, Fowler É. La continuité dans les milieux d’enseignement universitaire. Can Fam Physician 2022; 68:e18-e21. [PMID: 35063995 PMCID: PMC9810056 DOI: 10.46747/cfp.6801e18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- José François
- Professeur agrégé à la faculté de médecine de famille du Max Rady College of Medicine de l’Université du Manitoba à Winnipeg.,Correspondance D José François; courriel ,
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22
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Groot LJJ, Schers HJ, Burgers JS, Schellevis FG, Smalbrugge M, Uijen AA, van de Ven PM, van der Horst HE, Maarsingh OR. Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial. BMC Fam Pract 2021; 22:207. [PMID: 34666678 PMCID: PMC8526277 DOI: 10.1186/s12875-021-01511-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022]
Abstract
Background Continuity of care, in particular personal continuity, is a core principle of general practice and is associated with many benefits such as a better patient-provider relationship and lower mortality. However, personal continuity is under pressure due to changes in society and healthcare. This affects older patients more than younger patients. As the number of older patients will double the coming decades, an intervention to optimise personal continuity for this group is highly warranted. Methods Following the UK Medical Research Council framework for complex Interventions, we will develop and evaluate an intervention to optimise personal continuity for older patients in general practice. In phase 0, we will perform a literature study to provide the theoretical basis for the intervention. In phase I we will define the components of the intervention by performing surveys and focus groups among patients, general practitioners, practice assistants and practice nurses, concluded by a Delphi study among members of our group. In phase II, we will test and finalise the intervention with input from a pilot study in two general practices. In phase III, we will perform a stepped wedge cluster randomised pragmatic trial. The primary outcome measure is continuity of care from the patients’ perspective, measured by the Nijmegen Continuity Questionnaire. Secondary outcome measures are level of implementation, barriers and facilitators for implementation, acceptability and feasibility of the intervention. In phase IV, we will establish the conditions for large-scale implementation. Discussion This is the first study to investigate an intervention for improving personal continuity for older patients in general practice. If proven effective, our intervention will enable General practitioners to improve the quality of care for their increasing population of older patients. The pragmatic design of the study will enable evaluation in real-life conditions, facilitating future implementation. Trial registration number Netherlands Trial Register, trial NL8132. Registered 2 November 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01511-y.
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Affiliation(s)
- Lex J J Groot
- Department of General Practice, Amsterdam University Medical Centre, location VU University Medical Centre, van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands.
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525, EZ, Nijmegen, The Netherlands
| | - Jako S Burgers
- MUMC+/ Maastricht University, Department of General Practice, Care and Public Health Research Institute (CAPHRI), Universiteitssingel 40, 6229, ER, Maastricht, the Netherlands
| | - Francois G Schellevis
- Department of General Practice, Amsterdam University Medical Centre, location VU University Medical Centre, van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centre, location VU University Medical Centre, De Boelelaan 1109, 1081, HV, Amsterdam, the Netherlands
| | - Annemarie A Uijen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525, EZ, Nijmegen, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Data Science, Vrije Universiteit Amsterdam, De Boelelaan 1089a, 1081, HV, Amsterdam, the Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice, Amsterdam University Medical Centre, location VU University Medical Centre, van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
| | - Otto R Maarsingh
- Department of General Practice, Amsterdam University Medical Centre, location VU University Medical Centre, van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands
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23
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Bischof T, Kaiser B. Who cares when you close down? The effects of primary care practice closures on patients. Health Econ 2021; 30:2004-2025. [PMID: 34046966 DOI: 10.1002/hec.4287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 04/13/2021] [Accepted: 04/29/2021] [Indexed: 06/12/2023]
Abstract
This paper investigates the consequences that patients face when their regular general practitioner (GP) closes down her practice, typically due to retirement. We estimate the causal impact of closures on patients' utilization patterns, healthcare expenditures, hospitalizations, mortality, and health plan choices. Employing a difference-in-difference framework, we find that patients who experience a discontinuity of care persistently adjust their ambulatory utilization pattern by shifting visits away from GPs (-12%) toward specialists (+11%) and hospital outpatient facilities (+6%). In contrast, we find no evidence on adverse health effects as measured by hospitalizations and mortality. The impact on utilization is heterogeneous along several dimensions. In particular, we find geographic disparities between regions with high and low availability of primary care. We also observe that patients with chronic conditions substitute more strongly toward other providers. Our results have potential implications for health policy in at least two dimensions: first, practice closures lead to more fragmented care which may entail inefficiencies, and second, closures deteriorate access to primary care in regions with low physician density.
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Affiliation(s)
- Tamara Bischof
- Department of Economics, University of Bern, Bern, Switzerland
| | - Boris Kaiser
- BSS Volkswirtschaftliche Beratung, Basel, Switzerland
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24
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Skarshaug LJ, Kaspersen SL, Bjørngaard JH, Pape K. How does general practitioner discontinuity affect healthcare utilisation? An observational cohort study of 2.4 million Norwegians 2007-2017. BMJ Open 2021; 11:e042391. [PMID: 33593777 PMCID: PMC7888374 DOI: 10.1136/bmjopen-2020-042391] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Patients may benefit from continuity of care by a personal physician general practitioner (GP), but there are few studies on consequences of a break in continuity of GP. Investigate how a sudden discontinuity of GP care affects their list patients' regular GP consultations, out-of-hours consultations and acute hospital admissions, including admissions for ambulatory care sensitive conditions (ACSC). DESIGN Cohort study linking person-level national register data on use of health services and GP affiliation with data on GP activity and GP characteristics. SETTING Primary care. PARTICIPANTS 2 409 409 Norwegians assigned to the patient lists of 2560 regular GPs who, after 12 months of stable practice, had a sudden discontinuity of practice lasting two or more months between 2007 and 2017. PRIMARY AND SECONDARY OUTCOME MEASURES Monthly GP consultations, out-of-hours consultations, acute hospital admissions and ACSC admissions in periods during and 12 months after the discontinuity, compared with the 12-month period before the discontinuity using logistic regression models. RESULTS All patient age groups had a 3%-5% decreased odds of monthly regular GP consultations during the discontinuity. Odds of monthly out-of-hours consultations increased 2%-6% during the discontinuity for all adult age groups. A 7%-9% increase in odds of ACSC admissions during the period 1-6 months after discontinuity was indicated in patients over the age of 65, but in general little or no change in acute hospital admissions was observed during or after the period of discontinuity. CONCLUSIONS Modest changes in health service use were observed during and after a sudden discontinuity in practice among patients with a previously stable regular GP. Older patients seem sensitive to increased acute hospital admissions in the absence of their personal GP.
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Affiliation(s)
- Lena Janita Skarshaug
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Silje Lill Kaspersen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Digital, SINTEF, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord Universitet - Levanger Campus, Levanger, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
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25
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Osborne JD, Booth JS, O'Leary T, Mudano A, Rosas G, Foster PJ, Saag KG, Danila MI. Identification of Gout Flares in Chief Complaint Text Using Natural Language Processing. AMIA Annu Symp Proc 2021; 2020:973-982. [PMID: 33936473 PMCID: PMC8075438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Many patients with gout flares treated in the Emergency Department (ED) often do not receive optimal continuity of care after an ED visit. Thus, developing methods to identify patients with gout flares in the ED and referring them to appropriate outpatient gout care is required. While Natural Language Processing (NLP) has been used to detect gout flares retrospectively, it is much more challenging to identify patients prospectively during an ED visit where documentation is usually minimal. We annotate a corpus of ED triage nurse chief complaint notes for the presence of gout flares and implement a simple algorithm for gout flare ED alerts. We show that the chief complaint alone has strong predictive power for gout flares. We make available a de-identified version of this corpus annotated for gout mentions, which is to our knowledge the first free text chief complaint clinical corpus available.
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Affiliation(s)
- John D Osborne
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James S Booth
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tobias O'Leary
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amy Mudano
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Giovanna Rosas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria I Danila
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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Cheng N, Farley J, Qian J, Zeng P, Chou C, Hansen R. The association of continuity of care and risk of mortality in breast cancer patients with cardiometabolic comorbidities. J Psychosoc Oncol 2021; 40:184-202. [PMID: 33459213 DOI: 10.1080/07347332.2020.1867692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The association of continuity of care (COC) among providers and mortality risk for breast cancer patients with comorbidities is not sufficiently studied. DESIGN A retrospective cohort study using the 2006-2014 Surveillance, Epidemiology and End Results (SEER)-Medicare data. PARTICIPANTS Newly diagnosed female breast cancer patients (n = 57,578) with comorbidities (hypertension, hyperlipidemia, and/or diabetes). METHODS All-cause mortality was assessed annually for up to 5 years. COC was estimated using the Bice-Boxerman index, which included: 1) specialty COC capturing continuity of visits to the same provider type (Primary Care Physicians, Oncologists, and Other specialists) and 2) individual COC capturing continuous care to the same provider regardless of provider specialty. Cox proportional hazards models estimated the hazard ratio (HR) of all-cause mortality across quartile of the COC index. RESULTS Mortality was positively associated with advanced tumor stages and number of comorbidities (p < 0.05). Patients with high specialty COC (4th vs. 1st quartile, HR 1.34, 95%CI 1.29-1.40) had higher risks of mortality compared with those with low specialty COC. However, patients with high individual COC (4th vs. 1st quartile, HR 0.53, 95%CI 0.51-0.54) had lower risks of mortality compared to those with low individual COC. CONCLUSION Receiving care from fewer providers is associated with lower mortality and from fewer types of provider is associated with higher mortality. The results might be confounded by uncontrolled factors and provoke the need for alternative patient care models that recognize the balance between appropriate subspecialties and minimizing the fragmentation of care within and across subspecialties.
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Affiliation(s)
- Ning Cheng
- Department of Biomedical Affair, Edward Via College of Osteopathic Medicine Auburn Campus, Auburn, Alabama, USA
| | - Joel Farley
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jingjing Qian
- Harrison School of Pharmacy, Department of Health Outcomes Research and Policy, Auburn University, Auburn, Alabama, USA
| | - Peng Zeng
- Department of Mathematics and Statistics, Auburn University, Auburn, Alabama, USA
| | - Chiahung Chou
- Harrison School of Pharmacy, Department of Health Outcomes Research and Policy, Auburn University, Auburn, Alabama, USA
| | - Richard Hansen
- Harrison School of Pharmacy, Department of Health Outcomes Research and Policy, Auburn University, Auburn, Alabama, USA
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Mayo-Smith M, Radwin LE, Abdulkerim H, Mohr DC. Factors Associated With Patient Ratings of Timeliness of Primary Care Appointments. J Patient Exp 2020; 7:1203-1210. [PMID: 33457566 PMCID: PMC7786731 DOI: 10.1177/2374373520968979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
As access is the lowest rated dimension in surveys of outpatient experience, we sought to identify patient, practice, and provider factors associated with positive ratings of timeliness of primary care appointments. A cross-sectional study with multivariable, multilevel logistic regression was performed using survey responses from 236 695 individuals receiving care in the Veterans Health Administration (VA). Top box ratings (response of "always") for whether the patient reported receiving an appointment as soon as they needed in primary care for routine care and for care needed right away were the main outcomes. Independent variables capturing patient, practice, and provider factors were obtained from survey responses and VA databases. Degree of continuity with primary care provider and duration of relationship were strongly associated with higher ratings. Shorter primary care appointment wait times for both new and returning patients were associated with higher ratings. Independent wait times for mental health and specialty appointments had no effect. Older age, better self-reported physical and mental health, lower disease complexity, and rural residence were patient factors associated with higher ratings while gender, race, ethnicity, and education had little effect. Measures of continuity with primary care provider as well as appointment wait times have strong association with positive patient ratings of appointment timeliness. Patients treated in Veterans Affairs clinics may value continuity with their primary care provider over longer times. Initiatives to improve access could focus on improving continuity and ensuring efforts to improve access do not impact continuity.
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Affiliation(s)
- Michael Mayo-Smith
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Center for Primary Care, Harvard Medical School, Boston, MA, USA
| | - Laurel E. Radwin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Hassen Abdulkerim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - David C. Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
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Choi D, Choi S, Kim H, Kim K, Kim N, Ko A, Kim KH, Son JS, Yun JM, Kim Y, Park SM. Impact of continuity of care on cardiovascular disease risk among newly-diagnosed hypertension patients. Sci Rep 2020; 10:19991. [PMID: 33203931 DOI: 10.1038/s41598-020-77131-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Several previous studies have noted benefits of maintaining continuity of care (COC), including improved patient compliance, decreased health care cost, and decreased incidence of hospitalization. However, the association of COC in hypertension patients with subsequent cardiovascular disease (CVD) risk is yet unclear. Therefore, we aimed to investigate the impact of COC on CVD risk among newly-diagnosed hypertension patients. We conducted a cohort with a study population consisted of 244,187 newly-diagnosed hypertension patients in 2004 from the Korean National Health Insurance Service database. The participants were then divided into approximate quartiles of COC index, and followed from 1 January 2007 until 31 December 2017. Cox proportional hazards models were used to evaluate the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD risk according to quartiles. Compared to patients within the lowest quartile of COC index, those within the highest quartile of COC index had reduced risk for CVD (aHR 0.76, 95% confidence interval; CI 0.73–0.79), CHD (aHR 0.66, 95% CI 0.62–0.69) and stroke (aHR 0.84, 95% CI 0.80–0.88). COC among hypertension patients was associated with improved medication compliance and reduced risk of stroke and CVD. The importance of maintaining COC should be emphasized to reduce the risk of CVD among hypertension patients.
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Baltrus PT, Li C, H Gaglioti A. Having a Usual Source of Care Is Associated with Longer Telomere Length in a National Sample of Older Adults. J Am Board Fam Med 2020; 33:832-41. [PMID: 33219062 DOI: 10.3122/jabfm.2020.06.200008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To provide a potential biological, mechanistic link for the well-established association between primary care access and reduced mortality, this study sought to measure the impact of having a usual source of health care on leukocyte telomere length (LTL). DATA SOURCES Our study population included 3202 participants aged 50 to 84 years from National Health and Nutrition Examination Survey 1999 to 2001. STUDY DESIGN Cross-sectional Study. LTLs between people with and without a usual source of care were compared using unadjusted and adjusted linear regression models. Fully adjusted models accounted for demographic characteristics, health conditions, and health behaviors. PRINCIPAL FINDINGS After controlling for individual factors, health conditions, and health behaviors, people who had a usual source of health care had significantly longer LTL (β = 89.8 base pairs, P-value = .005) compared with those without a usual source of care; corresponding to approximately 7 years of life. CONCLUSIONS Having a usual source of health care is associated with longer LTL among older adults. This study provides a potential biologic link for the noted association between primary care access and reduced mortality that has been observed at the individual and population level.
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Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract 2020; 70:e600-e611. [PMID: 32784220 PMCID: PMC7425204 DOI: 10.3399/bjgp20x712289] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care. AIM This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care. DESIGN AND SETTING Systematic review of studies published in English or French from database and source inception to July 2019. METHOD Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality. RESULTS Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated. CONCLUSION This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.
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Affiliation(s)
- Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - George K Freeman
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | | | - M John Bankart
- Department of Health Sciences, University of Leicester, Leicester, UK
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Akyalcin S, Bruzzaniti A, Chávez EM, Delgado AJ, Duqum I, Kure L. Should dentistry be a specialty of medicine? Two viewpoints. J Dent Educ 2020; 84:1003-1010. [PMID: 32458423 DOI: 10.1002/jdd.12184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 11/10/2022]
Abstract
Dentistry and dental education are well-established domains with deep-rooted institutions, educational programs, organizational structures, and advanced specialty fields. Almost 100 years ago, Dr. William Gies, founder of the Columbia University College of Dental Medicine, stated that to best serve the oral health needs of the population, dentistry should be considered a specialty of medicine, and dental students should have the same solid foundation in the basic and clinical sciences as medical students. More recently, the report on "Advancing Dental Education in the 21st Century" recommends an increase in the integration of dental and medical education as a means to address 2 of its key challenges: "shrinking demand for dental services" and "shifting practice environment." However, it has also been argued that making dentistry and dental education a subspecialty of medicine and medical education will create logistical, structural, regulatory, and financial dilemmas. Instead of a drastic change to current dental educational, organizational, and institutional models, some argue a contemporary approach to dental education is required to ensure dentists are well prepared to address the healthcare needs of the population and future healthcare delivery systems and practice models. Recognizing the need for change in dental education to keep pace with changes in patient demographics and healthcare systems, the dental profession has the responsibility and opportunity to develop new models and paradigms that improve educational and clinical outcomes in our educational programs and future practice.
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Affiliation(s)
- Sercan Akyalcin
- Department of Orthodontics, Tufts University School of Dental Medicine, Boston, Massachusetts, USA
| | - Angela Bruzzaniti
- Department of Biomedical Sciences and Comprehensive Care, Indiana University School of Dentistry, Indianapolis, Indiana
| | - Elisa M Chávez
- Department of Diagnostic Sciences, Pacific Center for Special Care, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California, USA.,On Lok Lifeways, San Francisco, Fremont, California, USA
| | - Alex J Delgado
- Division of Operative Dentistry, Department of Restorative Dental Sciences, College of Dentistry, University of Florida, Gainesville, Florida, USA
| | - Ibrahim Duqum
- Division of Comprehensive Oral Health, Adams School of Dentistry, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Larisa Kure
- Administration and Finance, School of Dentistry, University of California, San Francisco, California, USA
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Abstract
OBJECTIVE To identify patient social risk factors associated with Continuity of Care (COC) index. DATA SOURCES/STUDY SETTING Medicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013. STUDY DESIGN We use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M). DATA COLLECTION/EXTRACTION METHODS We retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits. PRINCIPAL FINDINGS After adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05). CONCLUSIONS Medicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
| | - Jessica Mittler
- Department of Health Administration, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Jensen H, Møller H, Vedsted P. Characteristics of customary non-attenders in general practice who are diagnosed with cancer: A cross-sectional study in Denmark. Eur J Cancer Care (Engl) 2019; 28:e13143. [PMID: 31433525 DOI: 10.1111/ecc.13143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/22/2019] [Accepted: 08/01/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to explore individual and structural factors in patients with cancer and their potential association with customary non-attendance in general practice. MATERIALS AND METHODS We conducted a population-based cross-sectional study of all patients aged 50-89 years who were diagnosed with an incident cancer in 2009-2013 in Denmark. We investigated associations between being a customary non-attender (defined as having no consultations in general practice in the 19-36 months before diagnosis) and selected patient-related factors (demography, socioeconomic status), health-related factors (multimorbidity) and structural factors (urbanisation degree, list size of general practice and use of out-of-hours services) using logistic regression. RESULTS A total of 123,943 cancer patients were included; 11,567 (9.3%) of these were non-attenders. Non-attendance was associated with being more than 70 years of age, being single, having short or long education and being financially affluent. Non-attendance was rarely seen in cancer patients with (multi)morbidity, in individuals living in an area with 2,000-99,999 inhabitants and in individuals having contact with the out-of-hours services. CONCLUSION Specific groups of cancer patients were more often customary non-attenders in general practice. General practice may need to reach out more directly to these patients to ensure more timely cancer diagnosis.
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Affiliation(s)
- Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Unit for General Practice, Aarhus, Denmark
| | - Henrik Møller
- Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark.,The Danish Clinical Registries (RKKP), Aarhus, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care, Department of Public Health, Aarhus University, Aarhus, Denmark.,Research Unit for General Practice, Aarhus, Denmark
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Yang CP, Cheng HM, Lu MC, Lang HC. Association between continuity of care and long-term mortality in Taiwanese first-ever stroke survivors: An 8-year cohort study. PLoS One 2019; 14:e0216495. [PMID: 31116786 PMCID: PMC6530892 DOI: 10.1371/journal.pone.0216495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/22/2019] [Indexed: 11/18/2022] Open
Abstract
Background Continuity of care is considered to be an important principle of stroke care; however, few analyses of empirically related outcomes have been reported. Objective This study examined the correlation between the continuity of care for outpatients after a stroke event and the survival of stroke patients over the year following hospital discharge. Research design Data from the Taiwan National Health Insurance Database were used in this study. We defined stroke as the ICD-9-CM codes 430 to 437, and all patients were followed up regarding their survival for at least one year. The modified modified continuity index (MMCI) was used as the indicator of continuity of care. Cox proportional hazard models with robust sandwich variance estimates were employed to analyze the correlation between continuity of care and stroke-related death. Results A total of 9,252 stroke patients were included in the analysis. Those patients who had a high and a completed COC had a higher percentage of survival (97.25% and 95.39%) compared to the other two groups. After controlling for other variables, compared with the low-level continuity of care group, the moderate-level, high-level and completed continuity of care groups still showed a significantly lower risk of death HR (95% CI) were: 0.63 (0.49–0.80), 0.56 (0.40–0.79) and 0.50 (0.39–0.63), respectively. Conclusion Continuity of care may increase the survival among stroke patients and therefore plays an important role in management of stroke after survival.
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Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nutrition and Institute of Biomedical Nutrition, Hung Kuang University, Taichung, Taiwan
| | - Hao-Min Cheng
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, National Yang-Ming University, Taipei, Taiwan
- Department of Public Health, National Yang-Ming University, Taipei, Taiwan
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Chun Lu
- Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Nuring, Hung Kuang University, Taichung, Taiwan
| | - Hui-Chu Lang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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Lay-Flurrie S, Mathieu E, Bankhead C, Nicholson BD, Perera-Salazar R, Holt T, Hobbs FDR, Salisbury C. Patient consultation rate and clinical and NHS outcomes: a cross-sectional analysis of English primary care data from 2.7 million patients in 238 practices. BMC Health Serv Res 2019; 19:219. [PMID: 30954074 PMCID: PMC6451312 DOI: 10.1186/s12913-019-4036-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/24/2019] [Indexed: 12/04/2022] Open
Abstract
Background Primary care workload is high and increasing in the United Kingdom. We sought to examine the association between rates of primary care consultation and outcomes in England. Methods Cross sectional observational study of routine electronic health care records in 283 practices from the Clinical Practice Research Datalink from April 2013 to March 2014. Outcomes included mortality rate, hospital admission rate, Quality and Outcomes Framework (QOF) performance and patient satisfaction. Relationships between consultation rates (with a general practitioner (GP) or nurse) and outcomes were investigated using negative binomial and ordinal logistic regression models. Results Rates of GP and nurse consultation (per patient person-year) were not associated with mortality or hospital admission rates: mortality incidence rate ratio (IRR) per unit change in GP/ nurse consultation rate = 1.01, 95% CI [0.98 to 1.04]/ 0.97, 95% CI [0.93 to 1.02]; hospital admission IRR per unit change in GP/ nurse consultation rate = 1.02, 95% CI [0.99 to 1.04]/ 0.98, 95% CI [0.94 to 1.032]. Higher rates of nurse but not GP consultation were associated with higher QOF achievement: OR = 1.91, 95% CI [1.39 to 2.62] per unit change in nurse consultation rate vs. OR = 1.04, 95% CI [0.87 to 1.24] per unit change in GP consultation rate. The association between the rates of GP/ nurse consultations and patient satisfaction was mixed. Conclusion There are few associations between primary care consultation rates and outcomes. Previously identified demographic and staffing factors, rather than practice workload, appear to have the strongest relationships with mortality, admissions, performance and satisfaction. Studies with more detailed patient-level data would be required to explore these findings further. Electronic supplementary material The online version of this article (10.1186/s12913-019-4036-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Edouard Mathieu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tim Holt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Sumriddetchkajorn K, Shimazaki K, Ono T, Kusaba T, Sato K, Kobayashi N. Universal health coverage and primary care, Thailand. Bull World Health Organ 2019; 97:415-422. [PMID: 31210679 PMCID: PMC6560367 DOI: 10.2471/blt.18.223693] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 02/07/2019] [Accepted: 03/18/2019] [Indexed: 11/27/2022] Open
Abstract
Thailand’s policy on universal health coverage (UHC) has made good progress since its inception in 2002. Every Thai citizen is now entitled to essential preventive, curative and palliative health services at all life stages. Like its counterparts elsewhere, however, the policy faces challenges. A predominantly tax-financed system in a nation with a high proportion of people living in poverty will always strive to contain rising costs. Disparities exist among the different health insurance schemes that provide coverage for Thai citizens. National health expenditure is heavily borne by the government, primarily to reduce financial barriers to access for the poor. The population is ageing and the disease profiles of the population are changing alongside the modernization of Thai people’s lifestyles. Thailand is now aiming to enhance and sustain its UHC policy. We examine the merits of different policy options and aim to identify the most promising and feasible way to enhance and sustain UHC. We argue that developing the existing primary care system in Thailand has the greatest potential to provide more self-sustaining, efficient, equitable and effective UHC. Primary care needs to move from its traditional role of providing basic disease-based care, to being the first point of contact in an integrated, coordinated, community-oriented and person-focused care system, for which the national health budget should be prioritized.
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Affiliation(s)
- Kanitsorn Sumriddetchkajorn
- National Health Security Office, 4th Floor, Government Complex Building B, Chaengwattana Road, Laksi, Bangkok, 10210 Thailand
| | - Kenji Shimazaki
- National Graduate Institute for Policy Studies, Tokyo, Japan
| | - Taichi Ono
- National Graduate Institute for Policy Studies, Tokyo, Japan
| | | | - Kotaro Sato
- Hokkaido Centre for Family Medicine, Sapporo, Japan
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Hurtaud A, Aubin M, Ferrat E, Lebreton J, Paillaud E, Audureau E, Bastuji-Garin S, Chouaid C, Boisnault P, Clerc P, Canouï-Poitrine F. Continuity of care in general practice at cancer diagnosis (COOC-GP study): a national cohort study of 2853 patients. Br J Gen Pract 2019; 69:e88-96. [PMID: 30642910 DOI: 10.3399/bjgp19X700805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/09/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND At cancer diagnosis, it is unclear whether continuity of care (COC) between the patient and GP is safeguarded. AIM To identify patient-GP loss of COC around the time of, and in the year after, a cancer diagnosis, together with its determinants. DESIGN AND SETTING A post-hoc analysis of data from a prospective cohort of GPs in France, taken from a survey by the Observatoire de la Médecine Générale. METHOD A prospective GP cohort (n = 96) filed data on patients who were diagnosed with incident cancer between 1 January 2000 and 31 December 2010. COC was assessed by ascertaining the frequency of consultations and the maximal interval between them. (In France, patients see their referring/named GP in most cases.) A loss of COC was measured during the trimester before and the year after the cancer diagnosis, and the results compared with those from a 1-year baseline period before cancer had been diagnosed. A loss of COC was defined as a longer interval (that is, the maximum number of days) between consultations in the measurement periods than at baseline. Determinants of the loss in COC were assessed with univariate and multivariate logistic regression models. RESULTS In total, 2853 patients were included; the mean age was 66.1 years. Of these, 1440 (50.5%) were women, 389 (13.6%) had metastatic cancer, and 769 (27.0%) had a comorbidity. The mean number of consultations increased up to, and including, the first trimester after diagnosis. Overall, 26.9% (95% confidence interval [CI] = 25.3 to 28.6) of patients had a loss of COC in the trimester before the diagnosis, and 22.3% (95% CI = 20.7 to 23.9) in the year after. Increasing comorbidity score was independently associated with a reduction in the loss of COC during the year after diagnosis (adjusted odds ratio [OR] comorbidity versus no comorbidity 0.61, 95% CI = 0.48 to 0.79); the same was true for metastatic status (adjusted OR metastasis versus no metastasis 0.49, 95% CI = 0.35 to 0.70). CONCLUSION As COC is a core value for GPs and for most patients, special care should be taken to prevent a loss of COC around the time of a cancer diagnosis, and in the year after.
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Tran B, Falster M, Jorm L. Claims-based measures of continuity of care have non-linear associations with health: data linkage study. Int J Popul Data Sci 2018; 3:463. [PMID: 34095520 PMCID: PMC8142963 DOI: 10.23889/ijpds.v3i1.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Continuity of care (CoC) is considered a central element of good primary care and is often measured using medical claims data. Possible values of CoC depend on the number of claims which is related to health status. This study investigated the relationships between CoC and health status and risk of emergency hospitalisation. Methods Health insurance claims for consultations with general practitioners (GPs) in the 24 months following entry to the 45 and Up Study were used to calculate usual provider continuity (UPC) and the Continuity of Care Index (CoC Index). Relationships of CoC with number of claims, self-rated health and emergency hospitalisation were investigated using descriptive statistics and logistic regression models. Results Both measures of CoC were strongly related to number of claims and to measures of health status, which were in turn highly associated. Multivariable logistic regression models showed a weak positive relationship between CoC and odds of emergency hospitalisation for those with CoC less than 1, while individuals with perfect CoC had significantly lower odds of hospitalisation compared to all other categories of CoC. However, analyses stratified by, or adjusting for, number of claims showed no clear associations between CoC and risk of hospitalisation. Conclusions The pattern of association between CoC categories and emergency hospitalisation was non-linear and was confounded by the effect of number of claims. Future studies should apply caution in using claims-based measures of CoC as a continuous variable or employing an arbitrary cut-point, and should adjust for number of claims.
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Affiliation(s)
- Bich Tran
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
| | - Michael Falster
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
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Kim W, Jang SY, Lee TH, Lee JE, Park EC. Association between continuity of care and subsequent hospitalization and mortality in patients with mood disorders: Results from the Korea National Health Insurance cohort. PLoS One 2018; 13:e0207740. [PMID: 30452465 PMCID: PMC6242689 DOI: 10.1371/journal.pone.0207740] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/06/2018] [Indexed: 11/18/2022] Open
Abstract
Concerns have been raised about the loss of treatment continuity in unipolar and bipolar depressive disorder patients as continuity of care (COC) may be associated with patient outcomes. This study aimed to examine the relationship between COC and subsequent hospitalization, all-cause mortality, and suicide mortality in individuals with unipolar and bipolar disorder. Data were from the National Health Insurance (NHI) cohort, 2002 to 2013. Study participants included individuals first diagnosed with unipolar depressive disorder or bipolar affective disorder. The independent variable was COC for the first year of outpatient visits after diagnosis, measured using the usual provider of care (UPC) index. The dependent variables were hospitalization in the year after COC measurement, all-cause mortality, and suicide mortality. Analysis was conducted using logistic regression and Cox proportional hazards survival regression. A total of 48,558 individuals were analyzed for hospitalization and 48,947 for all-cause and suicide mortality. Compared to the low COC group, the medium [odds ratio (OR) 0.30, 95 percent confidence interval (95% CI) 0.19–0.47] and the high COC group (OR 0.14, 95% CI 0.09–0.21) showed statistically significant decreased odds of hospitalization. Additionally, lower likelihoods of suicide death were found in the high (HR 0.35, 95% CI 0.16–0.74) compared to the low COC group. The results infer an association between COC after first diagnosis of unipolar or bipolar depressive disorder and hospitalization and suicide mortality, suggesting the potential importance of treatment continuity in improving patient outcomes.
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Affiliation(s)
- Woorim Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Suk-Yong Jang
- Department of Preventive Medicine, Eulji University College of Medicine, Daejeon, Republic of Korea
| | - Tae-Hoon Lee
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Joo Eun Lee
- Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; 8:e021161. [PMID: 29959146 PMCID: PMC6042583 DOI: 10.1136/bmjopen-2017-021161] [Citation(s) in RCA: 332] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/15/2018] [Accepted: 04/20/2018] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality. DESIGN Systematic review without meta-analysis. DATA SOURCES MEDLINE, Embase and the Web of Science, from 1996 to 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients. RESULTS Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors. CONCLUSIONS This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important. PROSPERO REGISTRATION NUMBER CRD42016042091.
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Affiliation(s)
| | | | - Eleanor White
- St Leonard's Practice, Exeter, UK
- Medical School, University of Exeter, Exeter, UK
| | - Angus Thorne
- St Leonard's Practice, Exeter, UK
- Medical School, University of Manchester, Manchester, UK
| | - Philip H Evans
- St Leonard's Practice, Exeter, UK
- Medical School, University of Exeter, Exeter, UK
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Walker J, Payne B, Clemans-Taylor BL, Snyder ED. Continuity of Care in Resident Outpatient Clinics: A Scoping Review of the Literature. J Grad Med Educ 2018; 10:16-25. [PMID: 29467968 PMCID: PMC5821030 DOI: 10.4300/jgme-d-17-00256.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/27/2017] [Accepted: 10/30/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Continuity between patients and physicians is a core principle of primary care and an accreditation requirement. Resident continuity clinics face challenges in nurturing continuity for their patients and trainees. OBJECTIVE We undertook a scoping review of the literature to better understand published benchmarks for resident continuity; the effectiveness of interventions to improve continuity; and the impact of continuity on resident and patient satisfaction, patient outcomes, and resident career choice. METHODS We developed a MEDLINE search strategy to identify articles that defined continuity in residency programs in internal medicine, family medicine, and pediatrics published prior to December 31, 2015, and used a quality evaluation tool to assess included studies. RESULTS The review includes 34 articles describing 12 different measures of continuity. The usual provider of care and continuity for physician formulas were most commonly utilized, and mean baseline continuity was 56 and 55, respectively (out of a total possible score of 100). Clinic and residency program redesign innovations (eg, advanced access scheduling, team-based care, and block scheduling) were studied and had mixed impact on continuity. Continuity in resident clinics is lower than published continuity rates for independently practicing physicians. CONCLUSIONS Interventions to enhance continuity in resident clinics have mixed effects. More research is needed to understand how changes in continuity affect resident and patient satisfaction, patient outcomes, and resident career choice. A major challenge to research in this area is the lack of empanelment of residents' patients, creating difficulties in scheduling and measuring continuity visits.
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Hülür G, Heckhausen J, Hoppmann CA, Infurna FJ, Wagner GG, Ram N, Gerstorf D. Levels of and changes in life satisfaction predict mortality hazards: Disentangling the role of physical health, perceived control, and social orientation. Psychol Aging 2017; 32:507-520. [PMID: 28891665 DOI: 10.1037/pag0000187] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is well documented that well-being typically evinces precipitous decrements at the end of life. However, research has primarily taken a postdictive approach by knowing the outcome (date of death) and aligning, in retrospect, how well-being has changed for people with documented death events. In the present study, we made use of a predictive approach by examining whether and how levels of and changes in life satisfaction prospectively predict mortality hazards and delineate the role of contributing factors, including health, perceived control, and social orientation. To do so, we applied shared parameter growth-survival models to 20-year longitudinal data from 10,597 participants (n = 1,560 [15%] deceased; age at baseline: M = 44 years, SD = 17, range = 18-98 years) from the national German Socio-Economic Panel Study. Our findings showed that lower levels and steeper declines of life satisfaction each uniquely predicted higher mortality risks. Results also revealed moderating effects of age and perceived control: Life satisfaction levels and changes had stronger predictive effects for mortality hazards among older adults. Perceived control was associated with lower mortality hazards; however, this effect was diminished for those who experienced accelerated life satisfaction decline. Variance decomposition suggests that predictive effects of life satisfaction trajectories were partially unique (3%-6%) and partially shared with physical health, perceived control, and social orientation (17%-19%). Our discussion focuses on the strengths and challenges of a predictive approach to link developmental changes (in life satisfaction) to mortality hazards, and considers implications of our findings for healthy aging. (PsycINFO Database Record
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Affiliation(s)
- Gizem Hülür
- Department of Psychology, University of Zurich
| | | | | | | | | | - Nilam Ram
- Department of Human Development and Family Studies, Pennsylvania State University
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Knight JC, Mathews M, Aubrey-Bassler K. Relation between family physician retention and avoidable hospital admission in Newfoundland and Labrador: a population-based cross-sectional study. CMAJ Open 2017; 5:E746-E752. [PMID: 28986347 PMCID: PMC5741431 DOI: 10.9778/cmajo.20170007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Physician turnover, involving physicians' leaving clinical practice in a specific area, may disrupt continuity of care, leading to poorer health outcomes and greater use of health care services. The purpose of this study was to investigate the relation between family physician retention and avoidable hospital admission for ambulatory-care-sensitive conditions. METHODS We conducted a population-based cross-sectional study using provincial health administrative data for residents of Newfoundland and Labrador who held a provincial health card between 2001 and 2009. Five-year family physician retention was calculated by regional economic zone, and residents within economic zones were grouped into tertiles based on physician retention level. We compared hospital admission for ambulatory-care-sensitive conditions among tertiles while adjusting for covariates. RESULTS For 475 691 residents of the province, there was a negative relation between physician retention and hospital admission for ambulatory-care-sensitive conditions: residents of areas with moderate or low physician retention had admission rates that were 16.5% (95% confidence interval [CI) 12.6%-20.4%) and 19.9% (95% CI 15.2%-24.7%) higher, respectively, compared to areas with high retention. No relation was found when analysis was limited to those aged 65 years or more. INTERPRETATION The findings suggest that high physician retention is associated with lower rates of hospital admission for ambulatory-care-sensitive conditions even after control for other factors. This is consistent with our hypothesis that physician turnover acts to disrupt continuity of care, resulting in higher admission rates.
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Affiliation(s)
- John C Knight
- Affiliations: Primary Healthcare Research Unit (Knight, Aubrey-Bassler), Faculty of Medicine, Memorial University; Newfoundland and Labrador Centre for Health Information (Knight); Division of Community Health and Humanities (Knight, Mathews) and Discipline of Family Medicine (Aubrey-Bassler), Faculty of Medicine, Memorial University, St. John's, Nfld
| | - Maria Mathews
- Affiliations: Primary Healthcare Research Unit (Knight, Aubrey-Bassler), Faculty of Medicine, Memorial University; Newfoundland and Labrador Centre for Health Information (Knight); Division of Community Health and Humanities (Knight, Mathews) and Discipline of Family Medicine (Aubrey-Bassler), Faculty of Medicine, Memorial University, St. John's, Nfld
| | - Kris Aubrey-Bassler
- Affiliations: Primary Healthcare Research Unit (Knight, Aubrey-Bassler), Faculty of Medicine, Memorial University; Newfoundland and Labrador Centre for Health Information (Knight); Division of Community Health and Humanities (Knight, Mathews) and Discipline of Family Medicine (Aubrey-Bassler), Faculty of Medicine, Memorial University, St. John's, Nfld
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45
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Jensen H, Vedsted P, Møller H. Prognosis of cancer in persons with infrequent consultations in general practice: A population-based cohort study. Int J Cancer 2017; 141:2400-2409. [DOI: 10.1002/ijc.30916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Henry Jensen
- Department of Public Health; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University; Denmark
- Department of Public Health; Research Unit for General Practice, Aarhus University; Denmark
| | - Peter Vedsted
- Department of Public Health; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University; Denmark
- Department of Public Health; Research Unit for General Practice, Aarhus University; Denmark
| | - Henrik Møller
- Department of Public Health; Research Centre for Cancer Diagnosis in Primary Care, Aarhus University; Denmark
- Cancer Epidemiology and Population Health; King's College London; United Kingdom
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Kuo YF, Adhikari D, Eke CG, Goodwin JS, Raji MA. Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models. J Card Fail 2017; 24:9-18. [PMID: 28870732 DOI: 10.1016/j.cardfail.2017.08.459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 08/10/2017] [Accepted: 08/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs). METHODS AND RESULTS We used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32-1.37; odds ratio 1.32, 95% confidence interval 1.30-1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model. CONCLUSION The delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas; Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas.
| | - Deepak Adhikari
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Chiemeziem G Eke
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - James S Goodwin
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas; Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
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Poghosyan L, Liu J, Norful AA. Nurse practitioners as primary care providers with their own patient panels and organizational structures: A cross-sectional study. Int J Nurs Stud 2017; 74:1-7. [PMID: 28577459 DOI: 10.1016/j.ijnurstu.2017.05.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/25/2017] [Accepted: 05/08/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Health care systems globally are facing challenges of meeting the growing demand for primary care services due to a shortage of primary care physicians. Policy makers and administrators are searching for solutions to increase the primary care capacity. The effective utilization of nurse practitioners (NPs) has been proposed as a solution. However, organizations utilize NPs in variable capacities. In some settings, NPs serve as primary care providers delivering ongoing continuous care to their patients, referred to as patient panels, whereas in other settings they deliver episodic care. Little is known about why organizations deploy NPs differently. OBJECTIVES Investigate the NP role in care delivery-primary care providers with the own patient panels or delivering episodic care-within their organizations and understand how work environments affect their role. DESIGN A cross-sectional survey design was used to collect data from primary care NPs. SETTINGS The study was conducted in one state in the United States (Massachusetts). Data from 163 primary care organizations was obtained, which employed between one to 12 NPs. PARTICIPANTS 807 NPs recruited from the Massachusetts Provider Database received mail surveys; 314 completed and returned the survey, yielding a response rate of 40%. METHODS The survey contained measures of NP role in care delivery and work environment. NP role was measured by an item asking NPs to report if they deliver ongoing continuous care to their patient panel or if they do not have patient panel. The work environment was measured with the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of organization-level work environment on NP role in care delivery. RESULTS About 45% of NPs served as primary care providers with their own patient panel. Organization-level Independent Practice and Support subscale, an NP-PCOCQ subscale, had a significant positive effect on NP role (risk ratio=2.33; 95% CI: 1.06-5.13); with a one unit increase on this subscale, the incidence of the NPs serving as primary care providers with their own patient panel doubled. CONCLUSIONS NPs can help meet the increasing demand for primary care by taking responsibilities as primary care providers, and organizations can assign NPs their own patient panels. Supporting NP independent practice within organizations promotes NP role as primary care providers. Policy and organizational change focused on promoting NP work environments so NPs can practice as primary care providers can be an effective strategy to increase the primary care capacity.
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Affiliation(s)
- Lusine Poghosyan
- Columbia University School of Nursing, 617 W. 168th Street, GB 219, New York, NY 10032, United States.
| | - Jianfang Liu
- Columbia University School of Nursing, 617 W. 168th Street, GB 245, New York, NY 10032, United States.
| | - Allison A Norful
- Columbia University School of Nursing, 617 W. 168th Street, GB 239, New York, NY 10032, United States.
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Johnston KJ, Hockenberry JM. Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade-Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions. Health Serv Res 2017; 51:2176-2205. [PMID: 27891605 DOI: 10.1111/1475-6773.12600] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions. DATA SOURCES/STUDY SETTING Seven years (2006-2012) of panel data from the Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Regression models were used to estimate the effect of the specialty-type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes. DATA COLLECTION/EXTRACTION METHODS Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person-year observations. PRINCIPAL FINDINGS Involvement of both primary care physicians and disease-relevant specialists is associated with better compliance with process-of-care guidelines, but patients seeing disease-relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease-relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long-term care, and ambulatory care sensitive hospitalization (p < .05). CONCLUSIONS Annual involvement of disease-relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, MO
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
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Abstract
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.
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Young RA, Roberts RG, Holden RJ. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care. Ann Fam Med 2017; 15:175-182. [PMID: 28289120 PMCID: PMC5348238 DOI: 10.1370/afm.2014] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/19/2006] [Accepted: 10/12/2016] [Indexed: 11/09/2022] Open
Abstract
We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.
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Affiliation(s)
- Richard A Young
- JPS Hospital Family Medicine Residency Program, Fort Worth, Texas
| | - Richard G Roberts
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Richard J Holden
- Indiana University School of Informatics and Computing, Bloomington, Indiana
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