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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Continuity is associated with reduced costs - great - now we need a prospective study!
Continuity and Longitudinality
Responsibility for Care and Continuity of Care
Reducing health care costs will win the day for continuity
Patient-centeredness and health status of patients
Causality or correlation?
A landmark study
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George K Freeman, London, England Professor of General Practice, Imperial College London
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As a long time seeker of understanding about Continuity of Care, I was delighted to read the paper by Jan de Maeseneer and colleagues (1). Their findings suggest that more longitudinal continuity from one Family Physician saves money. This is what health care managers need to hear!
It makes intuitive sense that seeing the same doctor should lead to economy by saving duplication. On the other hand better interpersonal continuity could lead to better diagnosis and disclosure and consequent increased demand on resources. The seminal work by Hjortdahl in Norway indeed gave conflicting results on costs; more personal care was associated with saving of time and of tests but with more prescriptions for medication and referrals to specialists (2).
The problem that we now face is that De Maeseneer et al have found an association that is not necessarily causal. While it is attractive to argue that seeing the same doctor saves money, it is also possible that cheaper patients are more likely to see the same doctor. This latter interpretation gains some support from the method of measurement of longitudinal continuity employed in the present study. As I understand it, any patient who saw more than one family physician for whatever reason was classified as ‘low continuity’. Yet, this study was not set up to find out why some patients saw a second family physician at least once during a two year period. As Hjortdahl and I argued in 1997, there is no evidence that compelling patients to see the same doctor improves their care (and indeed some evidence to the contrary!) (3).
So we now need to build on De Maeseneer et al’s achievement and set up a prospective study, preferably randomised and controlled, which improves continuity for a sample of patients and shows that this sample indeed incurs reduced costs. Only then will we be able to go to managers with our hands on our hearts and argue that interpersonal continuity is in itself a sufficient healthcare outcome (4).
1 De Maeseneer J M, De Prins L, Gosset C, Heyerick J. Provider Continuity in Family Medicine: Does It Make a Difference for Total Health Care Costs? Ann Fam Med 2003;1:144-148.
2 Hjortdahl P, Borchgrevink C F. Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations. BMJ 1991;303:1181-4.
3 Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997;314:1870-1873.
4 Christakis D A. Continuity of Care: Process or Outcome? Ann Fam Med 2003;1:131-133.
Competing interests: None declared |
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Barbara Starfield, Baltimore, MD, USA Professor, Johns Hopkins University
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The papers in the September/October issue of the Annals of Family Medicine contribute to the continuing debate about the meaning and utility of ‘continuity of care’. Confusion about the definition of the term has been longstanding (Starfield 1980) and there is no end in sight, judging from the considerable numbers of literature reviews of the subject. The confusion stems from the absence of a systematic attempt to define critical terms early in the history of the field of health services research. This confusion is not limited to this term only; it is found, for example, for some critical concepts of ‘access’, which some researchers equate with ‘utilization’). It does not help, however, to subdivide the term according to what is meant. What is needed, are descriptive terms for the separate aspects encompassed by ‘continuity’. Virtually every dictionary definition of ‘continuity’ incorporates the notion of ‘uninterrupted succession of events.’ Under no stretch of imagination are ambulatory care visits ‘uninterrupted’! The only thing about ambulatory care events that might be considered uninterrupted is the availability of information. Thus, continuity is properly a mechanism to assure the flow of information, and it can be attained by a variety of means: standard medical records, patient-held records, computerized records, and practitioner and patient memory. Continuity is thus a structural mechanism to facilitate the processes of recognition of patient’s problems and care related to them. (Starfield 1998) ‘Interpersonal continuity’ is not only a matter of information (knowledge) flow. It is, most importantly, a mechanism to increase understanding. Therefore, a term other than continuity must be used for it. The term ‘longitudinality’ seems appropriate, in the absence of a better alternative, because it incorporates the notion of a long-term, patient-focused relationship. Contrary to the common perception that longitudinality requires or engenders ‘trust’, a healthy skepticism is more warranted in this day and age of adverse effects and errors. The mutual understanding between patients and their practitioners makes it possible to question decisions rather than to simply accept them as a matter of ‘trust’. Knowledge about patients and their care is necessary but insufficient; ‘longitudinality’ makes possible the attainment of understanding. It is time that we separated out knowledge from understanding, realizing the importance of both. Continuity is a mechanism to achieve knowledge; longitudinality is the mechanism for achieving understanding. References: Starfield B. Continuous confusion? Am J Public Health 1980; 70(2):117 -119. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. Competing interests: None declared |
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Matthew E. Ulven, Belleville, IL, USA Assistant Professor - Saint Louis University
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The residency program at which I teach has been struggling recently with the idea of patient ownership or stated another way, the physician's responsibility for the care of his/her patient, among some of the residents. This discussion of continuity of care seems directly on point. The sense of responsibility that physicians have for the care of their patients flows in part from the continuous interaction of the physician and his/her patient. It seems that when a medical system no longer fosters this relationship, not only does patient care seem to suffer, but I would argue that physician ownership suffers as well. What is the incentive to invest time in taking responsibility for the care of your patients, if in all likelihood some other physician within in the clinic will be providing care for the patient tomorrow? Who should assume reponsibility for the coordination of care for that patient then? It seems changes within the medical system have forced residency clinics to become so access-focused, that continuity of care becomes no longer possible. For instance, providing same-day access for patients is impossible if one is trying to foster continuity of care for physicians who are by the nature of their training only available 1-3 days a week. So in an access-focused clinic, patients by default will rarely ever see their assigned provider or even the same provider and by default I would argue that continuity of care then becomes a challenge at best, impossible at worst, and the ability to role model and inculcate patient ownership becomes increasingly difficult as well. Subsequently, I believe the care we provide our patients will suffer. I would covet the thoughts and ideas others have concerning this issue. Respectfully submitted, Matthew E. Ulven, MD Competing interests: None declared |
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Joseph E Scherger, San Diego, CA. USA Clinical Professor of Family Medicine
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Of all the outstanding articles and commentaries on continuity published in this issue and elsewhere, this data supporting others, that continuity of care lowers health care costs will win the day. Money drives health care structure, if not policy. At some level, even in fee for service systems, all health care is budgeted. Those concerned with health care spending need to have a renewed respect for the value of primary care with continuity. This study will be helpful in turning the tide back toward having a personal physician coordinate care over time, the essence of family medicine. Competing interests: None declared |
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Bengt Mattsson, Göteborg, Sweden Professor/General Practitioner, Dept of Primary Health Care, Göteborg University
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The article by De Maeseneer et al (1) is an interesting and important piece of work. It is in line with an increasing amount of recent evidence indicating the importance of a well-established primary health care system (2, 3). And by well-established is meant a primary care organization that encompasses basic elements like continuity, accessibility and comprehensiveness. De Maeseneer et al have made a vigorous attempt to eliminate weaknesses in the design of the study but as always, some limitations are at hand. The authors depict some of them - especially focusing on the lack of information with respect to the doctors. That is indeed one important shortcoming. But I think there is another essential limitation, not mentioned in the article. Those patients searching for continuity might be inclined to choose doctors who favour continuity. And care of these patients may be comparatively "cheap" and a kind of selection bias could be at hand. This is a parallel to an early study by Huygen et al that focused on patient-centeredness and health status of patients (4). A high level of patient-centeredness had a favourable impact on health status and economy. But those patients who searched for patient-centeredness could voluntarily have chosen that kind of doctor. It is impossible to bypass many difficulties in the effort to show the importance of primary health care by this kind of methodology. Statistics has its limitations. There are complementary methodologic approaches to come closer to a substantiation of the importance of primary health care. Qualitative methods are one alternative where the patients' own words and testimonies are brought to light (5). New contemplations and experiences will be made official and we need to be aware of the voice of the patients. We have recently finished a qualitative study (so far just in Swedish) among patients and asked for their experiences of the importance of continuity. The patients' words and descriptions do not "prove" in a strict bio-medical scientific way the advantages of continuity but the reading and interpretation of the interviews has a convincing impact that very well supplements the well-designed study by De Maeseneer et al. References 1. De Maeseneer JM, De Prins L, Gosset C, Heyerick J. Provider Continuity in Family Medicine: Does it make a difference for total health costs? Ann Fam Med 2003;1(3):144-8. 2.Engström S, Foldevi M, Borgquist L Is general practice effective? A systematic literature review. Scand J Prim Health Care. 2001;2:131-44. 3. Starfield B. Primary and speciality care interfaces: the imperative of disease continuity. Br J Gen Pract 2003;53:723-9 4. Huygen F, Mokkink H, Smits A et al. Relationship between the working styles of general practitioners and the health status of their patients. Br J Gen Pract 1992;42:141-4. 5. Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 2001;358:1818-9. Competing interests: None declared |
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Henk Schers, Nijmegen, Netherlands General practitioner-researcher University Medical Centre St Radboud, Wil van den Bosch
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De Maeseneer et al have carried out an excellent research job, which will contribute to the health policy debate and to discussions about the position of continuity of care in general practice. In a general practice setting, the authors studied the association between provider continuity and total health care costs in a correlational design. Being GPs from the Netherlands - a country with a long tradition of promoting continuity of care - we eagerly agree with their conclusion that continuity of care is one of the most important explaining variables for total health care costs. However, scientific rigour calls for criticism too. The authors suggest that their notable finding of an association between continuity and costs is close to a causal relationship: Stimulating provider continuity will cut back total health care costs. But what did the authors actually measure? In our opinion, they may have measured just some patient or GP characteristics. Firstly, patients who are used to visiting more than one GP might be the same patients that use a diversity of other health care resources also: more specialist care, more hospital care, more alternative medicine etc. Thus, lower costs might be related to high continuity, but actually are caused by patients’ health behaviour. Forcing these patients towards more continuity might not alter this. Moreover, patients who get seriously ill need help quickly and may be inclined to consult another doctor regularly. Normally, serious ill patients will generate higher costs. The multivariate model shows that the number of contacts with a GP is the most important predictor for total health care costs. This also suggests that mainly the outcome of health behaviour, more than the outcome of continuity of care, was measured. A remarkable finding was that patients with high continuity and an internal locus of control generated relatively low costs, whereas patients with low continuity and an internal locus of control generated relatively high costs. Do the authors have an explanation for this? The authors themselves are aware of another major limitation. GP characteristics may be a strong predictor of the achieved patient continuity as well. GPs with a positive attitude towards continuity might have closer relationships with their patients. If these GPs are the ones with high professional standards and an integrated working style with emphasis on preventing unnecessary prescribing and referring, costs may be lower due to the personal style of the doctor, and not to more or less continuity. Indeed, Mokkink et all have found such a relation before.1 1. Huygen FA, Mokkink HGA, Smits AJA, Son JaJ van, Meyboom WA, Eyck JThM van. Relationship between the working styles of general practitioners and the health status of their patients. British Journal of General Practice, 1992,42, 141-4. Competing interests: None declared |
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Manfred Maier, Vienna,Austria Head, Dpt. Gen.Practice
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The paper by Jan De Maeseneer et al. provides long awaited hard data of significant statistical value in support of continuity in GP for both the quality of health care provided and the economic impact on health care systems. Some interesting questions resulting from the study: How do the overall health care costs reported break down to specific items? What is the hospital referral rate in the two groups and does it contribute to the differences found? Could the influence of patient`s compliance be assessed? Could the same difference related to continuity in family medicine be expected at the specialist level? The result of the study should be made known to every health care politician and every executive of insurance companies/payer organisations. Competing interests: None declared |
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