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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Measuring interpersonal continuity
Interpersonal continuity and health system reform
Importance of measuring the interpersonal element of continuity
Continuity of care in a changing health care system.
continuity and patient satisfaction
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John W. Saultz, Portland, Oregon Oregon Health and Science Univ
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I am flattered that Professor Freeman enjoyed our paper on interpersonal continuity and I agree that this is a very difficult topic for family physicians to study objectively. For many of us, ongoing relationships with our patients is the primary characteristic that attracted us to family medicine as a career choice. Having spent hundreds of hours reading these papers, I honestly don't think that a truely skeptical policy analyst would be impressed much by this body of evidence. Our discipline has a longstanding history of using cross-sectional methods to study common health problems and issues. There is no aspect of family medicine that is less suited to such methods than continuity of care, an inherently longitudinal concept. I agree that our research often measures longitudinal continuity when we seek to study interpersonal continuity. I consider the following questions most relevant to our efforts to quantify interpersonal continuity: 1. Can the patient name an indivudual when asked if they have a personal physician (identification)? 2. If so, how long have they been under this person's care (duration)? 3. What percent of their visits are with this person (longitudinal care)? 4. How much does this personal relationship mean to the patient(qualitative value)? 5. Are they willing to wait longer or pay more or travel farther for such personal care (measurable value)? Finally, I think we need additional research addressing how interpersonal continuity fails. Imagine ten new patients coming to a family physicians office for the first time. Which ones will still be in the practice one year, five years, and ten years later? What patient, physician, and practice characteristics predict who will stay and who won't? We will have to have the patience to conduct cohort studies over a period of years to answer these questions. But we aren't going to understand interpersonal continuity until such studies are done. Competing interests: None declared |
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John W. Saultz, Portland, Oregon Oregon Health and Science univ
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Dr. Elizabeth A. Bayliss finds it unlikely that every family physician will be able to provide comprehensive and continuing care to any patient as American health care becomes more complex. I think this depends on how we choose to define comprehensive care. Once upon a time, most of America's family physicians were in solo practice. But this hasn't been the case for over a generation now, and we have never really come to terms with what group practice means to our care model. To me, it is a mistake to equate competence in caring for a disease with the skills needed to care for a patient. Very few of us practice on an island. We have partners, colleagues, and consultants. The real question we are trying to address in our research on interpersonal continuity is, "what should be the primary unit of patient trust and provider responsibility?" For many of our patients, health care is a personal service between two people, regardless of how many teammates stand behind the identified personal physician. We need to understand which patients feel this way and why before we get too far into the process of redesigning American health care. Competing interests: None declared |
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George K Freeman, London Academic General Practitioner
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I really enjoyed the paper from Saultz and Albedaiwi (1). I agree that interpersonal continuity of care is the element of CoC most relevant to primary care/general/family practice. It is indeed crucial to know if it makes a difference. Therefore, like Stewart in her magisterial editorial (2), I am much encouraged by these positive findings.
But most writers about continuity of care are enthusiasts for it and as academics we should not deceive ourselves. I wonder how much this paper would convince a skeptical policy maker. Indeed, there may be selection bias in that enthusiasts may wittingly or unwittingly select their most positive findings for submission, and editors tend to prefer positive findings. My own judgement is that evidence for the overall benefits of interpersonal continuity of care is as yet all too limited.
Patient satisfaction is itself a problematic measure. It has the great strength of being generic, as Stewart says. But satisfaction levels in primary care tend to be high and do not capture patients more specific feelings. Also satisfaction tells us little about how better interpersonal CoC works or about other benefits (or harms). More important, patients have competing priorities, particularly quick access, and so, even if satisfied, they may not be willing to wait for a practitioner they know and like.
I was really interested in the discussion section. I agree that a prospective recruitment survey of newly registered patients is highly desirable and I am hoping to undertake such a study in the UK over the next 2-3 years.
I have two other queries:
1 We need more on how to improve interpersonal continuity. Kibbe et al’s impressive study (3) is now 11 years old but I’m unaware of a sequel. Were the reported higher levels of same provider continuity maintained and were there associated measurable benefits?
2 Measurement of interpersonal continuity remains a challenge. Saultz and Albedawi hint at the difficulty in inferring the strength of a therapeutic relationship from studies that essentially measure contacts, at best asking patients whether they can identify their physician. Haggerty et al (4) have defined relational continuity as an ongoing therapeutic relationship between a patient and one or more providers. Saultz has previously noted (5) that relational continuity is similar to interpersonal continuity. But quantitative measures merely tell us about contacts, they say nothing about whether the relationship (if any) was therapeutic)
So how can we measure relational or interpersonal continuity most easily and cheaply? Any suggestions?
References
1 Saultz JW, Albedawi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2:445-451.
2 Stewart M. Continuity, Care, and Commitment: The Course of Patient-Clinician Relationships. Ann Fam Med. 2004;2:388-390.
3 Kibbe DC, Bentz E, McLaughlin CP. Continuous quality improvement for quality of care. Journal of Family Practice 1993;36:304-308.
4 Haggerty JL, Reid RJ, Freeman GK et al. Continuity of Care: a multidisciplinary review. Br Med J 2003;327:1219-1221.
5 Saultz JW. Defining and Measuring Interpersonal Continuity of Care. Ann Fam Med. 2003;1:134-143
Competing interests: None declared |
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Elizabeth A. Bayliss, Denver, CO Clinician researcher, KPCO, Asst. Professor, UCHSC
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In their article, Interpersonal Continuity of Care and Patient Satisfaction: A Critical Review (1), Drs. Saultz and Albedaiwi review the literature on one of the basic tenets of Family Medicine. In doing so they emerge with a consistent message: higher levels of interpersonal continuity of care correlate with higher levels of patient satisfaction. Not only is it reassuring to be reminded that this part of the definition of both family practice and primary care still holds true (2), it is particularly important to do so in the face of potential changes in our health care system. As we take a critical look at a health care system based on an acute care model and contemplate needed changes, it is worth noting what ‘matters’ to patients. However, it may be worth asking when it matters as well. We care for an increasing population of persons with chronic, not acute, medical conditions. We provide recommended preventive services (estimated to consume up to 7.4 hours per physician per day) (3). Should all care be delivered in the office visit? If so, is it important (or even possible) to have interpersonal continuity of care for each visit? Are there categories of visits for which interpersonal continuity of care matters more or less? Are there ways that we can use appropriate technologies to incorporate some population-based care into continuous relationships? It would be helpful to know if patients prefer, for example, continuity for chronic visits, but less for visits for minor acute illness. Or, as another example, whether interpersonal continuity can be maintained within an office where some preventive care is orchestrated by a nurse specialist. As our health care system evolves, I think it is unlikely that each primary care physician will be able to provide “comprehensive and continuing” care that addresses all of the acute, chronic, and preventive needs of all patients. Both patients and physicians have weighed in on the value of interpersonal continuity of care. The start of a satisfactory re- engineering of primary health care lies in the shared space where our priorities match. Let us use that knowledge to build an effective and efficient twenty-first century health care system. 1. Saultz JW and Albedaiwi W. Interpersonal continuity of care and patient satisfaction: A critical review. Ann Fam Med 2004;2:445-451. 2. Definitions of Family Practice and Primary Care. American Academy of Family Physicians. www.aafp.org 3. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635- 41. Competing interests: None declared |
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Richard Baker, Leicester, UK Department of Health Sciences, University of Leicester
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Saultz and Albedaiwi have provided a useful summary of the evidence about the relationship between continuity and satisfaction.1 They also highlight the difficulties of the current evidence, including the various definitions of continuity in use, and the disadvantage of lumping all patients together - some may regard continuity as important, but others may not. In a recent qualitative study in primary care, we approached the issue from a different direction.2 In investigating personal care, it became clear that consulting the same provider could facilitate personal care, but it was also possible to provide aspects of personal care in a consultation between strangers. When patients had complex problems, they tended to prefer to consult the provider with whom they had already established a relationship. In the United Kingdom, we are experiencing a flood of initiatives in primary care in order to improve access. In addition to offering consultations with nurse practitioners for people with acute minor illness, many services now provide care for people with chronic disorders such as diabetes or heart disease in guideline driven clinics run by nurses. Although little or no objective data are available, it is likely that continuity is less in nurse-led primary care services. At present, therefore, there is a risk that continuity is becoming more difficult to obtain for precisely those patients who prefer it. At present, we seem to be muddling the systems - patients who want continuity should be able to obtain it. We have not yet found a satisfactory way to organise primary care consulting systems to reliably provide continuity to those who want it, whilst at the same time providing efficiency and quick access. Perhaps the next generation of studies of continuity should compare the experiences of the users of different provider appointment systems. 1. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med 2004;2:445-451. 2. Tarrant C, Windridge K, Bolton M, Baker R, Freeman G. Qualitative study of the meaning of personal care in general practice. BMJ 2003;326:1310 (full version on bmj.com). Competing interests: None declared |
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