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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Still not quite there with definition? - but the challenge is to measure 'interpersonal' and show it makes a difference
Can a village care for a patient?
Re-framing Continuity
the need for better evidence
The Importance of Continuity of Care: Are we asking the wrong questions?
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George K Freeman, London, England Academic and General Practitioner
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I enjoyed Saultz's further contribution, with Lochner, to our understanding of outcomes associated with (inter)personal continuity of care. It is good to have an up to date assembly of the evidence.
Correspondence so far has been instructive about where next. Baker has called for RCTs, Green reminds us about the modern context of care and Bayliss specifically wants more recognition that modern care tends to be given by groups or teams. This is a big research agenda which will be challenging to fund. We need to be very clear about the research questions.
While Saultz and Lochner's review is the most comprehensive of its kind so far published, it was conceived and designed before the publication of Haggerty et al's differently framed review1 which emphasised that continuity is something experienced by patients and which identified three key elements - relational, managerial and informational. It is tempting, but wrong, to equate Saultz and Lochner's 'interpersonal' with Haggerty et al's 'relational'. This is because many of the studies cited by Saultz and Lochner were not able to measure the patient's experience of interpersonal continuity. In other words the interpersonal relationship stressed by Larry Green in his wise comment was not usually assessed. Instead, most studies of interpersonal continuity actually measured the number of contacts with the same physician, while being unable to comment on the quality of those contacts and whether they were part of a therapeutic relationship.
I heartily agree with my colleague Richard Baker about the desirability of randomized trials, where the intervention is intended to improve true interpersonal - i.e. relational continuity, where the patients' experiences of this are assessed and where outcomes of interest to policy makers such as improved well being and reduced costs are sought. And I agree with Elizabeth Bayliss that a good team may deliver good relational continuity - but again the patient's actual experience has to be the gold standard. A positive outcome from such a trial is needed to convince David Litaker. He speaks for many who wonder whether continuity of care (by which most actually mean interpersonal/relational continuity) may be more of a shibboleth than an essential attribute of General Practice & Family Medicine.
1 Haggerty JL, Reid RJ, Freeman GK, Starfield B, Adair CE, McKendry R.
Continuity of Care: a multidisciplinary review.
Br Med J 2003;327:1219-1221.
Competing interests: None declared |
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Elizabeth A. Bayliss, Denver, CO Physician, Clinician Investigator
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After reading Drs. Saultz and Lochner’s review [1], believers will need no convincing and skeptics should be (at least partially) persuaded that continuity of care is associated with improvement in certain clinical outcomes and possibly decreased costs of care. As the authors readily acknowledge, it is difficult to define continuity. It is not just about the duration of the doctor-patient relationship, but about the depth and content of the mutual knowledge gained during that time. One component may be the ability for a provider (or a provider’s team members) to care for a patient within the patient’s biopsychosocial context. Another may be the patient’s perception of having one’s needs met in a predictable pattern. In the best cases, this can promote collaborative and appropriate decision making and perhaps improved outcomes such as the decreased hospitalization rates noted in this review. One of the authors’ concerns is whether future health care will be based on the individual doctor-patient relationship or on a less personal ‘interdisciplinary team.’ But is a team approach less personal? If the ‘team’ is stable it may not be.[2] One could argue that it is quite possible for a patient to have a continuity relationship with more than one member of a provider’s office. (This idea was introduced years ago with the advent of shared overnight and weekend call schedules within multiple-provider practices.) It may even be possible for these relationships to be established and maintained in the context of the increasingly technologically sophisticated office environment that includes population-based tracking systems for care management and different forms of patient-provider communication. For example, communication may now be more likely to be initiated by the physician and his or her team for purposes of chronic illness care or preventive services. The technology is unlikely to go away, so if there is value in continuity of care (as is well suggested in this review), it behooves us as providers to determine how we can maintain continuity in the face of a changing office environment. This will take a commitment on the part of clinics and offices to maintain stable teams and to define and value continuity above and beyond the exclusive physician-patient relationship. (1) Saulz JW and Lochner J. Interpersonal continuity of care and care outcomes: A critical review. AnnFamMed 2005;3:159-66. (2) Campbell C and McGauley G. Doctor-patient relationships in chronic illness: insights from forensic psychiatry. BMJ 2005;330:667-670. Competing interests: None declared |
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Larry A Green, Washington, DC physician
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Saultz and Lochner continue their assessment of interpersonal continuity quite nicely with this piece. They partially frame their review around the Future of Family Medicine Project when they state: "A central question facing the future of family medicine is the degree to which we will provide personal health care based on the individual doctor- patient relationship, or whether we will seek to provide a medical home for patients based on an interdisciplinary team with less emphasis on personal care." Like other respondents, I want to reframe the debate. First, we are headed toward patient-centered care and the assurance of services for patients, and away from physician-centered care and the assurance of position or status of physicians. Second, a commitment to interpersonal care and a medical home need not be incompatible polarities. Third, currently available information technologies have changed forever how care is delivered, and they are sufficiently robust to permit integrated, if asynchronous, care. Fourth, no one practices alone anymore, and historic lip service to teamwork must give way to the real deal. And fifth, all of this means in part, that continuity of care, including an interpersonal component with one's chosen physician, is actually more possible now than ever before. (After all, the US now has in active clinical practice a primary care physician for every 1321 persons in the country). In short, there is no need to pose a medical home as an alternative to interpersonal contintuity. A medical home can be the platform on which people get their care, and within it, various members can play their part, including a physician with a personal, ongoing relationship with the patient. Buried in the data posted for the Future of Family Medicine Project are findings that what the people of the United States yearn for but cannot find, is not a building, not a concierge, not a nurse, and not another clinic. They yearn for a PHYSICIAN who will get to know them and STICK WITH THEM as they reap the benefits of modern medicine applied to their worries, problems and personal health care goals. But they don't think this type of physician exists anymore, and if such a physician should be fortuitously discovered, people doubt that the current ridiculous health care arrangements in the US do or would permit them to do their job as a personal physician. Let's add another framework for further research and work about interpersonal contintuity. Let's ask what it will take to permit people in the richest country on the planet to be able to select and stay with a physician of their choice who they trust and know, and who knows them not as a case or a CPT-4 number, but a living person, seeking to live a whole, meaningful life. Or, maybe we prefer to wait and see if the evidence supports medicine making any contributions to a whole, meaningful life. Competing interests: None declared |
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Richard Baker, Leicester, UK GP, professor
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In the UK, we are building up to a national election, and the political parties are starting to lay out their policies to the electorate. Health care will be a key issue in the election. The April 2nd issue of the Times newspaper draws attention to one difference between the two political parties; the Conservative party is promising to preserve small primary care practices because they provide continuity and personal care. Tony Blair’s Labour party, on the other hand, plans to promote the development of large primary care practices staffed by a wide range of professionals offering a mix of services – and almost certainly, therefore, less interpersonal continuity. It’s great that policy makers are beginning to talk about interpersonal continuity in primary care, but it would be even better if they were to base their policies on evidence. They would do well to read Saultz and Lochner’s review in the current issue of Annals as a start.1 It deals with an issue that really concerns them – cost. For primary care professionals committed to the idea of interpersonal continuity, the findings of the review will be reassuring and will reflect their experiences as providers. But will the evidence be sufficient to convince the policymakers? Saultz and Lochner have treated the evidence fairly, and it is encouraging that there are so many studies that fairly consistently indicate better outcomes and lower costs associated with interpersonal continuity. Policymakers, though, may be difficult to convince. It is disappointing that primary care researchers have not yet been able to provide irrefutable evidence of the benefit (or otherwise) of interpersonal continuity from large, good quality randomised trials. The importance of interpersonal continuity will remain in dispute in many countries until such evidence is available. I really hope that research funders in the UK, US and elsewhere will take note of the review’s conclusions and give priority to commissioning one or more trials. References 1. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Annals of Family Medicine 2005;3:159-66. Competing interests: None declared |
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David G. Litaker, Cleveland, Ohio Staff Physician, Louis Stokes Cleveland VA Medical Center
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Saultz and Lochner provide a useful review of data regarding the association between continuity of care, care delivery, and treatment outcomes. Although they report that results across studies have been inconsistent, they attribute much of this to methodological challenges, including differing definitions and methods of measurement, which may hamper recognition of such an association. Their call for studies definitively establishing this link, however, reflects a troubling perspective that has prevailed in primary care for too long: greater continuity of care must translate into higher quality care and better outcomes. In such statements, equipoise is imperiled. Is continuity of care universally important, or only for the most vulnerable, as some have started to suggest ? Can desirable treatment outcomes be achieved in settings in which continuity of care is uncommon, and what are the features of such organizations? Perhaps health system planners have been prudent in their reluctance to accept this “core assumption”: In focusing on the inevitability of a relationship between continuity of care and outcomes, we miss an opportunity to seek answers that prove more informative in guiding the development of health care delivery services in the future. Competing interests: None declared |
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