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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Continuity of care
What is continuity?
The new continuity measure is grounded in patients’ experiences
A new continuity measure: remarks on content and utility
Measuring continuity of care
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Martin C Gulliford, London, UK King's College London, Smriti Naithani, Luke Cowie, Myfanwy Morgan
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Professor Starfield observes that ‘there is no point to measuring [continuity] if we do not know what it is!’. This refers to Wittgenstein’s remark that ‘what we cannot speak about we must pass over in silence’ (1). Fortunately, we do know what ‘continuity of care’ is. In her 1980 commentary (2), Starfield clearly distinguished between two main concepts of continuity of care. Relational continuity, sometimes termed ‘longitudinality’, is characterised by the ‘continuous caring relationship’ between a patient and their usual professional. Management continuity is characterised by the delivery of a ‘seamless service’ through coordination of the work of different professionals and provider organizations (3,4). Starfield described the historical tension between the priorities of specialist as compared to primary care. ‘Continuity’ she wrote ‘should characterize those aspects of secondary and tertiary care that involve management of an episode of illness or chronic disease’ (reference 2, page 118). This association of the term continuity with specialist care may have inadvertently contributed to the confusion associated with the concept. Recently, however, there has been a shift in thinking with most writers adopting multi-dimensional models of continuity that accommodate the possibility of relational continuity in systems that strive to provide a seamless service (4). This shift in thinking is reflected in the organisation and delivery of primary care services, with increased specialisation of roles within primary care on the one hand, and increased integration and coordination of chronic illness care with hospital-based specialist services on the other. The family physician in solo practice is declining as a model of primary care delivery. Increasingly family physicians are organised into group practices that are also staffed by nurses and other allied professionals. There is increasing specialisation of roles within primary care with nurses often taking a leading role in the delivery of care for particular chronic illnesses. There is also a trend towards vertical integration of care pathways across organisational boundaries so as to facilitate appropriate and timely access to specialist care. Continuity of care does not just concern the family physician in primary care, but must be considered across all parts of the healthcare trajectory and must, of course, be both person-focused and disease-focused (5). In modern health systems, there may indeed be one doctor or nurse who knows the patient and their diabetes best, taking lead responsibility for the coordination of multi-disciplinary diabetes care. Our questionnaire represents one of a new generation of measures that is patient-experience based. It refers to care received for a particular illness. Both the conceptual model for our measure and the items are grounded in patients’ experiences, as described elsewhere (6). Each of the longitudinal continuity items is referenced to the preceding 12 month period. Access to a usual professional is essential for establishing and maintaining continuity; it would be surprising if the concepts of access and continuity did not overlap. The concept of coordination, represented by the team and cross-boundary continuity items, is of increasing importance in modern primary and chronic illness care. This questionnaire will be useful for evaluating patients’ experiences of care in diabetes. As a condition-specific measure, it is likely to be particularly sensitive to patients’ concerns in this condition. However, we are now working to produce a generic measure which may be utilised and compared across a range of chronic illnesses. Martin Gulliford, Smriti Naithani, Luke Cowie, Myfanwy Morgan References (1) Wittgenstein L. Tractatus logico-philosophicus. London: Routledge and Kegan Paul, 1961: page 74. (2) Starfield B. Continuous confusion? Am J Public Health 1980; 70:117-119. (3) MC Gulliford, S Naithani, M Morgan. What is ‘continuity of care’? J Health Services Research Policy 2006;11:248-50. (4) Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003; 327:1219-1221. (5) Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current well-being and future disease risk. BMJ 1998; 317: 1202-1208. (6) Naithani S, Gulliford MC, Morgan M. Patients’ perceptions and experiences of ‘continuity of care’ in diabetes. Health Expectations 2006;9:118-29. Competing interests: None declared |
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Barbara Starfield, Baltimore, MD The Johns Hopkins University
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The article, Measuring Continuity of Care in Diabetes Mellitus: An Experience-Based Measure, reverts to the disease-oriented concept of continuity as used in the older literature. In more recent times, continuity has been considered a feature of good primary care practice and, to distinguish it from the older use, has often been re-named as 'longitudinality'. In this article, a 19 item measure with four subdomains was used. Four items are referred to as 'longitudinal continuity', but all of these items inquire as to how often something happened, not over what length of time something happened. The four items in 'flexible continuity' all deal with characteristics of accessibility to diabetes-related services. The five items in 'team and cross-boundary continuity are all related to coordination. Only the 'relational continuity' items concern the way in which doctor and patients interact in the care of diabetes. Although there is high correlation between scores on the four subscales, this is no proof that they measure the same thing. Only criterion validity was assessed, and this is no proof of concept. The validity of the study itself for work in primary care is in doubt becasue the starting question to identify the regular source of care for diabetes was two questions in one: 'the doctor who knows you and your diabetes best'. What if the 'doctor who knows you best' is different from the 'doctor who knows your diabetes best'? Apparently the authors did not consider this possibility and left it to each respondent to decide which to respond to. The 'continuous confusion' in use of the term 'continuity persists twenty-seven years after it was first pointed out. Isn't it time to decide whether 'disease-focused continuity' and 'person focused continuity' are the same, with the same relevance to primary (person-focused) care and specialty (disease-focused)care? There is no point to measuring something if we do not know what it is! Competing interests: None declared |
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Martin C Gulliford, London, England Senior Lecturer in Public Health, King's College London, Smriti Naithani, Luke Cowie, Myfanwy Morgan
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We are grateful to Dr John Saultz and Drs Henk Schers and Annemarie Uijen for their interest in our recent paper which described the development and validation of a new questionnaire measure of continuity of care (1). In her 1980 commentary, Starfield (2) remarked on the confusion between two main concepts of continuity: relational continuity and management continuity. Multidimensional models of continuity of care aim to accommodate both of these main dimensions, as described by Freeman and others (3,4). Our earlier report (5) gave a detailed account of the qualitative patient interview data that provide empirical support for our conceptual model of continuity. The patient interview data were also used to identify items for the new measure of continuity of care. Based on these data, longitudinal continuity in chronic illness care is associated with remaining in regular contact with a usual health provider (continuity of carer) as well as receiving regular reviews, clinical tests and management advice (continuity of care). Our evidence shows that flexible continuity is associated with being able to obtain advice from a known and trusted professional when this is needed, as for example, when a patient obtains an urgent consultation when he or she has a problem (5). We emphasise that the items in our measure should generally be implemented in a single scale to measure the overall experience of continuity of care. Schers and Uijen go beyond the evidence in suggesting that the items for ‘team and cross boundary continuity’ have ‘little discriminatory value’. This is because the data were collected in one area that is served by only two or three specialist diabetes services. It may be that the context did not offer a critical test for these items. We are now working to develop a generic questionnaire measure which may be used in a range of chronic illnesses. We agree that a more universal measure should be a long-term objective. This will require a universally accepted definition of the concept of ‘continuity of care’. Martin Gulliford Smriti Naithani Luke Cowie Myfanwy Morgan Division of Health and Social Care Research, King's College London, UK (1) Gulliford MC, Naithani S, Morgan M. Measuring continuity of care in diabetes mellitus: an experience-based measure, ECC-DM. Ann Fam Med 2006;4: 548-555. (2) Starfield B. Continuous confusion? Am J Public Health 1980; 70:117-119. (3) Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essential element of modern general practice? Fam Pract 2003; 20:623-627. (4) MC Gulliford, S Naithani, M Morgan. What is ‘continuity of care’? J Health Services Research Policy 2006;11:248-50. (5) Naithani S, Gulliford MC, Morgan M. Patients’ perceptions and experiences of ‘continuity of care’ in diabetes. Health Expectations 2006;9:118-29. Competing interests: None declared |
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Henk J Schers, Nijmegen Department of general practice, University Medical Centre St Radboud., Annemarie Uijen
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By constructing a new measure for continuity of care, Gulliford and collegeaus have contributed to our knowledge about an important theme in general practice. They published a thorough piece of work on the development and validation of a new measurement instrument for continuity of care in diabetic patients. Their work will enable researchers to measure seperate dimensions of continuity. However, we also have a few concerns about the new measure. These are about the measure’s content and utility. Unintentionally, the authors may have contributed to 'continuous confusion', as Barbara Starfield called it more than 25 years ago. One of the confusing things is that their new instrument consists of four dimensions, which have been described earlier in the literature. The authors show their factorial design, which more or less justifies these dimensions. However, the article does not inform us about the content validation process. In our opinion, the items constituting each dimension, do not always reflect its meaning. For example, 'longitudinal continuity' constitutes a set of surprising items. Whereas most researchers on continuity would define longitudinal continuity as personal continuity over time1 or as care from as few professionals as possible consistent with other needs, 2 the underlying study only includes items on diabetes management in this dimension: such as the number of appointments in the last year, the number of appointment letters, and the number of blood tests taken in the last year. This is confusing. Also, the set 'flexible continuity' confuses. It appears to contain variables, which mainly concentrate on the accessibility of the practice, not on flexibility and adjustment to the needs of the individual over time.1 At last, quite unfortunately, it appeared that the measure for 'team and cross-boundary continuity', which will be growingly important in the future, only has little discriminatory value. As the authors mention justly, the dependence between the relational continuity items is undesired. They might consider the alternative of substituting this set of 6 (or 7) by just one item, and attributing a proportional weight to it. However, this would need more research. Another concern is our doubt whether it is desirable to develop disease-specific measures for continuity of care. Are we going to develop also continuity measures for heart failure, for pulmonary disease, and for stroke? Certainly from the research perspective, such efforts do not appear to be very cost-effective. In our opinion therefore, it might be interesting to strive for a universal continuity of care measure, which can be used in different health care settings, and for all types of illness. This will need international collaboration between research groups. Of course, such a process might be more complicated and time- consuming, but it certainly would strengthen the quality and utility of new measures. In spite of these comments, we congratulate the authors very much with this manuscript, which contributes to our knowledge on one of the core concepts in family medicine. (1) Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003; 327(7425):1219-1221. (2) Freeman G, Shepperd S, Robinson I, Ehrich K, Richards S, Pitman P et al. Continuity of Care: Report of a scoping exercise Summer 2000, for the SDO programme of NHS R&D (Draft). London: NCCSDO 2001. www.sdo.lshtm.ac.uk. 1-141. Competing interests: None declared |
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John W Saultz, Portland, Oregon, USA Oregon Health and Science University
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The paper by Gulliford et al is a terrific contribution to our understanding of one of family medicine's core principles. In carrying out this work, the authors have taken a somewhat new approach, allowing a more detailed look at continuity within a single disease model. Virtually every health care system in the developed world is interested in how to improve diabetes care, both as a quality and a cost containment issue. The measurement tool described in this paper will allow future researchers to examine four dimensions of continuity and to corelate these dimensions with other aspects of diabetes care. It will also allow us to design practice interventions intended to improve continuity of care for diabetics and measure the degree to which we achieve the desired outcome. I am hopeful that this approach to continuity of care research will precipitate more specificity in our understanding of when continuity of care is likely to contribute to quality outcomes. Gulliford and colleagues should be congratulated for an important contribution to this domaine of research. Competing interests: None declared |
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