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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Must we accept Sophie's Choice?
Exploratory maybe but rich nonetheless…
Practice Organization and Continuity of Care
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L Gordon Moore, Rochester, NY, USA Family Medicine Physician
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This is a terrific article. I'm well pleased to read studies of practice attributes that improve population experience of care and health. The authors have done an excellent job shedding light on patient priorities regarding practice qualities. In settings with limited resources for primary care this study can help us focus our efforts on the most valuable attributes. I find it interesting and heart warming that 25% of respondents did not accept Sophie's choice. I embed my self with these individuals who appear to be saying "Why force us to choose between valuable attributes? Why can we not have them all?" In the United States the answer stems from the policies robbing primary care of the very air we need to professionally survive. As stated by the authors, all the tested interventions improve patient experience of care and/or clinical outcome. The price for "all of the above" would be dwarfed by the savings accruing from the effective delivery of primary care. We must loose the stifling corset of inadequate payments, the shackles of fee-for-service, and the crushing burden of the uncompensated administrative and regulatory trivia game. Gordon Competing interests: None declared |
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Martin Fortin, Canada Professor, Département de médecine de famille, Université de Sherbrooke
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Despite the exploratory aspect and the limitations underlined by the authors, the study by Haggerty & al has a rich potential and offers concrete and practical tips for improving quality of the delivering of primary health care. The study is strong and well designed and was done during a critical moment in the province of Quebec, just at the start of an important primary care reform. As a family doctor and Director of a Family Medicine Group (FMG) in this province, I can use this study directly to make changes in my own organization. The exploratory character cannot be used as a reason for not moving towards improvement. The conclusions are well corroborated with studies in other countries. Moreover, as stated by the authors, non FMG-clinics can learn from this study and also make concrete changes to improve the way they are delivering care. What this study doesn’t explore is how the characteristics of the patients relate to the outcomes. I’m especially interested in patients with multiple chronic conditions. For those particular patients, accessibility, relational continuity and coordination continuity are crucial to deliver high quality of primary care and to avoid unnecessary hospitalization and certainly to keep the cost of care at a lower level. I would be really interested in knowing how those patients rate the care they are receiving from their clinic, and especially what could be done to improve it. Competing interests: None declared |
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Eric M Wall, Seattle, WA (USA) Senior Medical Director
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The article by Haggerty et al is interesting if a bit dated (2002). The outcomes under study were perceived accessibility, relational continuity and coordination continuity (coordination of care) by patients in Quebec in 2002. U.S. readers might be inclined to dismiss the findings because of the differences between their/our care system and that of Canada. I would bet that many of these findings are common to family practice settings in both countries nowadays as the supply of family physicians has declined in the face of rising demand. Not surprisingly, the way in which practices were organized influenced all three outcomes. The startlingly low perceived accessibility of family physicians by patients may well be influenced by low prevalence then and now of true team based care. Patient perception of provider continuity may well be partly mitigated when the patient related to the office team rather than a single physician. Few practices to date in the non-closed system of care widely prevalent in both countries have incorporated this care successfully. Care coordination, both perceived and real, can also be affected by team based care. Since 2002, the slow but steady adoption of electronic health systems with electronic messaging to and from the physician have improved the potential for this coordination. The term "medical home" is thrown around today a great deal. It alludes not to the family practices of the past, where coordination was physician-dependant but to the family practices of the future where real systems and processes work in concert with teams of care providers to address access, continuity and accountability in different ways. The authors note correctly that this was an exploratory study. At the same time, their findings remind us that the characteristics of the clinic setting in addition to that of the physician, play critical roles in the perception of accessibility and continuity of care by patients. Competing interests: None declared |
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