Continuity of Care: Process or Outcome?

Dimitri A. Christakis

doi:10.1370/afm.86

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Continuity of Care: Process or Outcome
Eric M. Wall

Published on: 13 November 2003
Why do we study continuity?
Howard B. Tandeter

Published on: 09 October 2003

Published on: (13 November 2003)
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Continuity of Care: Process or Outcome
Eric M. Wall, Portland, USA
It's been 20+ years since I published a review of the continuity of care literature. At the time, I was certainly attempting to be provocative in challenging a basic tenet (at least for me) of our discipline. The recent series of articles in the Annals revives this debate. Dr. Christakis throws down the gauntlet asserting that continuity of care in itself is an outcome. While I'm sure I agree with him (given my healt...
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It's been 20+ years since I published a review of the continuity of care literature. At the time, I was certainly attempting to be provocative in challenging a basic tenet (at least for me) of our discipline. The recent series of articles in the Annals revives this debate. Dr. Christakis throws down the gauntlet asserting that continuity of care in itself is an outcome. While I'm sure I agree with him (given my health services research background), his series of empirical questions posed in the last paragraph of his editorial are indeed critical regardless of the preceding academic discussion.
As someone who now leads a rather schizophrenic existence of a health plan administrator and a very part-time academic family physician and teacher, I have been hard pressed to justify continuity of care at the policy level. Admittedly flawed attempts at institutionalizing continuity (through primary care "gatekeepers") failed for many reasons well known to readers. Patients/consumers do indeed march with their feet. And they are not as a whole demanding continuity of care in the way we have understood it. At least in their purchase of health insurance. In this regard, Nutting is correct in asserting the different importance ascribed to continuity by different types of patients for different types of visits.
It may be more important to define a research agenda in this area that focusses on those individuals for whom continuity might be especially important- the young, the old, those with chronic medical conditions, etc. In the current period of hsopitalists and ambulatory care specialists, where does continuity have a role? At the policy level, the end result of interest is improved health outcomes. These certainly include quality of life, patient safety, physical and social function among others.
I believe that with the publication of the subsequent articles in the Annals, we are off to a good start. Clearly as core attribute of primary care, this research agenda is not completed.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (9 October 2003)
Page navigation anchor for Why do we study continuity?
Why do we study continuity?
Howard B. Tandeter, Beer-Sheva, Israel
Transient discontinuity of care [1], an editorial published in 1998 in the Journal of Family Practice, was my 2 cents’ contribution to the discussion on the issue of continuity. Continuity was seen as central to the philosophy and teaching of family medicine [2], and universally accepted as positive. Although this editorial pointed out a negative phenomena occurring during continuity based relations, it did not question...
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Transient discontinuity of care [1], an editorial published in 1998 in the Journal of Family Practice, was my 2 cents’ contribution to the discussion on the issue of continuity. Continuity was seen as central to the philosophy and teaching of family medicine [2], and universally accepted as positive. Although this editorial pointed out a negative phenomena occurring during continuity based relations, it did not question its cardinal value in family medicine. The present issue of the Annals brings new insights about continuity. The article by Saultz JW [3] discusses and classifies 142 of the 379 original article found in the literature addressing the issue of continuity. The literature reviewed looks at issues such as ways of measuring continuity, patient satisfaction, patient characteristics that correlate with choosing a continuity model, the effects of continuity on quality of care and on costs, and how do changes in the health care system affects continuity. Most of these issues are mainly relevant to systems in which continuity of care is under attack, or in which there is a choice between continuity and non-continuity. This is also the type of questions asked in Christakis’ editorial [4]: should continuity be imposed on those who do not want it? maybe those who have no interest in having a regular physician do not know what they are missing? Is it a process or an outcome measure? To tell you the truth, I can’t imagine a Cuban family physician asking himself these questions! In countries in which continuity is universal, and not a choice, most of these questions are irrelevant. The acceptance by a system of the fact that “a sustained partnership between patients and clinicians is a critical element of primary care”[5] should shift research from quantitative to qualitative, defining ways of making the best out of the continuity process, and not discussing whether continuity is good or bad, cost-effective or not. Humans are creatures of habits. Given the possibility, most patients will choose one doctor and keep a persistent/ continued relation. This process is obvious for all Cuban and most of Israeli family physicians, who work in systems in which continuity is taken for granted, and therefore it does not become a research question. So why do we find 379 articles in the literature of an issue that for many may not even be a good research question? Are we studying continuity or simply convincing the local systems that continuity is good? Just think about it…
REFERENCES
[1] Tandeter H, Vinson D. Transient discontinuity of care: others seeing what we have missed. J Fam Prac 1998; 47(6): 423-4. [2] Shahady EJ. Principles of family medicine: an overview. In: Slone PD, Slatt LM, Curtis P. Essentials of family medicine. Second edition. Baltimore,Md: Williams and Wlkins;1993: 3-8. [3] Saultz JW. Defining and Measuring Interpersonal Continuity of Care Ann Fam Med 2003 1: 134-143. [4] Christakis DA. Continuity of Care: Process or Outcome? Ann Fam Med 2003 1: 131-133. [5] Stange KC. In this Issue: Continuity of Care. Ann Fam Med 2003 1: 130- 131.
Competing interests: None declared
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Competing Interests: None declared.