Continuity of Primary Care: To Whom Does It Matter and When?

INTRODUCTION

Continuity of care has been conceptualized as a fundamental aspect of primary care since the resurgence of family practice more than 3 decades ago.^1–,³ More recently, a sustained patient-physician partnership has been advanced as a defining characteristic of primary care,^4,5 for which continuity is seen as a necessary, but not sufficient, condition.^5,6

There is evidence for a positive effect of continuity of care on both physician⁷ and patient^8–,¹¹ satisfaction with care and patient adherence to medical regimens,¹² pregnancy outcomes,¹³ emergency department^14,15 and hospital^14,16–,¹⁸ utilization, overall service utilization, and cost.^19,20 Research has failed, however, to show an effect of provider continuity on quality of care for patients with tonsillectomies,²¹ hospital mortality in patients transferred from nursing homes,²² utilization and costs of ambulatory care,²³ and patient satisfaction during prenatal visits and pregnancy complications.²⁴

In addition, there appears to be variability in the extent to which patients value continuity. Although patients often report more satisfaction with their care from a regular physician, recent studies have suggested that many might not be willing to wait to see their regular physician for acute illness.^25,26 The literature leaves unanswered the important questions of when continuity matters, to whom, and under what circumstances. Answering these questions will help to determine whether this theoretically fundamental tenet of primary care is relevant to the modern practice of medicine and to the design of health care systems.

In this study, we examined patients’ ratings of the importance of continuity of care with their family physician and their ratings of the adequacy of their visit according to physician seen and nature of the visit. We hypothesized that continuity of physician is more important to older, sicker, female patients and those with an established relationship with a physician. Further, we hypothesized that patients who place a higher value on continuity will rate the visit as less adequate when not seeing their regular physician and when the visit involves more complex problems.

METHODS

This study analyzed data from the Direct Observation of Primary Care Study, a multimethod cross-sectional study designed to describe the content and context of outpatient visits to family physicians.^27,28

RESULTS

The 138 participating physicians were demographically similar to national samples of family physicians, but contained a higher percentage of female and residency-trained physicians.^27,28

A total of 4,454 of 4,994 patients (89%) visiting the 138 physicians on observation days agreed to participate in the study. Of these, 3,283 (74%) returned exit surveys. Although the patient sample was demographically similar to patients seeing family and general practitioners in the National Ambulatory Medical Care Survey, participants were more likely than nonparticipants to be older, female, white, and married and to have a greater number of chronic illnesses, a longer relationship with the practice, and Medicare or fee-for-service insurance.^27,28 Of the 3,283 patients returning the exit survey, 2,763 (84%) provided complete information required for this analysis. These patients represent 61% of the eligible study population and constitute the analytic sample.

Association of patient characteristics with the degree to which patients valued continuity is shown in Table 1⇓. Patient age, sex, education, insurance, length of relationship with the physician, number of chronic conditions and medications, number of visits to the practice, and self-reported health status are associated with the value patients place on continuity. Parents of patients aged 0 to 6 years, and patients aged 40 to 64 years and 65 years and older reported greater value of continuity of care. The greatest PVC was reported by patients with Medicare and Medicaid, and by a small group with undetermined insurance status. All measures of poorer health status, with the exception of dysfunction associated with emotional problems, were strongly associated with PVC.

Patients reported seeing their regular physician on 2,459 (89%) of index visits. Those who value continuity were more likely to see their regular physician on the index visit and to report a longer duration of relationship with their physician. Patients valuing continuity rated the physician more highly on the key primary care components of accumulated knowledge of the patients, coordination of care, and interpersonal communication. Because most patients who valued continuity in our sample were able to see their regular physician, we lacked sufficient power to evaluate the independent effect of visit complexity.

Analyses shown in Table 2⇓ examine the effect of seeing the regular physician, PVC, and their interaction on several measures of patient assessment of the adequacy of their visit. The data show a consistent dose-response relationship between the degree to which patients value continuity and their assessments of the adequacy of and their satisfaction with the visit. By convention, if the association with the interaction term is statistically significant, the interaction should be interpreted, but not the individual main effects.³⁶ Although the study had adequate statistical power to detect relatively small differences, the main effects shown in Table 2⇓ all have moderate to large effect sizes (0.34–0.73) and the 4 interaction terms have large effect sizes (0.99–1.76).

To test the association of PVC with patient satisfaction with the physician, while controlling for confounding patient and visit characteristics, a series of regression models were evaluated. As shown in Table 3⇓, model 1 examines the effect of patient characteristics alone. Model 2 adds visit characteristics, resulting in an increase in the strength of the model as reflected in a near doubling of the percentage of variance explained (R² value ). Model 3 adds the main effects and the interaction term for seeing the regular physician and value of continuity. These analyses show that patient age, health status, and length of the index visit, all independently influence patient satisfaction with the physician. The significant interaction between PVC and visit to regular physician suggests that the effect of seeing a regular physician varies depending on the degree to which patients value continuity of care. Adding the interaction between the degree to which patients value and achieve continuity of care in model 3 more than triples the percentage of variance accounted for in patient satisfaction with the physician.

DISCUSSION

Continuity of physician care does not appear to be universally important to patients, but it is particularly important for certain patients during certain types of visits. Patients who value continuity, but do not see their own physician, report lower ratings for a variety of different dimensions of adequacy of care they receive on a given visit. Patients who value continuity tend to be female, at either end of the age spectrum, less educated, have Medicare or Medicaid coverage, have more health problems, require more medication, and report lower health status. Our study sample lacked sufficient statistical power to detect an association with complexity of visit. Nonetheless, we observed significant associations with older age and poorer reported health that suggest the potential importance of visit complexity and should encourage further study.

This study shows that some of the ambiguity in the literature could result from studies that do not distinguish among the types of patients and circumstances in which continuity might be particularly important. Consider 2 patients arranging a visit for an upper respiratory tract infection. One patient, a 35-year-old man specifically seeking an antibiotic might value a same-day appointment more than a visit with a regular physician. On the other hand, an elderly woman with marginal health insurance and substantial chronic obstructive pulmonary disease, who is concerned about the importance of her symptoms and who has already established a relationship with a primary care physician, might judge her care to be of higher quality if seen by a regular physician whom she trusts.

An important strength of this study is its ability to relate patient’s report of the value they place on continuity to their report of specific aspects of the perceived adequacy of primary care and satisfaction for a given visit, either with their regular or with another physician. Nonetheless, we acknowledge several limitations. Patients might have selected these family practices in part because of the opportunities for continuity of physician. For example, continuity of physician has been reported to be lower in health maintenance organization (HMO) clinics,³⁷ whereas only two practices in this study were closed-panel HMOs. In addition, the selection factors involved in the return of questionnaires might have biased the sample toward patients with greater experience of continuity. These factors, however, are likely to have reduced the variability among the independent variables and would tend to bias findings toward the null. Only 10% of our patient sample was not white, and there appeared to be no differences by race in value placed on continuity. Although other work has shown representativeness of physicians, patients,^38,39 and physicians’ practice patterns⁴⁰ from practice-based research networks, the possibility that the physicians or patients participating in this study were atypical in important ways cannot be completely eliminated. Finally, we assessed only a limited array of possible outcomes of continuity of care.

In the practice settings examined in this report, more than 90% of patients saw their regular physician. In these family practices it appears that patients were able to achieve continuity for many of those visits in which it is hypothesized to be important. Other study designs might examine effects of continuity on patient populations with more variation in the value placed on continuity and their ability to achieve it. It is also a concern to speculate about the extent to which continuity can be valued in the increasing number of settings in which it has not been experienced – it is hard to appreciate something that one has not experienced. The current organizational and financial restructuring of the health care system creates strong pressures against continuity, with employers changing plans and plans changing providers.^41,42 Forced disruption in continuity of care is common, particularly for those with a managed care type of insurance, and results in lower quality of primary care.⁴³ Forced disruption in continuity is more difficult for patients who are older, have more chronic illness, are in the middle of a workup for a new problem, or who have a longstanding relationship with the physician.⁴⁴ Only about 50% of patients in previous studies report continuity of physician,^37,45,46 and these rates could be lower for elderly minority patients^46,47 and those without health insurance.⁴⁸

Because continuity appears to have greater importance to vulnerable populations,^46,47,49.,⁵⁰ who in turn might experience greater difficulty achieving continuity, additional research to understand the complex effects of continuity takes on urgent policy importance. Until further evidence is available, the findings of this study should encourage design of practice systems that enhance provision of continuous, relationship-centered care, particularly for those vulnerable populations who most value and appear to benefit from it. These patients are more likely to be female, very young or old, less educated, insured through Medicare or Medicaid, and sicker by multiple measures. Because patients who have established a continuity relationship with a physician tend to value it and to report greater satisfaction and quality of care when they achieve continuity with this physician, systems to expand the experience of continuous care are needed to extend these benefits.