Article Figures & Data
Tables
- Table 1
Characteristics of the Study Population, and Comparison of Respondents With Nonrespondents at T2
Label Respondents (n=256) Nonrespondentsa (n=44) P Valueb Sociodemographic characteristics Mean age (SD), y 52.6 (15.6) 46.4 (15.5) .02 (t=−2.44) Female, % (SD) 71.1 (182) 75.0 (33) Education: high school completed or higher, % (n) 80.3 (204) 79.6 (35) Occupation, % (n) Work or studies 44.9 (115) 54.65 (24) .002 (χ2=17.2 (4 df) Job search 3.9 (10) 0 .003 (Fisher exact test) Not working for health reasons 8.2 (21) 25.0 (11) At home or maternity leave 9.4 (24) 4.55 (2) Retired 33.6 (86) 15.9 (7) Health characteristics At least 1 chronic disease, % (n) 78.3 (198) 84.1 (37) Physical functional status: mean SF-8 score (SD) 45.2 (9.8) 44.5 (10.5) Mental functional status: mean SF-8 score (SD) 44.7 (11.2) 43.0 (12.3) With a responsible health care clinician, % (n) None 7.0 (18) 11.4 (5) Family doctor 90.6 (232) 84.1 (37) Other (eg, nurse, specialist) 2.3 (6) 4.6 (2) Has an identified coordinator 77.3 (198) 65.9 (29) - Table 2
Patient Experience of Continuity of Care: Subscale Description and Item Provenance
Dimension Response Format Item Content Item Inspiration Pertaining to main health care clinician (management, relational) Coordinator role (5 items) Evaluative (hardly at all to totally) Assessment of how well coordinator knows all health care needs, maintains regular contact with the patient, contacts other clinicians, and helps patient getting care from other clinicians (only answered by those with identified coordinator) ACSS-MH10
PACIC25
2 newComprehensive knowledge of patient (4 items) Evaluative (hardly at all to totally) How much doctor takes into account the patients whole medical history, worries about health, responsibilities at home and personal values? (only answered by those with a personal doctor) PCAS13 Confidence and partnership (3 items) Evaluative (hardly at all to totally) Importance given to patient ideas about care, comfort in discussion of sensitive issues, confidence that doctor will look after patient (only answered by those with a personal doctor) PCAT-ae14
2 NewPertaining to several clinicians or team (team relational, management, informational) Confidence in team (2 items) Evaluative (hardly at all to totally) Assessment of how well the patient feels known and can count on members at regular clinic. ACSS-MH10
PCCQ5Role clarity and coordination (3 items each, (2 subscales) Reporting (never to almost always) Frequency of clinicians not working well together or giving the patient conflicting information (asked in reference to clinicians in own clinic and separately, between clinics, and elsewhere) CPCQ26
VANOCSS18
1 NewInformation gap between clinicians (6 items) Reporting (never, sometimes, often Frequency of information transfer problems: clinicians do not know recent history, results of recent tests, or changes made by other clinicians; patient has to provide information, repeat tests, or repeat information VANOCSS18
DCCS7
ACSS-MH10
Cancer27
1 NewPertaining to engaging patient as care partner (support to management, informational) Evidence of a care plan (7 items) Reporting (yes, no, not applicable) Patient recall of negotiation of health care goals and self-management, being explained about the impact of health condition, how and why to do treatment, required monitoring, expected health care trajectory ACSS-MH10
5 NewSelf-management information pro- vided (4 items) Evaluative (hardly at all to a lot) Assessment of information received from doctors and nurses in terms of helpfulness for staying healthy, doing treatments at home, and coping with minor complications (not receiving needed information most negative score) CTM6
Cancer27
HCCQ28
ACES29-
ACES = Ambulatory Care Experiences Survey; ACSS-MH = Alberta Continuity of Services Scale for Mental Health; CPCQ = Client Perceptions of Coordination Questionnaire; CTM = Care Transitions Measure; DCCS = Diabetes Continuity of Care Scale; HCCQ = Health Care Communication Questionnaire; PACIC = Patient Assessment of Care for Chronic Conditions; PCAT-ae = Primary Care Assessment Tool-Adult Edition; PCAS = Primary Care Assessment Survey; PCCQ = Patient Continuity of Care Questionnaire; VANOCSS = Veterans Affairs National Outpatient Customer Satisfaction Survey.
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Subscale (Items, Response Type, Range) Item-Total Correlation Range Cronbach α Factor Loadings Across Response Format Mean SD Median Skew Main clinician Coordinator role (5 items, evaluative,a 1 to 5) 0.65–0.74 0.87 0.60–0.66 3.65 0.88 3.76 −0.28 Comprehensive knowledge of patient (4 items, evaluative, 1 to 5) 0.70–0.78 0.89 0.74–0.79 3.70 0.86 4.0 0.49 Confidence and partnership (3 items, evaluative, 1 to 5) 0.71–0.76 0.86 0.76–0.79 3.9 0.79 4.0 −0.87 Various clinicians Confidence in team (2 items, evaluative, 1 to 5) 0.67 0.80 0.49–0.57 3.04 1.12 6 −0.15 Role clarity and coordination within clinic (3 items, reporting,b 0 to 3) 0.44–0.68 0.66 0.59–0.71c 0.43 0.82 1 1.96 Role clarity and coordination between clinics (3 items, reporting, 0 to 3) 0.60–0.72 0.82 0.76–0.80 0.44 0.91 0 1.95 Information gap between clinicians (6 items, reporting, 0 to 6) 0.50–0.70 0.85 0.58–0.75 1.9 1.9 1 0.65 Patient as partner Care plan (7 items, reporting, 0 to 7) 0.52–0.63 (dropped item 0.38) 0.81 0.41–0.65 (dropped item 0.31) 4.0 2.24 4 −0.26 Self-management information provided (4 items, evaluative, 1 to 5) 0.74–0.81 0.93 0.77–0.91c 3.86 1.16 4 −0.96 -
↵a Evaluative subscales were scored by averaging the value of individual items; range reflects response scale. Coordinator role is a weighted average giving higher weight to more difficult items.
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↵b Items in reporting subscales were first dichotomized to reflect presence of any problem (more than sometimes), then summed to reflect number of problems encountered.
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↵c Estimates across all response formats are not reliable due to small sample size.
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Subscale, Range Coordinator Role Comprehensive Knowledge Confidence and Partnership Confidence in Team Role Clarity in Clinic Role Clarity Between Clinics Information Gap Care Plan Self- Management Main clinician Coordinator role, 1 to 5 1.00 — — — — — — — — Comprehensive knowledge, 1 to 5 0.65 1.00 — — — — — — — Confidence and partnership, 1 to 5 0.60 0.79 1.00 — — — — — — Several clinicians Confidence in team, 1 to 5 0.55 0.46 0.47 1.00 — — — — — Role clarity and coordination within clinic, 0 to 3 −0.32 −0.29 −0.37 −0.34 1.00 — — — — Role clarity and coordination between clinics, 0 to 3 −0.15 −0.15 −0.24 −0.23 0.77 1.00 — — — Information gap between clinicians, 0 to 6 −0.19 −0.19 −0.24 −0.24 0.65 0.49 1.00 — — Patient as partner Care plan, 0 to 6 0.39 0.31 0.35 0.32 −0.08 0.00 −0.06 1.00 — Self-management information provided, 1 to 5 0.37 0.35 0.35 0.39 −0.25 −0.15 −0.17 0.51 1.00 Overall assessment of care Organized care, 1 to 5 (single item) 0.76 0.71 0.52 0.53 −0.55 −0.33 −0.35 0.41 0.46 - Table 5
Odds Ratio of Occurrence of Indicators of Problem Continuity Associated With Each Unit Increase in Continuity Subscale Score
Main Clinician Various Clinicians Various Clinicians Patient-Partner Indicator Yes % Coordinator Role
n=193Comprehensive Knowledge
n=239Partnership and Confidence
n=239Confidence in Team
n=247Role Clarity in Clinica
n=102Role Clarity Between Clinicsb
n=256Information Gapsc
n=256Care Pland
n=256Self- Management
n=216“Have you thought about changing your responsible provider?” 21.5 0.41 0.24 0.16 0.53 2.67 1.73 1.47 0.39 0.43 “Has your emotional or physical health suffered because you care is poorly organized?” 18.4 0.60 — 0.57 0.67 3.22 2.61 2.39 — 0.58 “Do you have to organize your health care yourself too much?” 15.2 0.27 0.50 0.47 0.60 6.71 1.93 1.70 0.60 0.38 “Were there times when it felt like no one was in charge of your care?” 28.0 0.34 0.51 0.42 0.35 6.29 2.13 2.41 0.47 0.31 “Were there times you felt abandoned, left to your own resources?” 29.7 0.53 — 0.61 0.50 2.97 2.00 2.13 0.59 0.44 “Have you used the Emergency Department?” (system reasons only) 9.4 — — — — 18.05 2.08 2.00 — — “Did you experience any medical errors?” (2 items) 10.6 — — — — 6.50 1.92 1.78 — — -
Note: Only statistically significant results shown, controlling for age, number of chronic conditions, educational achievement.
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↵a Categories regrouped to meet model assumption of logit linearity. Reference is 0 problems; effects for 1 and 2 to 3 problems.
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↵b Reference is 0 problems; effects for 1, 2, and 3 problems.
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↵c Reference is 0; effects are for 1, 2 to 3, 4 to 5, and 6 problems.
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↵d Reference is 0 to 2 elements; effects are for 3 to 4 and 5 to 6 elements.
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Additional Files
Supplemental Appendix
Supplemental Appendix. Operational Definition of the Instrument�s Properties
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file, 4 pages, 135 KB
The Article in Brief
Jeannie L. Haggerty , and colleagues
Background Patients often see multiple clinicians, so it is important to be able to assess whether there is continuity or fragmentation in their health care. This study develops and validates a tool to measure management of health problems over time from the patient perspective.
What This Study Found This new measure reliably captures nine dimensions of continuity experienced by patients when they encounter multiple caregivers in different places. The instrument includes a measure of team continuity, recognizing that patients can and do establish relational continuity with more than one clinician. The measure advances previous work by integrating different types of continuity.
Implications
- The ultimate test of this tool, the authors suggest, will be to show whether improving continuity translates into better quality of care and health outcomes.
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