Article Figures & Data
Figures
- Figure 1
Flowchart of study participants.
NHI = National Health Insurance; CV = cardiovascular.
Tables
Characteristics Value Age, years Mean (SD) 54.2 (12.5) Median (range) 54 (20–100) Sex, No. (%) Male 24,060 (50.7) Female 23,373 (49.3) Premium in Korean wona Mean (SD) 45,567 (37,077) Income level, No. (%) 1st quartile; low 12,062 (25.4) 2nd quartile 11,692 (24.6) 3rd quartile 12,360 (26.1) 4th quartile; high 11,319 (23.9) Place of residence, No. (%) Metropolitan area 24,742 (52.8) City area 16,830 (35.9) Rural area 5,327 (11.4) Charlson comorbidity score Mean (SD) 0.49 (0.81) Median (range) 0 (0–11) Number of visits, mean (SD) During the first 2 years 14.4 (7.9) During the second 2 years 14.2 (10.9) During the third 2 years 15.7 (14.7) Continuity of care indices, median (interquartile range) Most frequent provider continuity (MFPC) 0.88 (0.67–1.00) Modified, modified continuity index (MMCI) 0.93 (0.84–1.00) Continuity of care index (COC) 0.77 (0.49–1.00) -
↵a $1 (US) = ₩1,100 (Korean won), as of 2012.
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- Table 2
Risk of Death and Cardiovascular Endpoints by Level of Continuity of Care (N = 47,433)
Most Frequent Provider Continuity Modified, Modified Continuity Index Continuity of Care Index Endpoint Above Median Below Median Above Median Below Median Above Median Below Median All cause mortality No. of deaths (deaths per 1,000 py) 1,340 (11.5) 1,787 (15.4) 1,296 (11.3) 1,831 (15.5) 1,345 (11.6) 1,782 (15.4) Crude HR (95% CI) 1.00 (Ref) 1.33 (1.24–1.43) 1.00 (Ref) 1.37 (1.28–1.47) 1.00 (Ref) 1.33 (1.24–1.43) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.13 (1.05–1.21) 1.00 (Ref) 1.13 (1.05–1.21) 1.00 (Ref) 1.12 (1.04–1.21) Cardiovascular mortality No. of deaths (deaths per 1,000 py) 321 (2.8) 494 (4.3) 299 (2.6) 516 (4.4) 321 (2.8) 494 (4.3) Crude HR (95% CI) 1.00 (Ref) 1.54 (1.34–1.77) 1.00 (Ref) 1.67 (1.45–1.93) 1.00 (Ref) 1.54 (1.34–1.77) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.30 (1.12–1.50) 1.00 (Ref) 1.40 (1.21–1.62) 1.00 (Ref) 1.30 (1.13–1.50) Noncardiovascular mortality No. of deaths (deaths per 1,000 py) 1,019 (8.8) 1,293 (11.1) 997 (8.7) 1,315 (11.2) 1,024 (8.8) 1,288 (11.1) Crude HR (95% CI) 1.00 (Ref) 1.27 (1.17–1.38) 1.00 (Ref) 1.28 (1.18–1.39) 1.00 (Ref) 1.26 (1.16–1.37) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.07 (0.99–1.17) 1.00 (Ref) 1.05 (0.96–1.14) 1.00 (Ref) 1.07 (0.98–1.16) Myocardial infarctiona No. of incident events (incident events per 1,000 py) 144 (1.2) 232 (2.0) 147 (1.3) 229 (1.9) 144 (1.2) 232 (2.0) Crude HR (95% CI) 1.00 (Ref) 1.61 (1.31–1.98) 1.00 (Ref) 1.51 (1.23–1.86) 1.00 (Ref) 1.62 (1.31–1.99) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.57 (1.27–1.94) 1.00 (Ref) 1.51 (1.22–1.87) 1.00 (Ref) 1.57 (1.28–1.95) Cerebral infarctionb No. of incident events (incident events per 1,000 py) 427 (3.8) 668 (6.0) 422 (3.8) 673 (6.0) 427 (3.8) 668 (6.0) Crude HR (95% CI) 1.00 (Ref) 1.59 (1.41–1.80) 1.00 (Ref) 1.58 (1.40–1.78) 1.00 (Ref) 1.60 (1.41–1.80) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.43 (1.27–1.62) 1.00 (Ref) 1.43 (1.26–1.63) 1.00 (Ref) 1.44 (1.27–1.63) Cerebral hemorrhageb No. of incident events (incident events per 1,000 py) 141 (1.2) 184 (1.6) 136 (1.2) 189 (1.6) 141 (1.2) 184 (1.6) Crude HR (95% CI) 1.00 (Ref) 1.30 (1.05–1.62) 1.00 (Ref) 1.35 (1.08–1.68) 1.00 (Ref) 1.31 (1.05–1.63) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.19 (0.95–1.49) 1.00 (Ref) 1.20 (0.96–1.52) 1.00 (Ref) 1.19 (0.95–1.49) -
CI = confidence interval; HR = hazard ratio; py = person-year; Ref = reference value.
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↵a Multivariable adjustments included age, sex, income, Charlson comorbidity index, number of visits during the first 2 years, and residential area (for detail, see text).
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↵b Excluding those who developed the indicated outcome during the first 2 years after diagnosis.
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- Table 3
Risk of Death and Cardiovascular Outcomes by Level of Continuity of Care in Time-Dependent Analyses (N = 47,433)
Most Frequent Provider Continuity Modified, Modified Continuity Index Continuity of Care Index Outcome Above Median Below Median Above Median Below Median Above Median Below Median All cause death Crude HR (95% CI) 1.00 (Ref) 1.48 (1.38–1.59) 1.00 (Ref) 1.49 (1.39–1.61) 1.00 (Ref) 1.48 (1.38–1.59) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.32 (1.23–1.42) 1.00 (Ref) 1.30 (1.21–1.41) 1.00 (Ref) 1.32 (1.23–1.42) Cardiovascular mortality Crude HR (95% CI) 1.00 (Ref) 1.54 (1.34–1.78) 1.00 (Ref) 1.68 (1.46–1.94) 1.00 (Ref) 1.55 (1.34–1.78) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.30 (1.13–1.50) 1.00 (Ref) 1.40 (1.21–1.63) 1.00 (Ref) 1.31 (1.13–1.51) Non-cardiovascular mortality Crude HR (95% CI) 1.00 (Ref) 1.27 (1.17–1.38) 1.00 (Ref) 1.29 (1.19–1.40) 1.00 (Ref) 1.27 (1.17–1.37) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.08 (0.99–1.17) 1.00 (Ref) 1.05 (0.96–1.14) 1.00 (Ref) 1.07 (0.99–1.16) Myocardial infarctionb Crude HR (95% CI) 1.00 (Ref) 1.56 (1.27–1.92) 1.00 (Ref) 1.45 (1.17–1.78) 1.00 (Ref) 1.54 (1.25–1.89) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.61 (1.30–1.99) 1.00 (Ref) 1.50 (1.22–1.87) 1.00 (Ref) 1.59 (1.28–1.96) Cerebral infarctionb Crude HR (95% CI) 1.00 (Ref) 1.52 (1.34–1.71) 1.00 (Ref) 1.51 (1.34–1.71) 1.00 (Ref) 1.54 (1.36–1.74) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 1.39 (1.23–1.58) 1.00 (Ref) 1.40 (1.24–1.60) 1.00 (Ref) 1.42 (1.25–1.61) Cerebral hemorrhageb Crude HR (95% CI) 1.00 (Ref) 0.95 (0.76–1.18) 1.00 (Ref) 1.04 (0.83–1.29) 1.00 (Ref) 0.98 (0.79–1.22) Multivariable-adjusted HRa (95% CI) 1.00 (Ref) 0.87 (0.69–1.08) 1.00 (Ref) 0.93 (0.74–1.17) 1.00 (Ref) 0.89 (0.71–1.12) -
HR= hazard ratio; CI = confidence interval; Ref = reference standard.
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↵a Multivariable adjustments included age, sex, income, Charlson comorbidity index, number of visits during the first 2 years, and residential area (for detail, see text).
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↵b Excluding those who developed the indicated outcome during the first 2 years after diagnosis.
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Most Frequent Provider Continuity Modifed, Modifed Continuity Index Continuity of Care Index Characteristic Above Median Below Median Above Median Below Median Above Median Below Median Health care utilization, adjusted meana (SE) Total inpatient days (2005–2010) 7.4 (0.4) 11.4 (0.4) 7.4 (0.4) 11.4 (0.4) 7.4 (0.4) 11.4 (0.4) Difference (95% CI) 4.0 (2.8–5.2) 4.0 (2.8–5.2) 4.0 (2.9–5.2) Total outpatient days (2005–2010) 2 2.5 (0.2) 25.4 (0.2) 22.1 (0. 2) 25.8 (0.2) 22.5 (0.2) 25.4 (0.2) Difference (95% CI) 2.9 (2.3–3.4) 3.7 (3.1–4.2) 2.9 (2.3–3.5) Health care costs, 2005–2010, $ (US) Total inpatient cost, adjusted meana (SE) 853.7 (31.7) 1294.5 (31.6) 844.7 (32.3) 1297.1 (31.7) 851.5 (31.7) 1297.3 (31.6) Difference (95% CI) 440.9 (352.6–529.2) 452.4 (362.3–542.5) 4 45.7 (357.5 – 53 4.0) Total outpatient cost, adjusted meana (SE) 457.5 (17.7) 574.6 (17.6) 446.5(18.0) 5 83. 6 (17.7) 456.1 (17.7) 576 .1 (17.6) Difference (95% CI) 117. 0 (67.7–16 6.3) 136.7 (86.5–187.0) 119.7 (70.5–169.0) Total cost, adjusted meana (SE) 1311.1 (38.0) 1869.2 (37.9) 1291.3 (38.6) 1880.6 (38.0) 13 07.7 (37.9) 18 7 3.4 (37.9) Difference (95% CI) 557.9 (452.3–663.5) 589.1 (481.4–696.9) 565.5 (459.8–671.2) -
CI = confidence interval; SE = standard error. $1 (US) = ₩1,100 (Korean won), as of 2012.
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Note: All P values comparing above to below median utilization and cost parameters <0.001.
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↵a Multivariable adjustments included age, sex, income level (quartile), Charlson comorbidity index, number of visits during the first 2 years, and residential area (for detail, see text).
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Supplemental Appendixes 1-8
Supplemental Appendixes 1-8
Files in this Data Supplement:
- Supplemental data: Appendixes 1-8 - PDF file, 12 pages + cover
In Brief
Impact of Continuity of Care on Mortality and Health Care Costs: A Nationwide Cohort Study in Korea
Dong Wook Shin , and colleagues
Background Continuity of care, defined as an ongoing partnership between patient and clinician, is considered a core element of high-quality primary care, but its impact on mortality and health care costs is unclear. This study aims to determine the impact of continuity of care on mortality and health outcomes and costs in patients with newly diagnosed cardiovascular risk factors.
What This Study Found The study found that continuity of care is associated with reduced mortality, morbidity, and health care expenses and may provide added value in the management of chronic conditions. In particular, the study examined a random sample of more than 1,000,000 Korean National Health Insurance enrollees, 47,433 of whom had received new diagnoses of hypertension, diabetes, hypercholesterolemia or other complications. Evaluating the association of three standard indices of continuity of care with patients' overall mortality, cardiovascular mortality, incident cardiovascular events and health care costs over five years, lower indices of continuity of care were associated with higher all-cause and cardiovascular mortality, cardiovascular events and health care costs. Lower continuity of care was associated with increased inpatient and outpatient days and costs.
Implications
- While the findings cannot be generalized to other conditions, the results suggest that continuity of care is a robust predictor of outcomes in patients for conditions with available preventive interventions.
- The authors suggest that, with increasing fragmentation of health care systems and importance of cost containment, health care systems should be designed to support longer-term trusting relationships between patients and physicians, and health policies should encourage patients to concentrate their care with one physician.
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