Validation of 2 New Measures of Continuity of Care Based on Year-to-Year Follow-up With Known Providers of Health Care

Pierre Tousignant; Mamadou Diop; Michel Fournier; Yves Roy; Jeannie Haggerty; William Hogg; Marie-Dominique Beaulieu

doi:10.1370/afm.1692

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Figure 1
Definition of known provider continuity (KPC).

Note: Types of continuity in gray are not measured in this article, ie, among the physicians also seen in year X-1, as we did not distinguish between family physicians and specialists.

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Table 1

Operationalization of Measures in the Analysis

Variable	Minimum/Maximum	Groupings/Coding	Notes
Variables from validated patient questionnaires
Relational continuity	2.17/10	Range: 0–10	Cut-points selected to populate each category adequately and be the same for all survey measures to simplify interpretation
Interpersonal communication	2.67/10	Low: 0–6.9
Coordination within the clinic	1.71/10	Medium: 7–8.9
Coordination with specialists	2.5/10	High: >8.9
Overall coordination	3.9/10
Combined continuity z score	−4.05/1.55	Low: z < −0.5
		Medium: z = −0.5 to 0.49
		High: z= 0.5+
Known provider continuity (KPC) measures
Personal provider (PP) continuity	0/100	Low: 0–29	Adapted from Menec et al,³¹ McCusker et al,³² and Ionescu-Ittu et al³³ to populate adequately each category across all continuity measures
Multiple provider (MP) continuity	0/100	Medium: 30–74
		High: >74
Control variables
Morbidity: Resource Utilization Band		Low: 1
		High: 5
Age, y		20–59
		60–74
		≥75
Education level		Primary, secondary
		Postsecondary
		University graduate
		Missing

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Table 2

Characteristics of Patients in the Study

Variables	All Patients N = 765	Multiple Provider Continuity Level
Variables	All Patients N = 765	High n = 358 (>74%)	Moderate n = 334 (30%–74%)	Low n = 68 (<30%)
Sociodemographic characteristics
Women, %	48	51.7	48.8	32.4^a
Completed university, %	14.2	13.8	15.3	11.8^b
Mean age, y	66.7	67.1	67.1	62.1^a
Mean ambulatory visits, No.	10.7	9.0	12.9	10.9^c
With high morbidity (RUB 4 or 5), %	40	34.6	45.2	42.7^a
SF-12 PCS, mean score (range 0–100)	39.6	40.9	39.4	39.1^b
Known provider continuity (KPC)
With high multiple provider (MP) continuity, %	47.2	100	…	…
With high personal provider (PP) continuity, %	19.6	41.6	0	0^a
Continuity-related variables from questionnaires
Relational continuity
Mean score^d	8.5	8.9	8.4	7.5
With high continuity, %	41.7	43.1	40.9	38.7^b
Interpersonal communication
Mean score^d	8.7	9.0	8.9	8.0
With high communication, %	46.5	47.4	46.6	41.3^b
Coordination within the clinic
Mean score^d,^e	8.1	8.3	8.1	8.0
With high coordination, %^e	24.6	27.5	23.1	15.8^b
Coordination with specialists
Mean score^d,^f	7.9	8.4	8.1	6.9
With high coordination, %^f	39.4	41.9	36.8	40.0^b
Overall coordination
Mean score^d	9.0	9.3	9.0	8.4
With high coordination, %	58.4	43.9	36.5	31.7^a
High combined continuity score, %	34.0	37.3	31.4	30.0^a
With family physician, %	99.1	99.1	99.7	95.5^a

ANOVA = analysis of variance; RUB = Resource Utilization Band; SF-12 PCS = Short Form-12 physical component summary score.
↵a Tested and found significant (P ≤.05) by ANOVA or χ².
↵b Tested and not found significant (P >.05) by ANOVA or χ².
↵c Tested and not found significant by negative binomial regression.
↵d Means rescaled from 0–10, with 0 indicating low and 10 indicating high continuity/communitation/coordination; not tested statistically because distribution with ceiling effect.
↵e These results apply for 232 patients who had other physicians or nurses who worked in their physician’s office and played an important role in their care (30% of patients in ambulatory clinics); 109 of these patients had high, 104 moderate, and 19 low KPC-MP.
↵f These results apply for 447 patients who were referred to a specialist or education center for 1 of the 2 problems targeted by this study (diabetes, cardiovascular disease) (58.4% of patients in ambulatory clinics); 198 of these patients had high, 209 moderate and 40 low KPC-MP.

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Table 3

Relationships Between Patient Survey Measurements and Multiple Provider Continuity

Patient-Reported Measurements	Multiple Provider (MP) Continuity OR (95% CI)
Relational continuity (n = 727)
High	1.22 (0.87–1.69)
Moderate	1.26 (0.91–1.75)
Interpersonal communication (n = 735)
High	1.09 (0.74–1.62)
Moderate	1.06 (0.72–1.56)
Coordination within the clinic (n = 221)^a
High	1.12 (0.59–2.15)
Moderate	0.86 (0.50–1.49)
Coordination with specialists (n = 443)
High	1.07 (0.75–1.54)
Moderate	0.89 (0.61–1.31)
Overall coordination (n = 737)^b
High	2.02 (1.33–3.07)^c
Moderate	1.61 (1.06–2.46)^d
Combined continuity score (n = 704)
High	1.52 (1.11–2.09)^c
Moderate	1.48 (1.10–2.00)^c

OR = odds ratio.
↵a Using education as the control variable.
↵b Using sex as the control variable.
↵c P ≤.01.
↵d P ≤.05.

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Table 4

Relationships Between Survey Measurements and Personal Provider Continuity

Survey Measurements	Personal Provider (PP) Continuity OR (95% CI)
Relational continuity (n = 727)
High	1.14 (0.84–1.55)
Moderate	1.11 (0.81–1.50)
Interpersonal communication (n = 735)
High	1.00 (0.70–1.44)
Moderate	0.98 (0.68–1.40)
Coordination within the clinic (n = 221)^a
High	1.22 (0.69–2.18)
Moderate	1.05 (0.63–1.74)
Coordination with specialists (n = 443)
High	1.32 (0.93–1.88)
Moderate	1.09 (0.74–1.60)
Overall coordination (n = 738)
High	1.25 (0.84–1.86)
Moderate	1.10 (0.74–1.65)
Combined continuity score (n = 704)
High	1.30 (0.97–1.74)
Moderate	1.19 (0.90–1.57)

OR = odds ratio.
↵a Using education as the model control variable.

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In Brief

Validation of 2 New Measures of Continuity of Care Based on Year-to-Year Follow-up With Known Providers of Health Care

Pierre Tousignant , and colleagues

Background This study assesses two new measures of continuity of care, both versions of known provider continuity, which are easily measured in administrative databases. The measures capture the concentration of care from year to year with multiple physicians (KPC-MP) or a particular physician (KPC-PP), making them a potentially valuable and low cost-way to follow the effects of changes favoring group practice on continuity of care.

What This Study Found Analyzing survey and medical records data from 765 patients with diabetes or cardiovascular disease attending 28 primary care clinics in Quebec, Canada, researchers found KPC-MP was significantly related with a validated measure of overall care coordination and a combined continuity score summarizing five different validated survey measures. This is the first time a continuity measure that can be obtained from administrative databases has been found to be associated with a patient-reported measure of care coordination. Conversely, KPC-PP (year-to-year continuity with the physician seen most often) did not appear strongly related to patient-perceived measures of continuity.

Implications

At a time of major primary care reorganization involving multiple health care professionals, KPC measures based on administrative databases could become a valuable way to do research on continuity.