Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure

Mingliang Dai; Denise Pavletic; Jill C. Shuemaker; Craig A. Solid; Robert L. Phillips

doi:10.1370/afm.2880

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RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
Jace A Floyd, John W Cha, Kara E Brabb and Lorraine S Wallace

Published on: 28 February 2023
RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
Jace A Floyd, John W Cha, Kara E Brabb and Lorraine S Wallace

Published on: 28 February 2023
Measuring continuity in working family practices
Denis J Pereira Gray, Kate Sidaway-Lee, Philippa Whitaker and Philip H Evans

Published on: 20 December 2022

Published on: (28 February 2023)
Page navigation anchor for RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
Jace A Floyd, Undergraduate, The Ohio State University
Other Contributors:
John W Cha, Undergraduate

Kara E Brabb, Undergraduate

Lorraine S Wallace, Associate Professor-College of Medicine
As three students interested in healthcare delivery, we were interested in the development and validation of your physician-level continuity of care (CoC) measure. We agree that CoC is a central primary care tenet with clear benefits such as reduced hospitalization rates, lower mortality, and reduced costs for patients with chronic conditions or residents of long-term care facilities. As such, it is important to have an accurate measurement for healthcare systems to gauge primary care physician-level CoC.
After reading your paper, two main points came to mind. Firstly, we were curious about your perspective on the evolving definition of CoC. Particularly, what elements of CoC may not be included in your measure? You mentioned the inability to account for CoC in team-based healthcare systems. However, we are curious about other variables that could fine-tune and expand upon the CoC s measure in the future. For example, how will physician-level CoC scoring differ based on geographical location and scope of practice? Another question we had was whether the CoC scoring methodology places the onus of CoC on the physician rather than the health system overall (including patients, nurses, nurse practitioners, etc.)? With the American Board of Family Medicines’ development of an incentive system for improving CoC scores, how might physician burnout/burden be affected and addressed?
In the limitations section, you mention the potential expansion of your sample. How migh...
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As three students interested in healthcare delivery, we were interested in the development and validation of your physician-level continuity of care (CoC) measure. We agree that CoC is a central primary care tenet with clear benefits such as reduced hospitalization rates, lower mortality, and reduced costs for patients with chronic conditions or residents of long-term care facilities. As such, it is important to have an accurate measurement for healthcare systems to gauge primary care physician-level CoC.
After reading your paper, two main points came to mind. Firstly, we were curious about your perspective on the evolving definition of CoC. Particularly, what elements of CoC may not be included in your measure? You mentioned the inability to account for CoC in team-based healthcare systems. However, we are curious about other variables that could fine-tune and expand upon the CoC s measure in the future. For example, how will physician-level CoC scoring differ based on geographical location and scope of practice? Another question we had was whether the CoC scoring methodology places the onus of CoC on the physician rather than the health system overall (including patients, nurses, nurse practitioners, etc.)? With the American Board of Family Medicines’ development of an incentive system for improving CoC scores, how might physician burnout/burden be affected and addressed?
In the limitations section, you mention the potential expansion of your sample. How might your CoC scoring method be limited by the absence of Medicaid or uninsured patients and/or patients with fewer than two visits? We are curious as to whether you are interested in pursuing a subsequent study with a smaller sample size that explores specific areas of healthcare in greater detail that encapsulates a larger range of diverse patients.
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Competing Interests: None declared.
Published on: (28 February 2023)
Page navigation anchor for RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
RE: Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure
Jace A Floyd, Undergraduate, The Ohio State University
Other Contributors:
John W Cha, Undergraduate

Kara E Brabb, Undergraduate

Lorraine S Wallace, Associate Professor-College of Medicine
As three students interested in healthcare delivery, we were interested in the development and validation of your physician-level continuity of care (CoC) measure. We agree that CoC is a central primary care tenet with clear benefits such as reduced hospitalization rates, lower mortality, and reduced costs for patients with chronic conditions or residents of long-term care facilities. As such, it is important to have an accurate measurement for healthcare systems to gauge primary care physician-level CoC.
After reading your paper, two main points came to mind. Firstly, we were curious about your perspective on the evolving definition of CoC. Particularly, what elements of CoC may not be included in your measure? You mentioned the inability to account for CoC in team-based healthcare systems. However, we are curious about other variables that could fine-tune and expand upon the CoC s measure in the future. For example, how will physician-level CoC scoring differ based on geographical location and scope of practice? Another question we had was whether the CoC scoring methodology places the onus of CoC on the physician rather than the health system overall (including patients, nurses, nurse practitioners, etc.)? With the American Board of Family Medicines’ development of an incentive system for improving CoC scores, how might physician burnout/burden be affected and addressed?
In the limitations section, you mention the potential expansion of your sample. How migh...
Show More

As three students interested in healthcare delivery, we were interested in the development and validation of your physician-level continuity of care (CoC) measure. We agree that CoC is a central primary care tenet with clear benefits such as reduced hospitalization rates, lower mortality, and reduced costs for patients with chronic conditions or residents of long-term care facilities. As such, it is important to have an accurate measurement for healthcare systems to gauge primary care physician-level CoC.
After reading your paper, two main points came to mind. Firstly, we were curious about your perspective on the evolving definition of CoC. Particularly, what elements of CoC may not be included in your measure? You mentioned the inability to account for CoC in team-based healthcare systems. However, we are curious about other variables that could fine-tune and expand upon the CoC s measure in the future. For example, how will physician-level CoC scoring differ based on geographical location and scope of practice? Another question we had was whether the CoC scoring methodology places the onus of CoC on the physician rather than the health system overall (including patients, nurses, nurse practitioners, etc.)? With the American Board of Family Medicines’ development of an incentive system for improving CoC scores, how might physician burnout/burden be affected and addressed?
In the limitations section, you mention the potential expansion of your sample. How might your CoC scoring method be limited by the absence of Medicaid or uninsured patients and/or patients with fewer than two visits? We are curious as to whether you are interested in pursuing a subsequent study with a smaller sample size that explores specific areas of healthcare in greater detail that encapsulates a larger range of diverse patients.
Show Less

Competing Interests: None declared.
Published on: (20 December 2022)
Page navigation anchor for Measuring continuity in working family practices
Measuring continuity in working family practices
Denis J Pereira Gray, Consultant, St Leonard's Research Practice
Other Contributors:
Kate Sidaway-Lee, Research Fellow

Philippa Whitaker, Medical Student

Philip H Evans, Professor
Sir/Madam,

We welcome the article by Dai et al. (2022) and strongly support their main thrust that the current need is to find ways of measuring continuity of care in service family/general practices as well as continuing to undertake research studies on continuity. We agree that new measurement methods need to be patient-centred.

There are some limitations to their chosen method however. The authors properly declare that their modification of the Bice-Boxerman/COC Index requires a patient to consult twice or more during the time period of study. Including patients with only two consultations introduces an upwards bias since only two consultations are required for a score of 1. In UK general practice, the majority of patients consult only once or twice per year, so patients with two consultations will make up much of the sample. In addition, excluding all patients with one consultation per year loses many with valuable longer-term continuity.

The physician level metric has even more problems. A doctor’s score includes patients they have seen only once. These patients may have high continuity with other physicians. Doctor’s scores are therefore affected by continuity that they have no influence or control over. This reduces the proposed measure’s value as a quality metric in practice for physician-level continuity.

Their database is impressive but because it is linked to Medicare it represents a bias towards older patients who use Medicare in t...
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Sir/Madam,

We welcome the article by Dai et al. (2022) and strongly support their main thrust that the current need is to find ways of measuring continuity of care in service family/general practices as well as continuing to undertake research studies on continuity. We agree that new measurement methods need to be patient-centred.

There are some limitations to their chosen method however. The authors properly declare that their modification of the Bice-Boxerman/COC Index requires a patient to consult twice or more during the time period of study. Including patients with only two consultations introduces an upwards bias since only two consultations are required for a score of 1. In UK general practice, the majority of patients consult only once or twice per year, so patients with two consultations will make up much of the sample. In addition, excluding all patients with one consultation per year loses many with valuable longer-term continuity.

The physician level metric has even more problems. A doctor’s score includes patients they have seen only once. These patients may have high continuity with other physicians. Doctor’s scores are therefore affected by continuity that they have no influence or control over. This reduces the proposed measure’s value as a quality metric in practice for physician-level continuity.

Their database is impressive but because it is linked to Medicare it represents a bias towards older patients who use Medicare in the USA. Since older patients value and seek continuity their continuity results are likely to be skewed upwards compared with continuity measurements on the whole population served.

It is logical to measure continuity with a more inclusive measuring system that makes use of all consultations by all patients, and all ages, with all doctors in the practice. Every patient counts. Such a method (the SLICC, the St Leonard’s Index of Continuity of Care) has been reported (Sidaway-Lee et al., 2019) and has been recommended for national use in England by a Select Committee of the UK Parliament (2022). We suggest that it represents a simple, practical, alternative to the new need to measure continuity in working family/general practices.

References
Dai M, Pavletic D, Shuemaker JC, Solid CA, Phillips RL Jr. (2022) Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure. Ann Fam Med.20(6):535-540.

Sidaway-Lee, K., Pereira Gray, D. and Evans, P. (2019) A method for measuring continuity of care in day-to-day general practice: a quantitative analysis of appointment data. British Journal of General Practice; 69(682):e356-e362

Select Committee on Health and Social Care (2022) Report on the Future of Primary Care. London: https://committees.parliament.uk/work/1624/the-future-of-general-practic... of Commons.
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Competing Interests: All authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. Denis Pereira Gray, Kate Sidaway-Lee and Philip Evans declare that they work at the St Leonard’s Practice where the SLICC was first invented and named.