Measuring Continuity of Care in Diabetes Mellitus: An Experience-Based Measure

Martin C. Gulliford; Smriti Naithani; Myfanwy Morgan

doi:10.1370/afm.578

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Table 1.

Item Responses Combined Across Settings For 193 Patients With Complete Data

		Rotated Factor Loadings
Type of Continuity	Item-Score Correlation	Factor 1	Factor 2	Factor 3	Factor 4
LC = longitudinal continuity; FC = flexible continuity; RC = relational continuity; TCB = team and cross-boundary continuity. Note: Shaded areas indicate factor loadings associated with items in each subscale.
Longitudinal continuity
LC1. In the last 12 months, how many times have you spoken with staff at the practice/hospital about your diabetes?	0.377	0.178	−0.023	0.835	0.050
LC2. In the last 12 months, how many times has the practice/hospital sent you an appointment letter for your diabetes?	0.137	−0.067	0.038	0.131	0.202
LC3. In the last 12 months, how many times have you had a blood test taken for your diabetes at the practice/hospital?	0.313	0.095	−0.009	0.746	0.038
LC4. In the last 12 months, how many times have you seen your usual doctor or nurse at the practice/hospital?	0.644	0.647	0.012	0.549	−0.051
Flexible continuity
FC1. If you need advice urgently, how long does it take to get to speak to a doctor or nurse at the practice/hospital?	0.410	0.147	0.073	0.097	0.629
FC2. How would you rate the length of time you’ve had to wait before you spoke to a doctor or nurse at the practice/hospital?	0.572	0.234	0.287	0.026	0.712
FC3. If you have a problem with your diabetes, how well does your practice/hospital respond to it?	0.580	0.321	0.286	−0.016	0.522
FC4. If you need to speak to your usual doctor or nurse about your diabetes, how easy is it for you to speak to your usual doctor or nurse at the practice/hospital?	0.776	0.815	0.184	0.043	0.082
Relational continuity
RC1. How well does your usual doctor or nurse at the practice/hospital explain medical procedures and tests done for your diabetes?	0.833	0.927	0.076	0.073	0.153
RC2. My usual doctor or nurse involves me in decisions about my diabetes	0.817	0.912	0.128	0.064	0.067
RC3. My usual doctor or nurse listens to what I have to say	0.841	0.960	0.106	0.073	0.071
RC4. My usual doctor or nurse knows about my medical history	0.857	0.940	0.167	0.084	0.078
RC5. My usual doctor or nurse makes the best decisions about my diabetes treatment	0.858	0.944	0.150	0.058	0.109
RC6. My usual doctor or nurse is concerned about me	0.857	0.958	0.157	0.077	0.060
Team and cross-boundary continuity
TCB1. In general, how well is your diabetes care coordinated?	0.534	0.200	0.443	0.090	0.366
TCB2. They all give me the same information and advice	0.587	0.266	0.680	−0.058	0.205
TCB3. They all know my medical history	0.536	0.217	0.775	−0.032	0.044
TCB4. They all know about my diabetes treatment	0.579	0.216	0.813	0.019	0.083
TCB5. They share an agreed plan of treatment for my diabetes	0.564	0.199	0.676	0.006	0.233
Eigenvalues		8.02	2.39	1.41	0.88

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Table 2.

Properties of the Total Continuity of Care Scale and the Subdomains of Longitudinal, Flexible, Relational, and Team and Cross-Boundary Continuity

Scale	Number of Items	Average Inter-item Correlation	Cronbach’s α	Potential Range of Scores	Overall Mean of Patient Scores (SD)	Correlation With Total Continuity- of-Care Score
Figures are family practice-specific mean scale scores except where indicated.
Total continuity-of-care score	19	0.343	0.908	0–100	62.1 (16.0)	—
Longitudinal continuity	4	0.318	0.651	0–25	12.1 (5.3)	0.644
Flexible continuity	4	0.392	0.721	0–25	17.8 (4.7)	0.809
Relational continuity	6	0.917	0.985	0–25	15.3 (7.7)	0.896
Team and cross-boundary continuity	5	0.539	0.854	0–25	17.0 (3.2)	0.593

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Table 3.

Variation in Mean Continuity of Care Scores Among 19 Different Family Practices Based on 193 Patients

	Practice-Specific Mean Score
Scale	Lowest Scoring Practice	25%	Median	75%	Highest Scoring Practice	ICC (95% CI)	P Value
ICC = intraclass correlation coefficient; CI = confidence interval.
Total continuity of care score (0–100)	46	55	62	66	78	0.14 (0.04–0.32)	.001
Longitudinal continuity (0–25)	6	9	12	14	17	0.10 (0.03–0.27)	.005
Flexible continuity (0–25)	13	16	18	19	21	0.10 (0.03–0.27)	.005
Relational continuity (0–25)	6	12	14	17	21	0.09 (0.02–0.28)	.023
Team and cross-boundary continuity (0–25)	15	16	17	17	19	0.02 (0.00–0.23)	.211

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Table 4.

Distribution of Continuity-of-Care Scores by Type of Care Setting and Whether Practice Has Designated Lead Physician for Diabetes Care

Explanatory Variable	Number of Patients	Total Continuity Score	Longitudinal Continuity	Flexible Continuity	Relational Continuity	Team and Cross-Boundary Continuity
Note: Figures are mean (SD) except where indicated.
* Adjusted for whether practice has designated doctor for diabetes and clustering by family practice.
† Adjusted for type of care and clustering by family practice.
Type of care
Family practice only	44	65.1 (15.6)	12.5 (5.3)	18.4 (4.5)	17.0 (7.0)	17.2 (3.4)
Hospital clinic only	35	50.2 (18.1)	9.1 (5.4)	15.4 (5.9)	9.4 (9.5)	16.3 (3.1)
Shared care	114	64.7 (13.8)	12.8 (5.0)	18.3 (4.1)	16.5 (6.4)	17.1 (3.1)
Adjusted difference* (hospital clinic vs family practice or shared care) (95% CI)	—	−13.7 (−19.2 to −8.2)	−3.2 (−5.1 to −1.2)	−2.8 (−4.5 to −1.2)	−7.1 (−9.7 to −4.5)	−0.7 (−1.8 to 0.5)
P value	—	<.001	.001	.001	<.001	.239
Practice has designated physician for diabetes (No. of practices)
No designated doctor (7)	59	56.8 (15.4)	10.9 (4.7)	16.4 (5.3)	13.5 (8.1)	16.1 (2.5)
Designated doctor (9)	96	65.6 (16.0)	12.6 (5.3)	18.9 (4.3)	16.5 (7.4)	17.6 (3.3)
Not known (3)	38	61.6 (14.8)	12.6 (5.8)	17.2 (4.2)	15.1 (7.4)	16.7 (3.5)
Adjusted difference^† (designated vs no) (95% CI)	—	8.2 (2.7 to 13.6)	1.7 (−0.3 to 3.6)	2.3 (0.6 to 4.0)	2.7 (0.2 to 5.2)	1.5 (0.5 to 2.5)
P value	—	.003	.088	.007	.036	.003

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Tables

The Article in Brief

Measuring Continuity of Care In Diabetes Mellitus: An Experience-Based Measure

By Martin C. Gulliford, FRCP, and colleagues

Background An ongoing relationship between patient and doctor is important in managing diabetes, since diabetes care requires close cooperation between the patient and the health care team. Some diabetic patients, however, do not receive care on a regular basis. There are few methods available for measuring the ongoing relationship between patients and medical professionals (often called "continuity of care"). This study aimed to develop and test a questionnaire to measure continuity of care in patients with type 2 diabetes.

What This Study Found A questionnaire was developed, based on patient interviews, to measure diabetes patients' experience of continuity of care. It was tested in a survey of 193 diabetes patients in London, England. This study shows that the tool is a reliable and valid measure of experienced continuity of care.

Implications

The questionnaire may be used in family practice settings and by other specialists, and can be completed by the patient or presented in an interview format.
The questionnaire can increase understanding of factors that improve or harm patients' experiences of continuity of care.
Because it is short, acceptable to patients, and can be used in different care settings, the questionnaire can be used to routinely monitor quality of care.