Measuring continuity in working family practices

  • Denis J Pereira Gray, Consultant, St Leonard's Research Practice
  • Other Contributors:
    • Kate Sidaway-Lee, Research Fellow, St Leonard's Research Practice
    • Philippa Whitaker, Medical Student, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London.
    • Philip H Evans, Professor, Exeter University, College of Medicine and Health
20 December 2022

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.

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.
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