Measurement of Continuity in Primary Care

Continuity of care, a stated fundamental principle of family medicine, is reviewed in terms of its philosophy and definitions. A model of continuity in primary medical practice is proposed, consisting of five elements: the provider, consumer, encounter type, knowledge base, and environment of Philosophical Concepts The growth of the middle class in the eighteenth century permitted physicians to earn enough money to live and practice on their own in one area over a significant period of time. The stability of the physician increased accountability to patients, and the new paternalism of the wealthy led to the widespread development of hospitals. ' Continuity of care at this time was enhanced by the stability of population and doctor, but relied upon the doctor's memory; records were infrequently kept, and used mainly as aide-memoires for medications rather than as clinical records, a situation that continues to exist in many parts of the world today. The individual medical record achieved general acceptance only at the end of the nineteenth century.2 At the present time, concern over continuity of care seems to have grown in direct proportion to the increasing fragmentation of medical care, industrialization, and the mobility of patients and doctors alike. There appears to be a diversity of opinion regarding the nature and definition of continuity of care with resultant difficulty in interpreting the relative importance of the studies undertaken on the subject so far. Most commentators in the field of Family Medicine, as well as some in Pediatrics, conAddress reprint requests to Dr. Peter Curtis, Assistant Professor, Department of Family Medicine, University of North Carolina School of Medicine, Trailer 15, 269H, Chapel Hill, NC 27514. Dr. Rogers is a Fellow, Department of Family Medicine, University of Washington School of Medicine, Seattle. This paper, submitted to the Journal February 2, 1979, was revised and accepted for publication August 30, 1979. Editor's Note: See also related editorial, p 117, this issue. continuity. The elements are measurable, some more easily than others. There is need to define and operationalize the model more accurately in order to evaluate continuity in primary care medicine. (Am J Public Health 70:122-127, 1980.) tend that continuity is exemplified by the feeling of the physician which embodies a continuing and caring responsibility for the person and the family rather than concern about specific problems per se.3-6 It appears that this feeling of personal responsibility (even after regular office hours) grows, as continuity of care improves.3 It has also been suggested that the patient must accept certain responsibilities to maintain the "continuity contract." McWhinney notes that the nature of this contract is a central issue for family medicine and "is terminated only by mutual agreement, or by decision of one of the parties.' '6 Continuity of care is consequently viewed as an attitude as well as an activity and this seems to be the characteristic concept held by family physicians, in contrast to other disciplines which may regard it solely as a health care task.7 There is no established evidence, however, that the physician's feeling of responsibility leads to better care. An overall assertion has been made by primary care physicians that continuity is important to ambulatory care. The Royal College of General Practitioners in Great Britain states that the doctor should provide the patient with personal, primary and continuous care, and some North American authors regard it as a crucial issue for Family Medicine.6' 8-10 It is also described as a hallmark of primary care and identified as an important factor in the quality of care, the control of medical costs, patient satisfaction and in the enactment of national health insurance.3 11-13 Continuity also appears to be important to patients, to paramedical staffs, and to social scientists. Mechanic has observed that "if the physician is to respond to the individual, he must have some acquaintance with him and be sensitive to changing needs, and this requires time and continuity." 14 If expectations of AJPH February 1980, Vol. 70, No. 2 122 CONTINUITY OF PRIMARY CARE society include personal health care (that is when the system or the provider is interested in the patient as a person, rather than as a problem), then continuity of care is a prerequisite. What are the benefits so far postulated to support the contention that continuity is an essential to patient care? A number of good outcomes have been attributed to continuity including: * Improved doctor-patient relationships;3' 6 * Increased knowledge of and interest in the patient by the physician and other health staff;'3' '5 * Promotion of confidence and rapport with the doctor and the facilitation of the disclosure of personal information;3' 1' * Increased compliance and cooperation with medical instruction;3' 16. 17 * Reduced hospitalization rates, episodes of sickness and number of laboratory tests;' 8 * Increased patient satisfaction;'9' 20 * Reduced levels of disability, discomfort and dissatisfaction in chronic disease; reduced costs;4' 20. 21 * Reductions in missed appointments, and patient waiting time with improved punctuality;21-23 * Improved recognition of existing or previously elicited health problems;'5 * An improved environment for the use of psychotherapy;6, 24 * The acquisition ofnew knowledge in primary care;6' 7 * Improved management of family problems;7 In spite of this seemingly long list of benefits (some hypothetical, others confirmed by investigation) accruing from the provision of continuity of care, other authors have argued that the evidence that continuity alters the standards of medical practice is poor.4' 20, 25 There have been some definite negative findings. A survey of comprehensive care (which included continuity) in different population groups demonstrated that "emergency services" and "care available 24 hours a day" were ranked highest, while seeing the same physician or group at each visit was ranked lowest in 11 categories of comprehensive care.20 In two studies demonstrating a positive desire for discontinuity, patients regarded all physicians as equally effective and indicated a need to obtain the services of more than one doctor.20 In an attitude survey conducted by McDonald, et al, only six out of 375 patients experienced a desire to see only their personal physician and other investigators confirm that patients are not overly concerned with seeing only their own or the same doctor.26-28 Studies show that physicians personally value continuity of care. '6' 29 A Review ofthe Definition and Measurement of Continuity ofCare In order to establish the value of continuity in the medical care system, it is necessary to define and then measure it. The most comprehensive theoretical definition has been set out by Hennen who has defined five continuity dimensions: chronological, geographic, interdisciplinary, interpersonal, and informational.7 At a more operational level, a number of authors have defined continuity of care in such a way that effective measurement can be implemented. The matching of theoretical definition to practical measurement has been succinctly discussed by Hansen.30 Continuity of care has been defined by Bass and Windle as "the relationship between past and present care in conformity with the therapeutic needs of the patients.' '24 Gordis and Markovitz studied continuity in the context of the availability to the patient of the pediatrician at all hours, with some assistance from nurses and social workers.4 According to Breslau and Reeb, continuity was "the extent to which a single physician manages the health needs of a patient ... the more the patient visits occur with a single physician, the more care is considered continuous. ""I This measurable definition has been used by other authors,'2' 29. 31 On the other hand, Shorr and Nutting define continuity as "the rates of transition between major clinical elements; screening, definitive diagnostic evaluation, treatment and follow-up."32 Shortell states that continuity of medical care is the extent to which medical care services are received as a coordinated and uninterrupted succession of events, consistent with the medical care needs of the patient. 12 In addition to the difficulties of arriving at a reasonable definition, there has been some conceptual confusion between the "longitudinality" and the "continuity" of care. The former can be described as a locus of responsibility held over long periods of time-the regular source of care-but not necessarily related to the onset of presence of illness. On the other hand, continuity has often been used to describe care over the short term, either during an illness episode or for up to one or two years. Based on some of the above definitions and methods of measurement, attempts to measure continuity so far fall into two main categories. The first is one in which a "discontinuity" situation is identified and changed to a "continuity" situation. Evidence is then obtained that certain variables of care have improved, often in relation to a control group. The second category includes studies which attempt to document existence and completeness of an established continuity situation, usually with an implicit assumption that health outcomes are better in this system. In general, measurements have been directed towards the following situations: 1. Continuity of care given to the patient and the family by the provider or health team. This has been measured in terms of patient visits, illness episodes, or as a fraction of scheduled or unscheduled visits. 2. Continuity of care of the total health system, i.e., the investigation of missed appointment rates, number of duplicated tests, procedures and physical examinations, number of sources of care, referral letter return rate, patient dropout rate from screening or preventive programs. 3. Assessment of attitudes toward continuity of care. Patient, staffand physician attitudes have been surveyed following the implementation of continuity plans. A Proposed Model ofContinuity Continuity is defined in most dictionaries as "an uninterrupted succession," "an unbroken course," or "an unAJPH February 1980, Vol. 70, No. 2 123