A Longitudinal Examination of Continuity of Care and Avoidable Hospitalization

Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
Archives of internal medicine (Impact Factor: 17.33). 10/2010; 170(18):1671-7. DOI: 10.1001/archinternmed.2010.340
Source: PubMed


Few studies have examined the effect of continuity of care on avoidable hospitalization, and the results have been inconclusive. This study aimed to examine the effects of continuity of care on avoidable hospitalization and hospital admission for any condition in a health care system with a high level of access to care.
We used a longitudinal design to examine claims data that captured health care utilization between January 1, 2000, and December 31, 2006, under a universal coverage health insurance program in Taiwan. In total, 30 830 randomly selected subjects with 3 or more physician visits per year between 2000 and 2006 were analyzed in 3 age groups. The main outcome was avoidable hospitalization and hospital admission for any condition. A random intercept logistic regression model was used to control for age, sex, low-income status, health status, time effect, and random subject effect.
Higher continuity of care was significantly associated with lower likelihood of avoidable hospitalization in all 3 age groups. Similar associations were found for hospital admission for any condition in the 3 age groups.
Better continuity of care is associated with fewer avoidable hospitalizations and fewer hospital admissions for any condition in a health care system with easy access to care. Therefore, improvement of continuity of care is an appropriate path to follow in a universal coverage health care system.

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    • "Outpatient provider continuity is central to the “medical home” concept of the Patient Protection and Affordable Care Act and is key to good medical care[1]. It is associated with improved patient satisfaction,[2] increased use of appropriate preventive health services[3]–[7], greater medication compliance, lower hospitalization rates,[8]–[12] less emergency department use[13] and fewer duplicate tests.[14] Moreover, continuity of care with a primary care physician (PCP) has shown substantial reductions in mortality among older adults.[15] "
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    ABSTRACT: Little is known about the effect of provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care. Retrospective analysis of 69,247 Medicare beneficiaries aged 67 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1993 and December 31, 2005 who died within two years of diagnosis. We examined visit patterns to a primary care physician (PCP) and/or any provider one year prior to the diagnosis of advanced lung cancer as measures of continuity of care. Outcome measures were hospitalization, ICU use and chemotherapy use during the last month of life, and hospice use during the last week of life. Seeing a PCP or any provider in the year prior to the diagnosis of advanced lung cancer increased the likelihood of hospitalization, ICU care, chemotherapy and hospice use during the end of life. Patients with 1-3, 4-7 or >7 visits to their PCP in the year prior to the diagnosis of lung cancer had 1.0 (reference), 1.08 (95% CI; 1.04-1.13), and 1.14 (95% CI; 1.08-1.19) odds of hospitalization during the last month of life, respectively. Odds of hospice use during the last week of life were higher in patients with visits to multiple PCPs (OR 1.10: 95% CI; 1.06-1.15) compared to those whose visits were all to the same PCP. Provider continuity in the year prior to the diagnosis of advanced lung cancer was not associated with lower use of aggressive care during end of life. Our study did not have information on patient preferences and result should be interpreted accordingly.
    PLoS ONE 09/2013; 8(9):e74690. DOI:10.1371/journal.pone.0074690 · 3.23 Impact Factor
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    • "Canadian studies have supported a relationship between continuity of care and lower ER use among older adults [25], older men [26] and overall [27]. Continuity was also associated with lower ER use in a longitudinal study in Taiwan [28]. The evidence in favour of continuity is less clear-cut [22] in one area only: chronic disease management. "
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    ABSTRACT: Background Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care. Methods This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient’s perspective. Results Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics. Conclusions Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that ‘bigger is not always necessarily better’.
    BMC Family Practice 05/2013; 14(1):72. DOI:10.1186/1471-2296-14-72 · 1.67 Impact Factor
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    ABSTRACT: Advanced ("open") access scheduling, which promotes patient-driven scheduling in lieu of prearranged appointments, has been proposed as a more patient-centered appointment method and has been widely adopted throughout the United Kingdom, within the US Veterans Health Administration, and among US private practices. To describe patient and physician and/or practice outcomes resulting from implementation of advanced access scheduling in the primary care setting. Comprehensive search of electronic databases (MEDLINE, Scopus, Web of Science) through August, 2010, supplemented by reference lists and gray literature. Studies were assessed in duplicate, and reviewers were blinded to author, journal, and date of publication. Controlled and uncontrolled English-language studies of advanced access implementation in primary care were eligible if they specified methods and reported outcomes data. Two reviewers collaboratively assessed risk for bias by using the Cochrane Effective Practice and Organisation of Care Group Risk of Bias criteria. Data were independently extracted in duplicate. Twenty-eight articles describing 24 studies met eligibility criteria. All studies had at least 1 source of potential bias. All 8 studies evaluating time to third-next-available appointment showed reductions (range of decrease, 1.1-32 days), but only 2 achieved a third-next-available appointment in less than 48 hours (25%). No-show rates improved only in practices with baseline no-show rates higher than 15%. Effects on patient satisfaction were variable. Limited data addressed clinical outcomes and loss to follow-up. Studies of advanced access support benefits to wait time and no-show rate. However, effects on patient satisfaction were mixed, and data about clinical outcomes and loss to follow-up were lacking.
    Archives of internal medicine 04/2011; 171(13):1150-9. DOI:10.1001/archinternmed.2011.168 · 17.33 Impact Factor
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