A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system.
ABSTRACT 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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ABSTRACT: Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records. We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity. After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)). In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs. © 2015 Annals of Family Medicine, Inc.The Annals of Family Medicine 03/2015; 13(2):123-9. DOI:10.1370/afm.1739 · 4.57 Impact Factor
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ABSTRACT: Numerous studied suggest that better continuity of care could result in better health outcomes. However, few studies have examined the relationship between continuity of care and avoidable hospitalizations. A retrospective cohort study design was adopted. We used secondary data analysis based on claim data regarding health care utilization under a universal coverage health insurance scheme in Taiwan. The study population included 3,015 subjects who were newly diagnosed with chronic obstructive pulmonary disease (COPD) in 2006. The main outcome was COPD-related avoidable hospitalization, and the continuity of care index (COCI) was used to measure continuity of care. A logistic regression model was used to control for sex, age, low-income status, and health status. With regard to the effects of continuity of care on avoidable hospitalizations, dose-response trends were observed. The logistic regression model showed that after controlling for covariables, subjects in the low COCI group were 129% (adjusted odds ratio, 2.29; 95% confidence interval, 1.26-4.15) more likely to undergo COPD-related avoidable hospitalizations than those in the high COCI group. Patients with COPD with higher continuity of care had a significantly lower likelihood of avoidable hospitalization. To prevent future hospitalizations, health policy stakeholders should encourage physicians and patients to develop long-term relationships to further improve their health outcomes. © Copyright 2015 by the American Board of Family Medicine.The Journal of the American Board of Family Medicine 03/2015; 28(2):222-30. DOI:10.3122/jabfm.2015.02.140141 · 1.85 Impact Factor
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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 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 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 · 1.74 Impact Factor