Continuity of care: does it contribute to quality of care?

Continuity of care among diabetic patients in Accra, Ghana

Introduction

Diabetes mellitus is a fast-rising non-contagious disease of global importance that remains a leading cause of indisposition and death. Evidence shows that effective management of diabetes has a close link with continuity of care which is known to be the integral pillar of quality care. This study, therefore, sought to determine the extent of continuity of care between diabetic patients and their care providers as well as factors associated with relational continuity of care.

Methodology

This cross-sectional, facility-based study was conducted among diabetics in Accra, Ghana. We sampled 401 diabetic patients from three diabetic clinics in the region using a stratified and systematic random sampling technique. Data were collected using a structured questionnaire containing information on socio-demographic characteristics, the four dimensions of continuity of care, and patients' satisfaction. A 5-point Likert scale was used to measure patient's perception of relational, flexible, and team continuity, while most frequent provider continuity was used to measure longitudinal continuity of care. Scores were added for each person and divided by the highest possible score for each domain to estimate the continuity of care index. Data were collected and exported to Stata 15 for analysis.

Results

The results show that team continuity was the highest (0.9), followed by relational and flexibility continuity of care (0.8), and longitudinal continuity of care was the least (0.5). Majority of patients experienced high team (97.3%), relational (68.1%), and flexible (65.3%) continuity of care. Most patients (98.3%) were satisfied with the diabetes care they received from healthcare providers. Female subjects had higher odds of experiencing relational continuity of care as compared to male subjects. Furthermore, participants with higher educational levels were five times more likely to experience relational continuity of care than those with lower educational background.

Conclusion

The study demonstrated that the majority of diabetics had team continuity of care being the highest experienced among the four domains, followed by flexible and longitudinal being the least experienced. Notably, team and flexible continuity of care had a positive association with relational continuity of care. Higher educational level and being female were associated with relational continuity of care. There is therefore the need for policy action on the adoption of multidisciplinary team-based care.

Continuity of Care in Chronic Diseases: A Concept Analysis by Literature Review

PURPOSE

This study aimed to utilize concept analysis to obtain a better understanding of the concept of "continuity of care" in chronic diseases.

METHODS

The concept of continuity of care was analyzed using the Walker and Avant method. Covering literature in English from 1930 to 2018, the data sources included CINAHL Complete, Academic Search Complete, MEDLINE, PsyARTICLES, Health Source: Nursing/Academic Edition, Google Scholar, Science Direct, and the Cochrane Library.

RESULTS

A comprehensive definition of concept of continuity of care was developed based on a systematic search and synthesis. The key defining attributes were identified as (a) care over time, (b) the relationship between an individual patient and a care team, (c) information transfer, (d) coordination, and (e) meeting changing needs. The antecedents of continuity of care were having a chronic disease, inexperienced with disease management, a poorly coordinated healthcare system, and medical care limitations. The consequences of continuity of care were decreasing hospital admissions, reducing costs, reducing emergency room visits, improving the quality of life, improving patient satisfaction, and delivering good healthcare.

CONCLUSION

The thorough concept analysis provides insight into the nature of "continuity of care" in chronic diseases and also helps ground the concept in healthcare.

Continuity of care as a predictor of ongoing frequent attendance in primary care: a retrospective cohort study

BACKGROUND

Frequent attenders (FAs) in primary care receive considerable resources with uncertain benefit. Only some FAs attend persistently. Modestly successful models have been built to predict persistent attendance. Nevertheless, an association between relational continuity of care and persistent frequent attendance remains unclear, and could be important considering both the UK government and Royal College of General Practitioner's (RCGP) aim of improving continuity.

AIM

To identify predictive measures (including continuity) for persistent frequent attendance that may be modified in future interventions.

DESIGN & SETTING

This is a retrospective cohort study sampling 35 926 adult patients registered in seven Bristol practices.

METHOD

The top 3% (1227) of patients by frequency of GP consultations over 6 months were classed as FAs. Individual relational continuity was measured over the same period using the Usual Provider Continuity (UPC) index. Attendance change was calculated for the following 6 months. Multivariable logistic regression analysis was used to determine variables that predicted attendance change.

RESULTS

FAs were on average 8.41 years older (difference 95% confidence interval [CI] = 7.33 to 9.50, P<0.001) and more likely to be female (65.36% versus 57.88%) than non-FAs. In total, 79.30% of FAs decreased attendance over the subsequent 6 months. No association was found between continuity and subsequent attendance. Increasing age was associated with maintained frequent attendance.

CONCLUSION

Continuity does not predict change in frequent attendance. In addition to improving continuity, recent government policy is focused on increasing primary care access. If both aims are achieved it will be interesting to observe any effect on frequent attendance.

Primary medical care continuity and patient mortality: a systematic review

BACKGROUND

A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care.

AIM

This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care.

DESIGN AND SETTING

Systematic review of studies published in English or French from database and source inception to July 2019.

METHOD

Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality.

RESULTS

Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated.

CONCLUSION

This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

Continuity Index Measures in the Acute Care Hospital Setting: An Analytic Review and Tests Using Electronic Health Record Data and Computer Simulation

BACKGROUND AND PURPOSE

Multiple continuity indexes are available; however, their properties are insufficiently understood for examining the influence of nurse staffing patterns on patient outcomes. We conceptually and analytically examined continuity measures to reveal their properties and relationships with each other and identify potential limitations.

METHODS

We examined behavior of continuity indexes as applied to clinical practice data that were collected with the HANDS (Hands-On Automated Nursing Data System) and data from computer simulation.

RESULTS

Studied continuity measures exhibited very different statistical characteristics. Most importantly, many continuity measures contain a length-of-stay dependent term that is uncorrelated with continuity.

CONCLUSION

Findings provide a deep understanding of the conceptual foundations and properties of various continuity measures. Using findings, researchers can select proper measures and better interpret analysis outcomes.

Effect of continuity of care on health-related quality of life in adult patients with hypertension: a cohort study in China

Background

Continuity of care is widely considered a principle of primary care that decreases healthcare utilization and mortality. However, the effect of continuity of care on health-related quality of life (HRQoL) for adult patients with hypertension remains unclear.

Methods

To further evaluate the effect of continuity of care, we implemented a cohort study among hypertensive patients aged over 35 years (n = 1200) in six townships in Qianjiang District, Chongqing, China, between 2012 and 2014. The study ultimately included 1079 participants. The continuity of care index was calculated using claim-based longitudinal data obtained from hypertension follow-up service records. The baseline and endline survey-based data, tested by the SF-36 scale, were used to assess HRQoL. To control selection bias and examine the effect of continuity of care, a kernel-based propensity score matching difference-in-differences (DID) method was used. Additionally, descriptive statistics, chi-squared test, and Mann–Whitney nonparametric test were used to summarize characteristics, evaluate proportional differences, and analyze statistical differences, respectively.

Results

Our results showed that patients in the high continuity of care group presented greater improvement in both Physical Component Summary (PCS, DID = 5.192 ± 1.970, p < 0.001) and Mental Component Summary (MCS, DID = 7.900 ± 1.815, p = 0.008) than those in the low continuity of care group. Moreover, patients in the high continuity of care group showed significant improvement in physical functioning, role-physical, general health, role-emotional, and mental health.

Conclusions

Our findings indicate that a long-term physician-patient relationship may improve HRQoL in patients with hypertension. However, more unified measurement tools are needed to evaluate continuity of care. Further studies should include more study settings.

Indices for Continuity of Care: A Systematic Review of the Literature

This article systematically reviews published literature on different continuity of care (COC) indices that assess the physician-patient relationship and the applicability of such indices to pediatric and chronic-disease patient populations. Frequency and visit type may vary for pediatric and chronically ill patients versus healthy adult patients. Two investigators independently examined 5,070 candidate articles and identified 246 articles related to COC. Forty-four articles were identified that include 32 different indices used to measure COC. Indices were classified into those that calculated COC primarily based on duration of provider relationship (n = 2), density of visits (n = 17), dispersion of providers (n = 8), sequence of providers (n = 1), or subjective estimates (n = 4). The diversity of COC indices reflect differences in how this measure is conceptualized. No index takes into account the visit type. A unique index that reflects continuity in the physicianpatient relationship for pediatric and chronic disease populations is needed.

How unique is continuity of care? A review of continuity and related concepts

BACKGROUND

The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear.

OBJECTIVE

In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management.

METHODS

We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary.

RESULTS

Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective.

CONCLUSIONS

The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

An interpersonal continuity of care measure for Medicare Part B claims analyses

OBJECTIVES

This article presents an interpersonal continuity of care measure.

METHODS

We operationalized continuity of care as no more than an 8-month interval between any two visits during a 2-year period to either (a) the same primary care physician or (b) the same physician regardless of specialty. Sensitivity analyses evaluated two interval censoring algorithms and two alternative intervals. We linked Medicare Part A and B claims to baseline survey data for 4,596 respondents to the Survey on Asset and Health Dynamics Among the Oldest Old. We addressed the potential for selection bias by using propensity score methods, and we explored construct validity.

RESULTS

Interpersonal continuity with a primary care physician was 17.3%, and interpersonal continuity of care with any physician was 26.1%. Older participants; men; individuals who lived alone; people who had difficulty walking; and respondents with medical histories of arthritis, cancer, diabetes, heart conditions, hypertension, and stroke were most likely to have continuity. Individuals who had never married, were widowed, were working, or had low subjective life expectancy were least likely to have continuity.

DISCUSSION

Researchers can measure interpersonal continuity of care using Medicare Part B claims. Replication of these findings and further construct validation, however, are needed prior to widespread adoption of this method.

[Continuity of care of patient with diabetes and its affecting factors in Korea]

OBJECTIVES

The objectives of this study were to estimate the continuity of care for all Koreans with diabetes and to identify factors affecting the continuity of care.

METHODS

We obtained National Health Insurance claims data for patients with diabetes who visited health-care providers during the year 2004. A total of 1,498,327 patients were included as study subjects. Most Frequent Provider Continuity (MFPC) and Modified, Modified Continuity Index (MMCI) were used as indexes of continuity of care. A multiple linear regression analysis was used to identify factors affecting continuity of care.

RESULTS

The average continuity of care in the entire population of 1,498,327 patients was 0.89 +/- 0.17 as calculated by MFPC and 0.92 +/- 0.16 by MMCI. In a multiple linear regression analysis, both MFPC and MMCI were lower for females than males, disabled than non-disabled, Medicaid beneficiaries than health insurance beneficiaries, patients with low monthly insurance contributions, patients in rural residential areas, and patients whose most frequently visited provider is the hospital.

CONCLUSIONS

The continuity of care for patients with diabetes is high in Korea. However, women, the disabled and people of low socio-economic status have relatively low continuity of care. Therefore, our first priority is to promote a diabetes management program for these patients.

Interpersonal continuity of care and care outcomes: a critical review

PURPOSE

We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence.

RESULTS

Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity.

CONCLUSIONS

Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.

Current evidence on the impact of continuity of care

PURPOSE OF REVIEW

A core attribute of primary care, continuity of care, is usually viewed as the relationship between a patient and a single practitioner that extends beyond episodes of illness or care for a specific disease and is ongoing over time. The latest evidence of the effectiveness of continuity of care on outcomes for children and adolescents will be presented and placed into the context of prior literature.

RECENT FINDINGS

Despite numerous changes in health care delivery systems, recent studies found that clinician continuity continues to be highly valued by patients and their families. From January 1, 2002 to July 1, 2004, five new studies on physician continuity also assessed pediatric outcomes. These studies found an association between physician continuity and lower emergency department use and costs, better coordination of care, and greater patient and parent satisfaction with care. Two new studies on continuity with a primary care practice found that it was associated with higher receipt of recommended developmental, dental, and nutritional advice, as well as up-to-date immunization coverage.

SUMMARY

Organizational approaches to maximizing access while maintaining continuity require further development. Efforts to restructure provider reimbursement and information systems need to move from single encounter-based systems toward an emphasis on the provision of care over time, to reward and facilitate continuity of care and the positive patient outcomes with which it is associated.

Physician and staff turnover in community primary care practice

The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted. Research nurses collected data using practice genograms, key informant interviews, staff lists, practice environment checklists, medical record reviews, and patient questionnaires. The association of physician and staff turnover with practice characteristics, patient satisfaction, and preventive service data was tested. During a 2-year period, practices averaged a 53% turnover rate of staff. The mean length of duration of work at the current practice location was 9.1 years for physicians and 4.1 years for staff. Longevity varied by position, with a mean of 3.4 years for business employees, 4.0 years for clinical employees, and 7.8 years for office managers. Network-affiliated practices experienced higher turnover than did independent practices. Physician longevity was associated with a practice focus on managing chronic illness, keeping on schedule, and responding to insurers' requests. No association was found between turnover and patient satisfaction or preventive service delivery rates. Personnel turnover is pervasive in community primary care practices and is associated with employee role, practice network affiliation, and practice focus. The potentially disruptive effect of personnel turnover on practice functioning, finances, and longitudinal relationships with patients deserves further study despite the reassuring lack of association with patient satisfaction and preventive service delivery rates.

Defining and measuring interpersonal continuity of care

BACKGROUND

In an effort to learn more about the importance of continuity of care to physicians and patients, I reviewed the medical literature on continuity of care to define interpersonal continuity and describe how it has been measured and studied.

METHODS

A search of the MEDLINE database from 1966 through April 2002 was conducted to find articles focusing on the keyword "continuity of patient care," including all subheadings. Titles and abstracts of the resulting articles were screened to select articles focusing on interpersonal continuity in the physician-patient relationship or on the definition of continuity of care. These articles were systematically reviewed and analyzed for study method, measurement technique, and research theme.

RESULTS

A total of 379 original articles were found that addressed any aspect of continuity as an attribute of general medical care. One hundred forty-two articles directly related to the definition of continuity or to the concept of interpersonal continuity in the physician-patient relationship. Although the available literature reflects little agreement on how to define continuity of care, it is best defined as a hierarchy of 3 dimensions; informational, longitudinal, and interpersonal continuity. Interpersonal continuity is of particular interest for primary care. Twenty-one measurement techniques have been defined to study continuity, many of which relate to visit patterns and concentration rather than the interpersonal nature of the continuity relationship.

CONCLUSIONS

Future inquiry in family medicine should focus on better understanding the interpersonal dimension of continuity of care.

On being new to an insurance plan: health care use associated with the first years in a health insurance plan

BACKGROUND

We wanted to compare health care utilization and costs in the first year of being in a health insurance plan with those of subsequent years.

METHODS

We used claims data from an independent practitioner association (IPA)-style managed care organization in the Rochester, NY, metropolitan area from 1996 through 1999. Cross-sectional and panel analyses of up to 4 years of claims data were conducted, involving 335,547 adult patients assigned to the panels of 687 primary care physicians (internists and family physicians). Multivariate analyses, adjusting for age, sex, case mix, and socioeconomic status derived from ZIP codes, examined the relationship between the first year of health insurance and Papanicolaou tests, mammograms in women older than 40 years, physician use, avoidable hospitalization, and expenditures.

RESULTS

After multivariate adjustment, the first year of insurance was associated with a higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician, and higher expenditures, especially for testing. There was no relationship, however, between Papanicolaou test compliance and year of enrollment.

CONCLUSIONS

The findings suggest there might be adverse clinical and financial implications associated with changing insurance.

Continuity of primary care: to whom does it matter and when?

BACKGROUND

Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems.

METHODS

A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit.

RESULTS

Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician.

CONCLUSIONS

Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.

Continuity of care: a reconceptualization

Although continuity of care is considered an essential feature of good health care, researchers have used and measured continuity in many different ways, and no clear conceptual framework links continuity to outcomes. This article of offers a reconceptualization and definition of continuity based on agency theory. It posits that the value of continuity is to reduce agency loss by decreasing information asymmetry and increasing goal alignment. Three decades of empirical literature on continuity were examined to assess whether this model would provide greater clarity about continuity. Some authors measured improved information transfer, but more appeared to assume that continuity would lead to better information. Most authors appeared to have assumed that goal alignment was present and did not measure it. The model of continuity based on agency theory appears to provide a useful conceptual tool for health services research and policy.

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children

CONTEXT

The benefits of continuity of pediatric care remain controversial.

OBJECTIVE

To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization.

DESIGN

Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider.

MAIN OUTCOME MEASURES

ED utilization and hospitalization.

RESULTS

Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma.

CONCLUSIONS

Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

Predicting patient intent to return from satisfaction scores

This study describes the development of a patient satisfaction assessment instrument used at the Medical University of South Carolina Outpatient Services clinics. Three years of responses were analyzed and a logistic regression model is presented to identify components of care that predict patient intent to return for additional care. Waiting time and understanding doctor's explanation were the only items that were significant predictors of intent to return. Additionally, the calculated probability of a return visit was used to calculate the potential impact of changes in mean satisfaction scores on the number of patient visits to the hospital ambulatory clinics.

Continuity of care: a challenge for ambulatory oncology nursing

Continuity of care has many facets and challenges both as a philosophy and in practice. In an abstract sense, it represents an ideal to which health care professionals strive. It is becoming a professional and consumer expectation that each health care professional contribute to continuity of care. Although a variety of organizational models for providing continuity of care have been established in which nursing plays a prominent role, recent research suggests that some frontline nursing personnel may not fully understand their responsibility to continuity of care. There is a need for nursing curricula in both basic and continuing education programs to address continuity of care concepts, models, and methodologies to strengthen awareness of patient care needs across the disease continuum and across care settings. Performance expectations that include professional accountability for continuity of care also encourage greater attention to this issue.

Assessing the impacts of community-based health care policies and programs for older adults

This article presents a framework for evaluating long-term care policies and programs to determine how well community-based programs benefit the older adult population. Equity, accessibility, quality, and efficiency are identified as core criteria for implementing and evaluating long-term care policy. Special problems with conducting process and/or outcome evaluation of community-based programs are noted, and findings of evaluation research on community-based health care programs are reviewed. Most previous research indicates that community-based health programs for older adults are not a substitute for institutional care and do not reduce either informal caregiving or ambulatory medical services. The article concludes with policy implications.

Regular source of primary medical care and patient satisfaction

As hypothesized, results indicate the greater the degree of continuity in the physician/patient relationship, the higher the level of patient satisfaction. The level of continuity was related to each of the five scale items individually and to the overall patient satisfaction scale. Even when patient background characteristics were controlled, continuity remained a key predictor of satisfaction with primary care received. This study demonstrates the importance of conceptualizing continuity on a continuum, or at least across several categories, rather than reducing it to an either/or construct. Important differences in patient satisfaction occur between and among patients who see the same physician for each episode of primary care, who attend a small group of physicians working together, who attend a clinic or medical center where a different physician may be seen on each occasion, and who do not have a regular source of care. To the extent that patient satisfaction is accepted as a worthwhile objective for the delivery of medical care, emphasis should be placed on providing the maximum feasible level of continuity. This goal is applicable to nurses and other members of the health care team as well as to physicians. It is certainly relevant for those in position to determine an institution's commitment to providing continuous care. For example, directors of prepaid medical plans are increasingly favoring arrangements that include some degree of continuity between physician and patient. Many medical schools that offer courses in patient management are expanding their emphasis on the value of continuity in the physician/patient relationship.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing the patient-provider relationship

This article analyzes some of the central elements of the patient-provider relationship i.e. continuity of care, communication, compliance, and the various elements of the consultation itself. This analysis is based on the review of relevant literature. The same principles apply to this relationship regardless of the provider category. When aiming at good care the recognition of the real need of care and the sharing of information with the patient in a proper and effective way are important. These skills belong to the professional competence of the provider. Continuity of care is the element facilitating the forming of a good patient-provider relationship. The importance of the patient-provider consultation is very great. The immediate, intermediate and long term outcomes of the consultation have been studied by several researchers. The immediate outcomes such as the patient satisfaction strongly influence the intermediate outcomes and also the long term outcomes all-though the intermediate (i.e. compliance) and long term (i.e. change in health status) is also strongly influenced by the patient's sociocultural environment. On the other hand, the patient's health understanding can be much enhanced through skillful communication by the provider during the consultation in a good patient-provider relationship. This, again, connects the elements of consultation very tightly with the success or failure of the care process and the patient's future use of health services.

An attempt to influence health care visits of frequent hospital emergency facility users

In this study, 445 patients under 19 years of age who visited an urban hospital emergency facility for acute illnesses four or more times over 2 years were randomly divided into two groups. The parents of 230 of the patients received three letters that stressed the value of continuous pediatric care and the lack of continuity available in emergency facilities. The letters indicated a willingness to offer advice as to how they could obtain continuing care. The remaining 215 patients served as controls. During the following year, the patients whose parents received the letters and the controls were compared in their visits to the hospital's emergency facility, primary care unit, and subspecialty clinics. Very few differences were noted between the two groups.