The association between continuity of care in the community and health outcomes: a population-based study

Continuity of care between dyslipidemia patients and multiple providers: A cohort study

OBJECTIVE

This study aimed to investigate the impacts of continuity of care (COC) between patients and multiple providers, i.e., doctors and community pharmacists, on clinical and economic outcomes.

METHODS

This is a retrospective cohort study and analyzed Korean national claims data for ambulatory care setting between 2007 and 2018. Patients with dyslipidemia newly diagnosed in 2008 were identified. COC between providers and patients was computed using the continuity of care index (COCI). Based on COCIs, the study patients were allocated to four groups: HM/HP, HM/LP, LM/HP, and LM/LP. Each symbol represents H for high, L for low, M for doctor, and P for pharmacist. The primary study outcome was the incidence of atherosclerotic cardiovascular disease (ASCVD).

RESULTS

126,710 patients were included. Percentages of patients in the four study groups were as follows: HM/HP 35%, HM/LP 19%, LM/HP 12%, and LM/LP 34%. During the seven-year outcome period, 8,337 patients (6.6%) developed an ASCVD, and percentages in the study groups were as follows; HM/HP 6.2%, HM/LP 6.3%, LM/HP 6.8%, and LM/LP 7.1%. After adjusting for confounding covariates, only the LM/LP group had a significantly higher risk of ASCVD than the reference group, HM/HP (aHR = 1.16 [95% confidence interval = 1.10~1.22]). The risk of inappropriate medication adherence gradually increased 1.03-fold in the HM/LP group, 1.67-fold in the LM/HP, and 2.26-fold in the LM/LP group versus the HM/HP group after adjusting for covariates. Disease-related costs were lower in the HM/HP and LM/HP groups.

CONCLUSIONS

The study shows that patients with high relational care continuity with doctors and pharmacists achieved better clinical results and utilized health care less, resulting in reduced expenses. Further exploration for the group that exhibits an ongoing relationship solely with pharmacists is warranted.

Does commission on cancer (CoC) accreditation mitigate the effect of care fragmentation on clinical outcome in localized rectal cancer?

BACKGROUND

Studies of fragmented care (FC) in rectal cancer have not adjusted for indicators of hospital quality and may misrepresent the effects of FC.

METHODS

We queried the National Cancer Database to identify patients undergoing care for clinical stage II and III rectal adenocarcinoma between 2006 and 2019. Those undergoing FC were sub-categorized based on whether (FC CoC) or not (FC non-CoC) they received systemic therapy at CoC accredited facilities.

RESULTS

44,339 patients met inclusion criteria; 23,921 (54 ​%) underwent FC, 16,929 (71 ​%) FC non-CoC. Differences in utilization of neoadjuvant therapy (92.3 ​% vs 89.7 ​% vs 89.5 ​%, p ​< ​0.01) and 5-year overall survival (76.1 vs 75.5 vs 74.1 %, p ​< ​0.01) between treatment cohorts were marginal.

CONCLUSION

In patients undergoing multimodality therapy for rectal cancer, care fragmentation is not associated with long-term clinical outcome. Decisions regarding where these patients go for systemic therapy may be safely made on the basis of ease of access.

The effect of general practice team composition and climate on staff and patient experiences: a systematic review

BACKGROUND

Recent policy initiatives seeking to address the workforce crisis in general practice have promoted greater multidisciplinarity. Evidence is lacking on how changes in staffing and the relational climate in practice teams affect the experiences of staff and patients.

AIM

To synthesise evidence on how the composition of the practice workforce and team climate affect staff job satisfaction and burnout, and the processes and quality of care for patients.

DESIGN & SETTING

A systematic literature review of international evidence.

METHOD

Four different searches were carried out using MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science. Evidence from English language articles from 2012-2022 was identified, with no restriction on study design. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and data were synthesised thematically.

RESULTS

In total, 11 studies in primary healthcare settings were included, 10 from US integrated healthcare systems, one from Canada. Findings indicated that when teams are understaffed and work environments are stressful, patient care and staff wellbeing suffer. However, a good relational climate can buffer against burnout and protect patient care quality in situations of high workload. Good team dynamics and stable team membership are important for patient care coordination and job satisfaction. Female physicians are at greater risk of burnout.

CONCLUSION

Evidence regarding team composition and team climate in relation to staff and patient outcomes in general practice remains limited. Challenges exist when drawing conclusions across different team compositions and definitions of team climate. Further research is needed to explore the conditions that generate a 'good' climate.

Effects of Non-Face-to-Face Chronic Care Management on Service Utilization and Outcomes Among US Medicare Beneficiaries with Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) results in heavy economic and disease burdens in Louisiana. The Centers for Medicare and Medicaid Services has reimbursed non-face-to-face chronic care management (NFFCCM) for patients with two or more chronic conditions since 2015.

OBJECTIVE

To assess the impacts of NFFCCM on healthcare utilization and health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included Medicare fee-for-service beneficiaries with T2DM and at least one additional chronic disease between 2014 and 2018.

EXPOSURES

At least one record of NFFCCM Current Procedural Terminology codes.

MAIN MEASURES

The health outcomes in the study included major adverse cardiovascular events (MACE), all-cause mortality, and heart failure. The monthly service utilization and continuity of care index for primary care were also included. The propensity score method was used to balance the baseline differences between the two groups. Weighted multivariate regression models were developed using propensity score weights to assess the impacts of NFFCCM on outcomes.

KEY RESULTS

During the 5 years of study period, 8415 patients among the 118,643 Medicare beneficiaries received at least one NFFCCM. Patients receiving any NFFCCM had reduced healthcare utilization compared with patients not receiving NFFCCM, including 0.012 (95% CI - 0.014 to - 0.011; p < 0.001) fewer monthly hospital admissions, 0.017 (95% CI - 0.019 to - 0.016; p < 0.001) fewer monthly ED visits, and 0.399 (95% CI 0.375 to 0.423; p < 0.001) more monthly outpatient encounters. Patients receiving NFFCCM services had lower MACE event rates of 7.4% (95% CI 7.1 to 7.8%; p < 0.001), all-cause mortality rate of 7.8% (95% CI 7.4 to 8.1%; p < 0.001), and heart failure rate of 0.3% (95% CI 0.2 to 0.5%; p < 0.001), respectively.

CONCLUSIONS AND RELEVANCE

These findings suggest that reimbursement for NFFCCM was associated with the shifting high-cost utilization to lower-cost primary health care settings among patients with diabetes in Louisiana.

Fragmentation of Care in Patients with Peritoneal Metastases Undergoing Cytoreductive Surgery

BACKGROUND

The delivery of multimodal treatment at a high-volume center is known to optimize the outcomes of gastrointestinal malignancies. However, patients undergoing cytoreductive surgery (CRS) for peritoneal metastases often must 'fragment' their surgical and systemic therapeutic care between different institutions. We hypothesized that this adversely affects outcomes.

PATIENTS AND METHODS

Adults undergoing CRS for colorectal or appendiceal adenocarcinoma at our institution between 2016 and 2022 were identified retrospectively and grouped by care network: 'coordinated care' patients received exclusively in-network systemic therapy, while 'fragmented care' patients received some systemic therapy from outside-network providers. Factors associated with fragmented care were also ascertained. Overall survival (OS) from CRS and systemic therapy-related serious adverse events (SAEs) were compared across the groups.

RESULTS

Among 85 (80%) patients, 47 (55%) had colorectal primaries and 51 (60%) received fragmented care. Greater travel distance [OR 1.01 (CI 1.00-1.02), p = 0.02] and educational status [OR 1.04 (CI 1.01-1.07), p = 0.01] were associated with receiving fragmented care. OS was comparable between patients who received fragmented and coordinated care in the colorectal [32.5 months versus 40.8 months, HR 0.95 (CI 0.43-2.10), p = 0.89] and appendiceal [31.0 months versus 27.4 months, HR 1.17 (CI 0.37-3.74), p = 0.55] subgroups. The frequency of SAEs (7.8% versus 17.6%, p = 0.19) was also similar.

CONCLUSIONS

There were no significant differences in survival or SAEs based on the networks of systemic therapy delivery. This suggests that patients undergoing CRS at a high-volume center may safely receive systemic therapy at outside-network facilities with comparable outcomes.

Primary care utilisation, adherence to guideline-based pharmacotherapy and continuity of care in primary care patients with chronic diseases and multimorbidity - a cross-sectional study

BACKGROUND

To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care.

METHODS

Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years.

PARTICIPANTS

Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015.

PRIMARY OUTCOME MEASURES

In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity.

RESULTS

Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines.

CONCLUSIONS

Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

Profiles of patients with substance-related disorders who dropped out or not from addiction treatment

This longitudinal study identified profiles of patients with substance-related disorders (SRD) who did or did not drop out of specialized addiction treatment, integrating various patterns of outpatient service use. Medical administrative databases of Quebec (Canada) were used to investigate a cohort of 16,179 patients with SRD who received specialized addiction treatment. Latent class analysis identified patient profiles, based on multi-year outpatient service use. Four patient profiles related to treatment dropout were identified: patients who did not drop out and were low service users (Profile 1); patients who did not drop out and were high service users (Profile 2); patients who dropped out and were low service users (Profile 3); patients who dropped out and were high service users (Profile 4). Profile 1 had the best health and social conditions, while Profile 4 had the worst. The risks of being frequent emergency department users, being hospitalized or dying were highest in Profile 4, followed by Profiles 3, 2 and 1. Assertive treatment programs may be suited to Profile 4 and intensive case management programs to Profile 3. Collaborative care with higher psychosocial interventions and regularity of care may be extended to Profile 2 and interventions integrating motivational treatment to Profile 1.

What quantifies good primary care in the United States? A review of algorithms and metrics using real-world data

Primary care physicians (PCPs) play an indispensable role in providing comprehensive care and referring patients for specialty care and other medical services. As the COVID-19 outbreak disrupts patient access to care, understanding the quality of primary care is critical at this unprecedented moment to support patients with complex medical needs in the primary care setting and inform policymakers to redesign our primary care system. The traditional way of collecting information from patient surveys is time-consuming and costly, and novel data collection and analysis methods are needed. In this review paper, we describe the existing algorithms and metrics that use the real-world data to qualify and quantify primary care, including the identification of an individual's likely PCP (identification of plurality provider and major provider), assessment of process quality (for example, appropriate-care-model composite measures), and continuity and regularity of care index (including the interval index, variance index and relative variance index), and highlight the strength and limitation of real world data from electronic health records (EHRs) and claims data in determining the quality of PCP care. The EHR audits facilitate assessing the quality of the workflow process and clinical appropriateness of primary care practices. With extensive and diverse records, administrative claims data can provide reliable information as it assesses primary care quality through coded information from different providers or networks. The use of EHRs and administrative claims data may be a cost-effective analytic strategy for evaluating the quality of primary care.

Patient-level predictors of temporal regularity of primary care visits

BACKGROUND

Patients with chronic diseases should meet with their primary care doctor regularly to facilitate proactive care. Little is known about what factors are associated with more regular follow-up.

METHODS

We studied 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease), cared for by Leumit Health Services, an Israeli health maintenance organization. Patients were divided into the quintile with the least temporally regular care (i.e., the most irregular intervals between visits) vs. the other four quintiles. We examined patient-level predictors of being in the least-temporally-regular quintile. We calculated the risk-adjusted regularity of care at 239 LHS clinics with at least 30 patients. For each clinic, compared the number of patients with the least temporally regular care with the number predicted to be in this group based on patient characteristics.

RESULTS

Compared to older patients, younger patients (age 40-49), were more likely to be in the least-temporally-regular group. For example, age 70-79 had an adjusted odds ratio (AOR) of 0.82 compared to age 40-49 (p < 0.001 for all findings discussed here). Males were more likely to be in the least-regular group (AOR 1.18). Patients with previous myocardial infarction (AOR 1.07), atrial fibrillation (AOR 1.08), and current smokers (AOR 1.12) were more likely to have an irregular pattern of care. In contrast, patients with diabetes (AOR 0.79) or osteoporosis (AOR 0.86) were less likely to have an irregular pattern of care. Clinic-level number of patients with irregular care, compared with the predicted number, ranged from 0.36 (fewer patients with temporally irregular care) to 1.71 (more patients).

CONCLUSIONS

Some patient characteristics are associated with more or less temporally regular patterns of primary care visits. Clinics vary widely on the number of patients with a temporally irregular pattern of care, after adjusting for patient characteristics. Health systems can use the patient-level model to identify patients at high risk for temporally irregular patterns of primary care. The next step is to examine which strategies are employed by clinics that achieve the most temporally regular care, since these strategies may be possible to emulate elsewhere.

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic

BACKGROUND

Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.

OBJECTIVE

We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.

RESEARCH DESIGN

This was a cohort study.

PARTICIPANTS

Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.

METHODS

Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.

RESULTS

MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing.

CONCLUSIONS

Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

Profiles, correlates, and risk of death among patients with mental disorders hospitalized for psychiatric reasons

This study identified profiles of hospitalized patients with mental disorders (MD) based on their 3-year hospitalization patterns and clinical characteristics and compared sociodemographic profiles and other service use correlates as well as risk of death within 12 months after hospitalization. Quebec (Canada) medical administrative databases were used to investigate a 5-year cohort of 4,400 patients hospitalized for psychiatric reasons. Latent class analysis, chi-square tests and survival analysis were produced. Three profiles of hospitalized patients were identified based on hospitalization patterns and other patient characteristics. Profile 3 patients had multiple hospitalizations and early readmissions, worst health and social conditions, and used the most outpatient services. Profiles 2 and 1 patients had only one hospitalization, of brief duration in the case of Profile 2 patients, who had mainly common MD and made least use of psychiatric care. All Profile 1 patients were hospitalized for serious MD but received least continuity of physician care and fewest biopsychosocial interventions. Risk of death was higher for Profiles 3 and 2 versus Profile 1 patients. Interventions like early follow-up care after hospitalization for Profile 3, collaborative care between general practitioners and psychiatrists for Profile 2, and continuous biopsychosocial care for Profile 1 could be greatly improved.

Predictors of Death From Physical Illness or Accidental/Intentional Causes Among Patients With Substance-Related Disorders

OBJECTIVE

This study identified patient clinical and sociodemographic characteristics, and, more originally, service use patterns as predictors of death from physical illness or accidental/intentional causes.

METHODS

A cohort of 19,015 patients with substance-related disorders (SRD) from 14 addiction treatment centers was investigated using Quebec (Canada) health administrative databases. Death was studied over a 3-year period (April 1, 2013, to March 31, 2016), and most predictors from 4 years to 12 months prior to the time of death, using multinomial logistic regression.

RESULTS

Frequent emergency department (ED) use strongly predicted both causes of death, suggesting that outpatient care responded inadequately to patient needs. Only receipt of specialized SRD and psychiatric care significantly decreased the risk of death from physical illness, with trends toward significance for accidental/intentional death. Hospitalization, greater material deprivation and having SRD-chronic physical illnesses or alcohol-related disorders most strongly predicted risk of death from physical illness. Sociodemographic characteristics, mainly social deprivation, were more likely to predict accidental/intentional death.

CONCLUSIONS

Outpatient services could be improved by increasing outreach and motivational interventions and, for ED and hospital units, better screening, brief intervention, and referral to treatment, particularly for men and socially deprived patients at high risk of accidental/intentional death. Patients with more severe health conditions, notably older or materially deprived men at higher risk of death from physical illness, could benefit from programs like assertive community treatment or intensive case management that respond well to diverse and continuous patient needs. Collaborative care between SRD and health services could also be improved.

Multi-institutional Care in Clinical Stage II and III Esophageal Cancer

BACKGROUND

Management of clinical stage II or III esophageal cancer requires multidisciplinary care. Multi-institutional care has been associated with worse survival in other malignant diseases. This study aimed to determine the impact of multi-institutional care on survival in patients with stage II or III esophageal cancer.

METHODS

The 2004 to 2016 National Cancer Database was queried for patients with clinical stage II or III esophageal cancer who received neoadjuvant chemotherapy with or without radiation therapy followed by surgical resection. Patients were stratified into 2 groups: multi-institutional or single-institution care. Survival between groups was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. Multivariable logistic regression was performed to identify factors associated with multi-institutional care.

RESULTS

Overall, 11 399 patients met study criteria: 6569 (57.6%) received multi-institutional care and 4,830 (42.4%) received care at a single institution. In a multivariable analysis, factors associated with multi-institutional care were later year of diagnosis, greater distance from treating facility, residence in an urban or rural setting (vs metro), and residence in states without Medicaid expansion. Care at a single institution was associated with Black race, lack of insurance, and treatment at higher-volume or academic centers. Despite these differences, patients who received multi-institutional care had survival comparable to that in patients who received care at a single institution (HR, 0.97; 95% CI, 0.92-1.03; P = .30).

CONCLUSIONS

In this National Cancer Database analysis, multi-institutional care was not associated with inferior overall survival. As complex cancer care becomes more regionalized, patients may consider receiving part of their cancer care closer to home, whereas traveling to surgical centers of excellence should be encouraged.

Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

BACKGROUND

This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.

METHODS

A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.

RESULTS

Profile 1 patients (47% of the sample), labeled "Low outpatient service users", received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled "Moderate outpatient service users", received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they  were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled "High outpatient service users", received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.

CONCLUSIONS

Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Does fragmented cancer care affect survival? Analysis of gastric cancer patients using national insurance claim data

BACKGROUND

We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data.

METHODS

From a nationwide sampled cohort database, we identified National Health Insurance beneficiaries diagnosed with gastric cancer (ICD-10: C16) in South Korea during 2005-2013. We analyzed the results of a multiple logistic regression analysis using the generalized estimated equation model to investigate which patient and institution characteristics affected fragmented cancer care during the first year after diagnosis. Then, survival analysis using the Cox proportional hazard model was conducted to investigate the association between fragmented cancer care and five-year mortality.

RESULTS

Of 2879 gastric cancer patients, 11.9% received fragmented cancer care by changing their most visited medical institution during the first year after diagnosis. We found that patients with fragmented cancer care had a higher risk of five-year mortality (HR: 1.310, 95% CI: 1.023-1.677). This association was evident among patients who only received chemotherapy or radiotherapy (HR: 1.633, 95% CI: 1.005-2.654).

CONCLUSIONS

Fragmented cancer care was associated with increased risk of five-year mortality. Additionally, changes in the most visited medical institution occurred more frequently in either patients with severe conditions or patients who mainly visited smaller medical institutions. Further study is warranted to confirm these findings and examine a causal relationship between fragmented cancer care and survival.

Predictors of Length of Hospitalization and Impact on Early Readmission for Mental Disorders

Length of hospitalization, if inappropriate to patient needs, may be associated with early readmission, reflecting sub-optimal hospital treatment, and translating difficulties to access outpatient care after discharge. This study identified predictors of brief-stay (1-6 days), mid-stay (7-30 days) or long-stay (≥31 days) hospitalization, and evaluated how lengths of hospital stay impacted on early readmission (within 30 days) among 3729 patients with mental disorders (MD) or substance-related disorders (SRD). This five-year cohort study used medical administrative databases and multinomial logistic regression. Compared to patients with brief-stay or mid-stay hospitalization, more long-stay patients were 65+ years old, had serious MD, and had a usual psychiatrist rather than a general practitioner (GP). Predictors of early readmission were brief-stay hospitalization, residence in more materially deprived areas, more diagnoses of MD/SRD or chronic physical illnesses, and having a usual psychiatrist with or without a GP. Patients with long-stay hospitalization (≥31 days) and early readmission had more complex conditions, especially more co-occurring chronic physical illnesses, and more serious MD, while they tended to have a usual psychiatrist with or without a GP. For patients with more complex conditions, programs such as assertive community treatment, intensive case management or home treatment would be advisable, particularly for those living in materially deprived areas.

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

Profiles, Correlates and Outcomes Among Patients Experiencing an Onset of Mental Disorder Based on Outpatient Care Received Following Index Emergency Department Visits

OBJECTIVE

This 5-year longitudinal study evaluated patients with an onset of mental disorder (MD) following index emergency department (ED) visits, in terms of (1) patient profiles based on 12-month outpatient follow-up care received, (2) sociodemographic and clinical correlates, and (3) adverse health outcomes for the subsequent 2 years.

METHODS

Data from administrative databases were collected for 2541 patients with an onset of MD, following discharge from Quebec ED. Latent class analysis was performed to identify patient profiles based on the adequacy of follow-up care after ED discharge. Bivariate analyses examined associations between class membership and sociodemographic and clinical correlates, high ED use (3 + visits/yearly), hospitalizations, and suicidal behaviors.

RESULTS

Five classes of patients were identified. Class 1, the smallest, labeled "patient psychiatrist only," included mainly young patients with serious MD. Classes 2 and 3, roughly 20%, were labeled "high use of patient general practitioner (GP) and psychiatrist" and "low use of patient GP and psychiatrist," respectively. Both included patients with complex MD, but Class 2 had more women and older patients with chronic physical illnesses. The 2 largest classes were labeled "no usual patient service provider" (Class 5) and "patient GP only" (Class 4). Class 5 included more younger men with substance-related disorders, while Class 4 had the older patients living in rural areas, many with common MD and chronic physical illnesses. Class 3 patients had the poorest outcomes, followed by Classes 1 and 2, while Classes 4 and 5 had the best outcomes.

CONCLUSIONS

Results revealed that nearly 40% of patients experiencing an onset of MD received little or no outpatient care following ED discharge. Higher severity or complexity of MD and, to a lesser extent, no or low GP follow-up may explain these adverse outcomes. More adequate, continuous care, including collaborative care, is needed for these vulnerable, high-needs patients.

Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer

BACKGROUND

Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival.

METHODS

The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods.

RESULTS

Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05).

CONCLUSIONS

For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.

Glycemic Control and Diabetes Related Complications in Adults with Type 1 Diabetes Mellitus and ADHD

OBJECTIVE

To assess the correlation of co-morbid ADHD and diabetes-related complications in patients with type-1-diabetes-mellitus (T1DM).

METHODS

A retrospective cross-sectional study was conducted during 2018 using the Leumit-Health-Services(LHS) database. Diabetes-related complications were assessed in patients with T1DM and ADHD (T1DM-ADHD+) and compared with patients with T1DM alone (T1DM-ADHD-).

RESULTS

Out of 789 adult-patients with T1DM, 75 (9.5%) were T1DM-ADHD+, matched to 225 T1DM-ADHD-. HbA₁C levels were higher in T1DM-ADHD+ patients (8.1% ± 1.6 vs. 7.4% ± 1.2, p < .01), as well as diabetes-related complications: neuropathy (22.7% vs. 5.8%, p < .01), ulcers (8% vs. 0.9%, p < .05), limb amputation (5.3% vs. 0.9%, p < .05), albuminuria (15.5% vs. 2.8%, p < .01), chronic renal failure (10.6% vs. 2.5%, p = .01), and emergency room admissions rate (26.7% vs. 15.1%, p < .05). In sub-analysis, lower average HbA₁C levels and diabetic ulcer rates were found among ADHD patients treated with stimulants, all p < .05.

CONCLUSION

Co-morbidity of ADHD and T1DM is associated with poor glycemic control and higher complication rates.

Exploring the health care utilization of children and youth in the care of child welfare: a retrospective matched cohort study

BACKGROUND

Children and youth whose lives intersect with child welfare systems are amongst the most vulnerable paediatric populations. Despite the increased rates of chronic conditions, these children and youth often experience unmet health care needs.

OBJECTIVES

To examine patterns of health care utilization from birth for children and youth in the care of a child welfare authority.

METHODS

This retrospective matched cohort design study examined children/youth aged 0-18 who had visited a paediatric tertiary care facility from 2016 April 1 to 2017 March 31 and had "social worker" documented as their guardian. A control cohort was matched based on age and sex. Primary outcomes of interest included primary health care, emergency, outpatient, and inpatient visits. Visits for immunizations, physiological development, well-baby checks, mental health, and oral health were also examined.

RESULTS

A total of 200 cases and 200 controls were included in our cohort. No statistically significant differences were found between primary care visits, well-baby checks, inpatient admissions, outpatient mental health visits, or immunizations for children in care in comparison to their controls. There was a significant difference in oral health visits, lack of physiological development, and emergency department visits for children in care when compared to their controls.

CONCLUSIONS

Our study revealed disparities in health care utilization amongst children in the care of child welfare in comparison to those who are not, highlighting the need for improved practice, policy, and research initiatives. A collaborative data collection/sharing system is needed to identify and track the health care of this vulnerable population.

Predictors of Frequent Emergency Department Use and Hospitalization among Patients with Substance-Related Disorders Recruited in Addiction Treatment Centers

Few studies have assessed the overall impact of outpatient service use on acute care use, comparing patients with different types of substance-related disorders (SRD) and multimorbidity. This study aimed to identify sociodemographic and clinical characteristics and outpatient service use that predicted both frequent ED use (3+ visits/year) and hospitalization among patients with SRD. Data emanated from 14 Quebec (Canada) addiction treatment centers. Quebec administrative health databases were analyzed for a cohort of 17,819 patients over a 7-year period. Multivariable logistic regression models were produced. Patients with polysubstance-related disorders, co-occurring SRD-mental disorders, severe chronic physical illnesses, and suicidal behaviors were at highest risk of both frequent ED use and hospitalization. Having a history of homelessness, residing in rural areas, and using more outpatient services also increased the risk of acute care use, whereas high continuity of physician care protected against acute care use. Serious health problems were the main predictor for increased risk of both frequent ED use and hospitalization among patients with SRD, whereas high continuity of care was a protective factor. Improved quality of care, motivational, outreach and crisis interventions, and more integrated and collaborative care are suggested for reducing acute care use.

Investigating characteristics of patients with mental disorders to predict out-patient physician follow-up within 30 days of emergency department discharge

BACKGROUND

Prompt follow-up at emergency department discharge is a key indicator of healthcare quality and patient recovery. To improve services, better knowledge of predictors for out-patient physician follow-up within 30 days after discharge is needed.

AIMS

We investigated clinical and sociodemographic characteristics and service use to predict patients with mental disorders with or without physician follow-up after emergency department use.

METHOD

This study used data extracted from clinical administrative databases for 9514 patients who attended an emergency department in Quebec (Canada) in 2014-2015 (index visit) for mental health reasons. Patient clinical and sociodemographic characteristics from 2012-2013 to 2014-2015, and service use 12 months before the index visit, were investigated as predictors for patients with or without prompt follow-up, using hierarchical logistic regression.

RESULTS

Two-thirds of patients did not receive prompt physician follow-up. Patients with level 1-2 illness acuity at emergency department triage (needing immediate or urgent care); those with adjustment or bipolar disorders, but without alcohol-related disorders (clinical characteristics); and patients with higher continuity of physician care, more psychosocial interventions in community healthcare centres and prior hospital admission (service use characteristics) were more likely to receive prompt out-patient follow-up.

CONCLUSIONS

Access to medical care was poor, considering the high needs of this population. The role of the emergency department as a gateway for accessing out-patient care may be strengthened by strategies like screening, brief intervention including motivational treatments, brief case management offered by emergency department staff, timely referral to services and better post-discharge planning. Collaborative care for patients attending emergency departments should also be improved.

Predictors of Emergency Department Use for Suicidal Behaviors among Patients with Substance-Related Disorders

OBJECTIVE

This study aimed to identify predictors of emergency department (ED) use for suicide ideation or suicide attempt compared with other reasons among 14,158 patients with substance-related disorders (SRD) in Quebec (Canada).

METHODS

Longitudinal data on clinical, sociodemographic, and service use variables for patients who used addiction treatment centers in 2012-13 were extracted from Quebec administrative databases. A multinomial logistic regression was produced, comparing predictors of suicide ideation or attempts to other reasons for ED use in 2015-16.

RESULTS

Patients using ED for both suicide ideation and attempt were more likely to have bipolar or personality disorders, problems related to the social environment, 4+ previous yearly outpatient consultations with their usual psychiatrist, high prior ED use, and dropout from SRD programs in addiction treatment centers in the previous 7 years, compared with those using ED for other reasons. Patients with alcohol- or drug-related disorders other than cannabis and living in the least materially deprived areas, urban territories, and university healthcare regions made more suicide attempts than those using ED for other reasons. Patients with common mental disorders, 1-3 previous yearly outpatient consultations with their usual psychiatrist, one previous treatment episode in addiction treatment centers, and those using at least one SRD program experienced more suicide ideation than patients using ED for other reasons.

CONCLUSION

Clinical variables most strongly predicted suicidal behaviors, whereas completion of SRD programs may help to reduce them. SRD services and outreach strategies should be reinforced, particularly for patients with complex issues living in more advantaged urban areas. HIGHLIGHTSOver 10% of ED visits were for suicidal behaviors among patients with SRD.ED use for suicidal behaviors was mainly associated with clinical variables.Addiction treatment centers may help reduce ED use for suicidal behaviors.

Association Between Team-Based Continuity of Care and Risk of Cardiovascular Diseases Among Patients With Diabetes: A Retrospective Cohort Study

OBJECTIVE

Cardiovascular diseases (CVD) are a long-term sequela of diabetes. Better individual-based continuity of care has been reported to reduce the risk of chronic complications among patients with diabetes. Maintaining a one-to-one patient-physician relationship is often challenging, especially in public health care settings. This study aimed to evaluate the relationship between higher team-based continuity of care, defined as consultations provided by the same physician team, and CVD risks in patients with diabetes from public primary care clinics.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study in Hong Kong of 312,068 patients with type 2 diabetes and without any history of CVD at baseline (defined as the earliest attendance at a doctor's consultation in a public-sector clinic between 2008 and 2018). Team-based continuity of care was measured using the usual provider continuity index (UPCI), calculated by the proportion of consultations provided by the most visited physician team in the 2 years before baseline. Patients were divided into quartiles based on their UPCI, and the characteristics of the quartiles were balanced using propensity score fine stratification weights. Multivariable Cox regression was applied to assess the effect of team-based continuity of care on CVD incidence. Patient demographics, smoking status, physiological measurements, number of attendances, comorbidities, and medications were adjusted for in the propensity weightings and regression analyses.

RESULTS

After an average follow-up of 6.5 years, the total number of new CVD events was 52,428. Compared with patients in the 1st quartile, patients in the 2nd, 3rd, and 4th quartiles of the UCPI had a CVD hazard ratio (95% CI) of 0.95 (0.92-0.97), 0.92 (0.89-0.94), and 0.87 (0.84-0.89), respectively, indicating that higher continuity of care was associated with lower CVD risks. The subtypes of CVD, including coronary heart disease and stroke, also showed a similar pattern. Subgroup analyses suggested that patients <65 years of age had greater benefits from higher team-based continuity of care.

CONCLUSIONS

Team-based continuity of care was associated with lower CVD risk among individuals with type 2 diabetes, especially those who were younger. This suggests a potential flexible alternative implementation of continuity of care in public clinics.

Continuity of care of Swiss residents aged 50+: a longitudinal study using claims data

Background

Continuity of care (COC) should be measured for healthcare quality monitoring and evaluation and is a key process indicator for integrated care. Measurement of COC using routinely collected data is widespread, but there is no consensus on which indicator to use and the relevant time horizon to apply. Information about COC is especially warranted in highly fragmented healthcare systems, such as in Switzerland. Our study aimed to compare COC measures in Swiss residents aged 50+ obtained with various indices and time horizons.

Methods

Using insurance claims data, we computed and compared several commonly used visit-based Continuity of Care Indices (COCIs): Bice-Boxerman Index, Usual Provider of Care, Herfindahl-Hirschman Index, Modified, Modified Continuity Index and Modified Continuity Index, based on all doctor visits and on primary care (PC) visits only. Indices were computed over short (1 year) and medium (4 years) terms.

Results

The mean indices based on all visits varied between 0.51 and 0.77, while PC indices presented less variation with a median of 1.00 for all but one index. Indices focusing on a variety of individual providers decreased with time horizon, while indices focusing on the overall number of visits and providers showed the opposite trend. These findings suggest fundamental differences in the interpretation of COCIs.

Conclusions

Broad COC appeared moderately low in Switzerland, although comparable to other countries, and PC COC was close to one. The choice of indices and time horizon influenced their interpretation. Understanding these differences is key to select the appropriate index for the monitoring of COC.

Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data

Objective

To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data.

Methods

We used data on 240′000 insured individuals aged 50+ for the period 2015–2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities.

Results

The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex (“high-cost high-need”) individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence.

Conclusions

Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers.

•

We investigated the relationship between multimorbidity and COC, using claims-based data.

•

We applied three approaches of expressing multimorbidity in claims data: simple counts, expert-based and data-driven.

•

Association between COC and multimorbidity expressed in simple counts was modest, while expert-based approach showed larger heterogeneity.

•

Data-driven approach revealed that most complex individuals tended to have higher COC.

Predictors of no, low and frequent emergency department use for any medical reason among patients with cannabis-related disorders attending Quebec (Canada) addiction treatment centres

INTRODUCTION

Patients with substance-related disorders and mental disorders (MD) contribute substantially to emergency department (ED) overcrowding. Few studies have identified predictors of ED use integrating service use correlates, particularly among patients with cannabis-related disorders (CRD). This study compared predictors of low (1-2 visits/year) or frequent (3+ visits/year) ED use with no ED use for a cohort of 9836 patients with CRD registered at Quebec (Canada) addiction treatment centres in 2012-2013.

METHODS

This longitudinal study used multinomial logistic regression to evaluate clinical, sociodemographic and service use variables from various databases as predictors of the frequency of ED use for any medical reason in 2015-2016 among patients with CRD.

RESULTS

Compared to non-ED users with CRD, frequent ED users included more women, rural residents, patients with serious MD and chronic CRD, dropouts from programs in addiction treatment centres and with less continuity of physician care. Compared with non-users, low ED users had more common MD and there more workers than students.

DISCUSSION AND CONCLUSIONS

Multimorbidity, including MD, chronic physical illnesses and other substance-related disorders than CRD, predicted more ED use and explained frequent use of outpatient services and prior specialised acute care, as did being 12-29 years, after controlling for all other covariates. Better continuity of physician care and reinforcement of programs like assertive community or integrated treatment, and chronic primary care models may protect against frequent ED use. Strategies like screening, brief intervention and treatment referral, including motivational therapy for preventing treatment dropout may also be expanded to decrease ED use.

Relationship between continuity of care and clinical outcomes in patients with dyslipidemia in Korea: a real world claims database study

Dyslipidemia is a risk factor for atherosclerotic cardiovascular disease and requires proactive management. This study aimed to investigate the association between care continuity and the outcomes of patients with dyslipidemia. We conducted a retrospective cohort study on patients with dyslipidemia by employing the Korea National Health Insurance claims database during the period 2007–2018. The Continuity of Care Index (COCI) was used to measure continuity of care. We considered incidence of atherosclerotic cardiovascular disease as a primary outcome. A Cox's proportional hazards regression model was used to quantify risks of primary outcome. There were 236,486 patients newly diagnosed with dyslipidemia in 2008 who were categorized into the high and low COC groups depending on their COCI. The adjusted hazard ratio for the primary outcome was 1.09 times higher (95% confidence interval: 1.06–1.12) in the low COC group than in the high COC group. The study shows that improved continuity of care for newly-diagnosed dyslipidemic patients might reduce the risk of atherosclerotic cardiovascular disease.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

BACKGROUND

Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.

AIM

To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

DESIGN AND SETTING

Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

METHOD

Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

RESULTS

Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years.

CONCLUSION

Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.

Continuity of GP care for patients with dementia: impact on prescribing and the health of patients

Background

Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown.

Aim

To estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia.

Design and setting

A retrospective cohort study with 1 year of follow-up anonymised medical records from 9324 patients with dementia, aged ≥65 years living in England in 2016.

Method

CGPC measures include the Usual Provider of Care (UPC), Bice–Boxerman Continuity of Care (BB), and Sequential Continuity (SECON) indices. Regression models estimated associations with PIPs and survival analysis with incidence of AHOs during the follow-up adjusted for age, sex, deprivation level, 14 comorbidities, and frailty.

Results

The highest quartile (HQ) of UPC (highest continuity) had 34.8% less risk of delirium (odds ratio [OR] 0.65, 95% confidence interval [CI] = 0.51 to 0.84), 57.9% less risk of incontinence (OR 0.42, 95% CI = 0.31 to 0.58), and 9.7% less risk of emergency admissions to hospital (OR 0.90, 95% CI = 0.82 to 0.99) compared with the lowest quartile. Polypharmacy and PIP were identified in 81.6% (n = 7612) and 75.4% (n = 7027) of patients, respectively. The HQ had fewer prescribed medications (HQ: mean 8.5, lowest quartile (LQ): mean 9.7, P<0.01) and had fewer PIPs (HQ: mean 2.1, LQ: mean 2.5, P<0.01), including fewer loop diuretics in patients with incontinence, drugs that can cause constipation, and benzodiazepines with high fall risk. The BB and SECON measures produced similar findings.

Conclusion

Higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.

Assessment of the effects of methodological choice in continuity of care research: a real-world example with dyslipidaemia cohort

OBJECTIVE

To determine if the choice of methodological elements affects the results in continuity of care studies.

DESIGN

This is a retrospective cohort study. The association between continuity of care and clinical outcome was investigated using the Continuity of Care Index. The association was explored in 12 scenarios based on four definitions of the relative timing of continuity and outcome measurements in three populations (three Ps × four Ts).

SETTING

National Health Insurance claims from all primary and secondary care facilities in South Korea between 2007 and 2015.

PARTICIPANTS

Participants were patients diagnosed with dyslipidaemia, made ≥2 ambulatory visits and were newly prescribed with ≥1 antihyperlipidaemic agent at an ambulatory setting in 2008. Three study populations were defined based on the number of ambulatory visits: 10 084 patients in population 1 (P1), 8454 in population 2 (P2) and 4754 in population 3 (P3).

MAIN OUTCOME MEASURE

Hospitalisation related to one of the four atherosclerotic cardiovascular diseases, including myocardial infarction, stable or unstable angina, ischaemic stroke and transient ischaemic attack.

RESULTS

Concurrent measure of continuity and outcome (T1) showed a significantly higher risk of hospitalisation (adjusted HRs: 2.73-3.07, p<0.0001) in the low continuity of care group, whereas T2, which measured continuity until the outcome occurred, showed no risk difference between the continuity of care groups. T3, which measured continuity as a time-varying variable, had adjusted HRs of 1.31-1.55 (p<0.05), and T4, measuring continuity for a predefined period and measuring outcomes in the remaining period, had adjusted HRs of 1.34-1.46 (p<0.05) in the low continuity of care. Within each temporal relationship, the effect estimates became more substantial as the inclusion criteria became stricter.

CONCLUSIONS

The study design in continuity of care studies should be planned carefully because the results are sensitive to the temporal relationship between continuity and outcome and the population selection criteria.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia

BACKGROUND

Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization.

METHODS

National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities.

RESULTS

Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities.

CONCLUSION

Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.

Effects of continuity of care on health outcomes among patients with diabetes mellitus and/or hypertension: a systematic review

Background

The rising prevalence of non-communicable diseases (NCDs) such as diabetes mellitus (DM) and hypertension (HT) has placed a tremendous burden on healthcare systems around the world, resulting in a call for more effective service delivery models. Better continuity of care (CoC) has been associated with improved health outcomes. This review examines the association between CoC and health outcomes in patients with DM and/or HT.

Methods

This was a systematic review with searches carried out on 13 March 2021 through PubMed, Embase, MEDLINE and CINAHL plus, clinical trials registry and bibliography reviews. Eligibility criteria were: published in English; from 2000 onwards; included adult DM and/or HT patients; examined CoC as their main intervention/exposure; and utilised quantifiable outcome measures (categorised into health indicators and service utilisation). The study quality was evaluated with Critical Appraisal Skills Programme (CASP) appraisal checklists.

Results

Initial searching yielded 21,090 results with 42 studies meeting the inclusion criteria. High CoC was associated with reduced hospitalisation (16 out of 18 studies), emergency room attendances (eight out of eight), mortality rate (six out of seven), disease-related complications (seven out of seven), and healthcare expenses (four out of four) but not with blood pressure (two out of 13), lipid profile (one out of six), body mass index (zero out of three). Six out of 12 studies on diabetic outcomes reported significant improvement in haemoglobin A1c by higher CoC. Variations in the classification of continuity of care and outcome definition were identified, making meta-analyses inappropriate. CASP evaluation rated most studies fair in quality, but found insufficient adjustment on confounders, selection bias and short follow-up period were common limitations of current literatures.

Conclusion

There is evidence of a strong association between higher continuity of care and reduced mortality rate, complication risks and health service utilisation among DM and/or HT patients but little to no improvement in various health indicators. Significant methodological heterogeneity in how CoC and patient outcomes are assessed limits the ability for meta-analysis of findings. Further studies comprising sufficient confounding adjustment and standardised definitions are needed to provide stronger evidence of the benefits of CoC on patients with DM and/or HT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01493-x.

Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders

Few studies have examined predictors of recurrent high ED use. This study assessed predictors of recurrent high ED use over two and three consecutive years, compared with high one-year ED use. This five-year longitudinal study is based on a cohort of 3121 patients who visited one of six Quebec (Canada) ED at least three times in 2014–2015. Multinomial logistic regression was performed. Clinical, sociodemographic and service use variables were identified based on data extracted from health administrative databases for 2012–2013 to 2014–2015. Of the 3121 high ED users, 15% (n = 468) were recurrent high ED users for a two-year period and 12% (n = 364) over three years. Patients with three consecutive years of high ED use had more personality disorders, anxiety disorders, alcohol or drug related disorders, chronic physical illnesses, suicidal behaviors and violence or social issues. More resided in areas with high social deprivation, consulted frequently with psychiatrists, had more interventions in local community health service centers, more prior hospitalizations and lower continuity of medical care. Three consecutive years of high ED use may be a benchmark for identifying high users needing better ambulatory care. As most have multiple and complex health problems, higher continuity and adequacy of medical care should be prioritized.

Influence of organization and demographic characteristics of primary care practices on continuity of care: analysis of a retrospective cohort from 287 primary care practices covering about 6 million people in Catalonia

Background

There is evidence that an ongoing patient-physician relationship is associated with improved health outcomes and more efficient health systems. The main objective of this study is to describe the continuity of care in primary healthcare in Catalonia (Spain) and to analyze whether the organization of primary care practices (PCP) or their patients’ sociodemographic characteristics play a role in its continuity of care.

Methods

Four indices were used to measure continuity of care: Usual Provider Index (UPC), Modified Modified Continuity Index (MMCI), Continuity of Care Index (COC), and Sequential Continuity Index (SECON). The study was conducted on 287 PCP of the Catalan Institute of Health (Institut Català de la Salut—ICS). Each continuity of care index was calculated at the patient level (3.2 million patients and 35.5 million visits) and then aggregated at the PCP level. We adjusted linear regression models for each continuity index studied, considering the result of the index as an independent variable and demographic and organizational characteristics of the PCP as explanatory variables. Pearson correlation tests were used to compare the four continuity of care indices.

Results

Indices’ results were: UPC: 70,5%; MMCI: 73%; COC: 53,7%; SECON: 60,5%. The continuity of care indices had the highest bivariate correlation with the percentage of appointments booked with an assigned health provider (VISUBA variable: the lower the value, the higher the visits without an assigned health provider, and thus an organization favoring immediate consultation). Its R² ranged between 56 and 63%, depending on the index. The multivariate model which explained better the variability of continuity of care indices (from 49 to 56%) included the variables VISUBA and rurality with a direct relationship; while the variables primary care physician leave days and training practices showed an inverse relationship.

Conclusion

Study results suggest that an organization of primary care favoring immediate consultation is related to a lower continuity of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01414-y.

Retrospective cohort study to investigate the 10-year trajectories of disease patterns in patients with hypertension and/or diabetes mellitus on subsequent cardiovascular outcomes and health service utilisation: a study protocol

INTRODUCTION

Hypertension (HT) and diabetes mellitus (DM) and are major disease burdens in all healthcare systems. Given their high impact on morbidity, premature death and direct medical costs, we need to optimise effectiveness and cost-effectiveness of primary care for patients with HT/DM. This study aims to find out the association of trajectories in disease patterns and treatment of patients with HT/DM including multimorbidity and continuity of care with disease outcomes and service utilisation over 10 years in order to identify better approaches to delivering primary care services.

METHODS AND ANALYSIS

A 10-year retrospective cohort study on a population-based primary care cohort of Chinese patients with documented doctor-diagnosed HT and/or DM, managed in the Hong Kong Hospital Authority (HA) public primary care clinics from 1 January 2006 to 31 December 2019. Data will be extracted from the HA Clinical Management System to identify trajectory patterns of patients with HT/DM. Complications defined by ICPC-2/International Classification of Diseases-Ninth Revision, Clinical Modification diagnosis codes, all-cause mortality rates and public service utilisation rates are included as independent variables. Changes in clinical parameters will be investigated using a growth mixture modelling analysis with standard quadratic trajectories. Dependent variables including effects of multimorbidity, measured by (1) disease count and (2) Charlson's Comorbidity Index, and continuity of care, measured by the Usual Provide Continuity Index, on patient outcomes and health service utilisation will be investigated. Multivariable Cox proportional hazards regression will be conducted to estimate the effect of multimorbidity and continuity of care after stratification of patients into groups according to respective definitions.

ETHICS AND DISSEMINATION

This study was approved by the institutional review board of the University of Hong Kong-the HA Hong Kong West Cluster, reference no: UW 19-329. The study findings will be disseminated through peer-reviewed publications and international conferences.

TRIAL REGISTRATION NUMBER

NCT04302974.

Impact of Co-occurring Mental Disorders and Chronic Physical Illnesses on Frequency of Emergency Department Use and Hospitalization for Mental Health Reasons

Background: Patients with mental disorders (MD) are at high risk for a wide range of chronic physical illnesses (CPI), often resulting in greater use of acute care services. This study estimated risk of emergency department (ED) use and hospitalization for mental health (MH) reasons among 678 patients with MD and CPI compared to 1,999 patients with MD only. Methods: Patients visiting one of six Quebec (Canada) ED for MH reasons and at onset of a MD in 2014-15 (index year) were included. Negative binomial models comparing the two groups estimated risk of ED use and hospitalization at 12-month follow-up to index ED visit, controlling for clinical, sociodemographic, and service use variables. Results: Patients with MD, more severe overall clinical conditions and those who received more intensive specialized MH care had higher risks of frequent ED use and hospitalization. Continuity of medical care protected against both ED use and hospitalization, while general practitioner (GP) consultations protected against hospitalization only. Patients aged 65+ had lower risk of ED use, whereas risk of hospitalization was higher for the 45-64- vs. 12-24-year age groups, and for men vs. women. Conclusion: Strategies including assertive community treatment, intensive case management, integrated co-occurring treatment, home treatment, and shared care may improve adequacy of care for patients with MD-CPI, as well as those with MD only whose clinical profiles were severe. Prevention and outreach strategies may also be promoted, especially among men and older age groups.

Factors Related to 30-day Readmission following Hospitalization for Any Medical Reason among Patients with Mental Disorders: Facteurs liés à la réhospitalisation à 30 jours suivant une hospitalisation pour une raison médicale chez des patients souffrant de troubles mentaux

OBJECTIVE

This study evaluated the contributions of clinical, sociodemographic, and service use variables to the risk of early readmission, defined as readmission within 30 days of discharge following hospitalization for any medical reason (mental or physical illnesses), among patients with mental disorders in Quebec (Canada).

METHODS

In this longitudinal study, 2,954 hospitalized patients who had visited 1 of 6 Quebec emergency departments (ED) in 2014 to 2015 (index year) were identified through clinical administrative databanks. The first hospitalization was considered that may have occurred at any Quebec hospital. Data collected between 2012 and 2013 and 2013 and 2014 on clinical, sociodemographic, and service use variables were assessed as related to readmission/no readmission within 30 days of discharge using hierarchical binary logistic regression.

RESULTS

Patients with co-occurring substance-related disorders/chronic physical illnesses, serious mental disorders, or adjustment disorders (clinical variables); 4+ outpatient psychiatric consultations with the same psychiatrist; and patients hospitalized for any medical reason within 12 months prior to index hospitalization (service use variables) were more likely to be readmitted within 30 days of discharge. Patients who made 1 to 3 ED visits within 1 year prior to the index hospitalization, had their index hospitalization stay of 16 to 29 days, or consulted a physician for any medical reason within 30 days after discharge or prior to the readmission (service use variables) were less likely to be rehospitalized.

CONCLUSIONS

Early hospital readmission was more strongly associated with clinical variables, followed by service use variables, both playing a key role in preventing early readmission. Results suggest the importance of developing specific interventions for patients at high risk of readmission such as better discharge planning, integrated and collaborative care, and case management. Overall, better access to services and continuity of care before and after hospital discharge should be provided to prevent early hospital readmission.

Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study

OBJECTIVES

To control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan's National Health Insurance Administration (NHIA) launched the 'early-CKD programme' in 2011 to extend care and education to patients with CKD. This study aims to evaluate the effectiveness of the early-CKD programme in terms of continuity of care (COC).

DESIGN AND PARTICIPANTS

This study used secondary data from 2010 to 2014 provided by the NHIA to identify 86 581 participants each for the intervention and control groups. Patients with CKD who participated in the early-CKD programme between 2011 and 2013 were defined as the intervention group. For the control group, propensity score matching was used to select patients with CKD who did not participate in the programme, but were seen by the same group of physicians.

INTERVENTION

A multidisciplinary care model for patients with early CKD launched in 2011.

PRIMARY OUTCOME MEASURES

Outcome variables included the continuity of care index (COCI), which measures a physician's COC; number of essential examinations; and resource utilisation. To better identify the difference between groups, we separated COCI into two groups based on mean: high (above mean) and low (below mean). A generalised estimating equation model was used to examine the effects of the early-CKD programme.

RESULTS

The programme significantly increased the number of essential examinations/tests administered to patients (β=0.61, p<0.001) and improved COCI between physicians and patients (OR=4.18, p<0.001). Medical expenses (β=1.03, p<0.001) and medication expenses (β=0.23, p<0.001) significantly increased after the programme was implemented, but patients' kidney-related hospitalisations and emergency department visits decreased (β=-0.13, p<0.001).

CONCLUSION

From the COC viewpoint, the programme in Taiwan showed a positive effect on COCI, number of essential examinations and resource utilisation.

Guideline Concordance of Statin Treatment Decisions: A Retrospective Cohort Study

Guidelines recommend initiation of statins depending on cardiovascular risk and low-density lipoprotein cholesterol (LDL-C) levels. In this retrospective cohort study, we aimed to assess guideline concordance of statin treatment decisions and to find determinants of undertreatment in Swiss primary care in the period 2016–2019. We drew on electronic medical records of 8060 statin-naive patients (50.0% female, median age 59 years) with available LDL-C levels and cardiovascular risk. Guideline concordance was assessed based on the recommendations of the European Society of Cardiology, and multilevel logistic regression was performed to find determinants of undertreatment. We found that statin treatment was initiated in 10.2% of patients during one year of follow up. Treatment decisions were classified as guideline-concordant in 63.0%, as undertreatment in 35.8% and as overtreatment in 1.2%. Among determinants of undertreatment were small deviation from LDL-C treatment thresholds (odds ratio per decrease by 1 mmol/L: 2.09 [95% confidence interval 1.87–2.35]), high compared with very high cardiovascular risk (1.64 [1.30–2.05]), female sex (1.31 [1.05–1.64]), and being treated by older general practitioners (per 10 year decrease: 0.74 [0.61–0.90]). In conclusion, undertreatment of patients at high or very high cardiovascular risk was common, but general practitioners considered cardiovascular risk and LDL-C in their treatment decisions.

Impact of continuity of care on cardiovascular disease risk among newly-diagnosed hypertension patients

Several previous studies have noted benefits of maintaining continuity of care (COC), including improved patient compliance, decreased health care cost, and decreased incidence of hospitalization. However, the association of COC in hypertension patients with subsequent cardiovascular disease (CVD) risk is yet unclear. Therefore, we aimed to investigate the impact of COC on CVD risk among newly-diagnosed hypertension patients. We conducted a cohort with a study population consisted of 244,187 newly-diagnosed hypertension patients in 2004 from the Korean National Health Insurance Service database. The participants were then divided into approximate quartiles of COC index, and followed from 1 January 2007 until 31 December 2017. Cox proportional hazards models were used to evaluate the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD risk according to quartiles. Compared to patients within the lowest quartile of COC index, those within the highest quartile of COC index had reduced risk for CVD (aHR 0.76, 95% confidence interval; CI 0.73–0.79), CHD (aHR 0.66, 95% CI 0.62–0.69) and stroke (aHR 0.84, 95% CI 0.80–0.88). COC among hypertension patients was associated with improved medication compliance and reduced risk of stroke and CVD. The importance of maintaining COC should be emphasized to reduce the risk of CVD among hypertension patients.

Longitudinal continuity of care during antenatal and delivery in the Volta Region of Ghana

OBJECTIVE

To determine the extent of longitudinal continuity of care (CoC) during pregnancy and delivery in the Volta Region of Ghana.

METHODS

Longitudinal data were used from the National Health Insurance Claims Dataset for the period January to December 2013 for pregnant women who sought antenatal and delivery care in the region. Pregnant women who delivered at a health facility with at least three visits were included in the study. Five CoC indices were calculated for each pregnant woman.

RESULTS

Of the 14 474 pregnant women included in the study, 58.4% had perfect CoC. Mean CoC indices were: most frequent provider continuity (MFPC) 0.82 ± 0.25; modified, modified continuity index (MMCI) 0.86 ± 0.20; continuity of care index (COCI) 0.76 ± 0.30; sequential continuity index (SECON) 0.80 ± 0.28; and place of delivery continuity (PDC) 0.68 ± 0.41.

CONCLUSION

There are relatively medium to high levels of CoC indices during pregnancy and delivery, with place of delivery CoC having the lowest score, an indication that more pregnant women switched providers during delivery. There is a need for policy to ensure CoC during pregnancy.

Continuity of care and its associations with self-reported health, clinical characteristics and follow-up services after percutaneous coronary intervention

AIMS

Complexity of care in patients with coronary artery disease is increasing, due to ageing, improved treatment, and more specialised care. Patients receive care from various healthcare providers in many settings. Still, few studies have evaluated continuity of care across primary and secondary care levels for patients after percutaneous coronary intervention (PCI). This study aimed to determine multifaceted aspects of continuity of care and associations with socio-demographic characteristics, self-reported health, clinical characteristics and follow-up services for patients after PCI.

METHODS

This multi-centre prospective cohort study collected data at baseline and two-month follow-up from medical records, national registries and patient self-reports. Univariable and hierarchical regressions were performed using the Heart Continuity of Care Questionnaire total score as the dependent variable.

RESULTS

In total, 1695 patients were included at baseline, and 1318 (78%) completed the two-month follow-up. Patients stated not being adequately informed about lifestyle changes, medication and follow-up care. Those experiencing poorer health status after PCI scored significantly worse on continuity of care. Patients with ST-segment elevation myocardial infarction scored significantly better on informational and management continuity than those with other cardiac diagnoses. The regression analyses showed significantly better continuity (P ≤ 0.034) in patients who were male, received written information from hospital, were transferred to another hospital before discharge, received follow-up from their general practitioner or had sufficient consultation time after discharge from hospital.

CONCLUSION

Risk factors for sub-optimal continuity were identified. These factors are important to patients, healthcare providers and policy makers. Action should be taken to educate patients, reconcile discharge plans and organise post-discharge services. Designing pathways with an interdisciplinary approach and shared responsibility between healthcare settings is recommended.

Continuity of Care in Swiss Cancer Patients Using Claims Data

BACKGROUND

Continuity of care is positively associated with beneficial patient outcomes. Data on the level of continuity of care in the ambulatory setting in Switzerland are lacking.

AIM

The aim of this study was to evaluate continuity of care in Swiss cancer patients based on routine data of mandatory health insurance using four established continuity scales.

METHODS

Retrospective analysis of Swiss claims data (N=23'515 patients with incident use of antineoplastics). The Usual Provider Continuity score, the Modified Modified Continuity Index, the Continuity of Care index, and the Sequential Continuity Index were analyzed based on consultations with general practitioners (GPs), physician specialists and ambulatory hospital wards.

RESULTS

Using information of health insurance claims, the number of consultations and the general level of continuity of care in Swiss cancer patients are high. Continuity of care scores were significantly associated with sociodemographic and regional factors. When focusing on consultations with GPs only, all four scores consistently showed high values indicating high levels of continuity. Continuity with general practitioners was associated with lower costs and lower risks for hospitalization and death.

CONCLUSION

This is the first study giving insight into continuity of care in Swiss cancer patients. The present study shows that continuity of care is measurable using health insurance claims data. It indicates that continuity with general practitioners is associated with a beneficial outcome.

Visit Entropy Associated with Diabetic Control Outcomes

BACKGROUND

Chronic diseases such as type 2 diabetes place a large burden on the health care system and are associated with increased morbidity and mortality. A team-based multidisciplinary approach that organizes care to improve chronic disease management may actually decrease traditional continuity of care metrics. Visit entropy (VE) provides a novel measure of care organization produced by team-based approaches. Higher VE, reflecting more disorganized care, has been associated with more hospital readmissions. We hypothesized that higher VE was also associated with reduced adherence to the D5 quality criteria.

METHODS

A retrospective study of 6590 adult diabetic patients in 5 established medical home practices was conducted. Multivariate logistic regression was used to determine if VE was associated with the dependent variable of D5 control. Separate models for usual provider continuity, continuity of care index, and sequence continuity were also constructed.

RESULTS

Less organized care with a higher VE was associated with decreased odds of D5 control (odds ratio = 0.88; 95% confidence interval, 0.80 to 0.97). The other continuity measures were not significant. Age, education level, and initial HgA1c were significant covariates, but sex, race, endocrine consults, and Charlson comorbidity were not significant. The Number Needed to be Exposed to more organized care to produce 1 more controlled diabetic was 32.5.

CONCLUSIONS

More organized care reflected by a lower VE is associated with improved odds of D5 diabetic control. VE represents a better measure of care organization in team-based medical home environments than traditional continuity of care metrics.

Effect of fragmentation of cancer care on treatment use and survival in hepatocellular carcinoma

BACKGROUND

Fragmented cancer care (FC), or care received from multiple institutions, increases systemic health care costs and potentiates cancer care disparities. There is a paucity of data on mechanisms contributing to FC and the resulting effect on patient outcomes. This study characterized patient- and hospital-level factors associated with FC, time to treatment (TTT), and overall survival (OS) in patients with hepatocellular carcinoma (HCC).

METHODS

Patients newly diagnosed with HCC from 2004 to 2015 and receiving treatment were identified in the Texas Cancer Registry. Patient- and hospital-level factors were compared across 2 cohorts: an FC treatment group and a nonfragmented cancer care (NFC) treatment group. Covariate-adjusted treatment use and OS were compared between the 2 treatment groups.

RESULTS

Among 4329 patients with HCC, 1185 (27.4%) received FC, and 3144 (72.6%) received NFC. Compared with NFC patients, FC patients had larger tumors (median size ≥4 cm, 52.6% vs 35.2%; P < .001), and a higher proportion had a regional/metastatic stage (35.9% vs 26.7%; P < .001). Among patients with localized disease, FC was associated with decreased odds of curative therapy (odds ratio, 0.83; 95% confidence interval [CI], 0.7-0.9). FC was associated with worse OS (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24) and increased TTT (HR, 0.76; 95% CI, 0.7-0.8). In the subset of patients with localized-stage HCC who received curative therapy, FC was associated with worse OS (median survival, 67 vs 43 months; HR, 1.2; 95% CI, 1.0-1.4) and increased TTT (HR, 0.74; 95% CI, 0.7-0.8).

CONCLUSIONS

FC patients were less likely to undergo curative therapy when they were diagnosed at an early stage. After covariate adjustment, newly diagnosed patients with HCC receiving FC had worse OS and increased TTT.

Cancer care continuity: A qualitative study on the experiences of French healthcare professionals, patients and family caregivers

Introduction

Continuity of care has many positive outcomes. Yet, in oncology, it may rapidly be disrupted. It is therefore essential to investigate the perceptions of users. Our aim was thus to describe and compare the perceptions of cancer care continuity of patients, family caregivers and various healthcare professionals involved in cancer care in France, one of the countries most affected by cancer.

Methods

The urology and senology cancer departments of two hospitals, as well as community physicians, were involved: 54 hospital healthcare professionals including mainly physicians, nurses and medical secretaries; 12 city physicians; 41 patients and their family caregivers. We carried out a qualitative study using N-Vivo® and a deductive approach to code the interviews into the following dimensions of continuity: informational, organisational and relational.

Results

Three different perspectives were highlighted: hospital healthcare professionals primarily focused on organisational aspects (71% of their discourse), city physicians on their need for information from hospitals (40% of their discourse) and patients/caregivers on relational aspects with professionals (51% of their discourse). However, the three dimensions of continuity were intertwined, as the major focus of each type of participant impacted their perspective of the other spheres of coordination.

Discussion

Working on the main perspective of each category of person involved in cancer care could improve, in turn, the other spheres of continuity for these people. For example, dealing with organisational issues with hospital physicians could be an indirect and original way to enhance their relationships with patients, which are so important to the latter.