A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire

Factors affecting the experience of joined-up, continuous primary care in the absence of relational continuity: an observational study

BACKGROUND

There is an international trend towards the at-scale provision of primary care services, with such services often provided in different settings by a clinician unfamiliar to the patient. It is often assumed that, in the absence of relational continuity, any competent clinician can deliver joined-up, continuous care if they have access to clinical notes.

AIM

To explore the factors that affect the potential for providing joined-up, continuous care in a system where care is delivered away from a patient's regular practice, by a different organisation and set of staff.

DESIGN AND SETTING

Case studies of two extended-access providers in the north of England.

METHOD

Case studies were carried out between September 2021 and January 2022 in two sites. Data collected included observations of patient-healthcare professional interactions, interviews with staff and patients, and documentation. Analysis took place using a constant comparison approach. Data were coded. A model of the factors affecting continuity was constructed.

RESULTS

The potential for joined-up, continuous care appears dependent on staff, patient, and system factors. This includes diverse elements such as the attitude of clinicians to care coordination and the ability of an organisation to retain staff.

CONCLUSION

Healthcare systems increasingly rely on the assumption that any competent clinician can deliver joined-up, continuous care if they have access to clinical notes. This appears not to be the case. This study presents a model of factors affecting the patient's experience of continuity. The model needs validating in in-hours general practice and other settings.

Women's Empowerment in the Context of Rural West Bengal: An Index Construction with Exploratory Factor Analysis

Background

Women's empowerment, a precondition of sustainable development, is a multidimensional and complex concept, often described with three interrelated components: resources, agency, and achievement. There is no universal construct for women's empowerment; rather, it has been assessed based on the context. It had been hardly explored in rural West Bengal.

Objectives

This study was formulated to construct a women's empowerment index (WEI), in rural West Bengal, and assess the reliability of the index.

Methods

A community-based cross-sectional study focusing on Women's Empowerment, Child Health and Nutrition (WE-CHANT) was conducted in a community development block in West Bengal. Mother (of reproductive age)-child (6-59 months) pairs were recruited from 20 villages by two-stage sampling (n = 268). Mothers were interviewed. Exploratory factor analysis (EFA) with oblique rotation was conducted with 25 measurement variables to construct the WEI. The internal consistency was assessed with Cronbach's alpha, item-rest, average inter-item, inter-domain, and domain-to-index correlation.

Results

A 12-item (factor loading ≥0.40) WEI comprising three domains-decision-making power, attitude toward gender-based violence (GBV), and social independence-was constructed with acceptable internal consistency (Cronbach's alpha = 0.747). The multidimensionality of the index was also observed.

Conclusion

A concise agency-based WEI was constructed, where decision-making power was explored as the major domain. This index in the context of rural West Bengal could be further utilized to assess women's empowerment and elicit its association with resources and achievements.

Continuity of care among diabetic patients in Accra, Ghana

Introduction

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

Methodology

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

Results

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

Conclusion

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

Does continuity of care improve patient satisfaction? An instrumental variable approach

Numerous studies have investigated the relationship between continuity of care (COC) and patient satisfaction. However, COC and patient satisfaction were measured simultaneously; therefore, the direction of causality remains understudied. This study examined the effect of COC on the patient satisfaction of elderly individuals using an instrumental variable (IV) approach. Nationwide survey data acquired using a face-to-face interview were used to measure the patient-reported COC experiences of 1,715 participants. We applied an ordered logit model controlled for observed patient characteristics and a two-stage residual inclusion (2SRI) ordered logit model that accounted for unobserved confounding factors. Patient-perceived COC importance was used as an IV for patient-reported COC. The ordered logit models indicated that patients with high or intermediate patient-reported COC scores were more likely to perceive more patient satisfaction than those with low COC scores. Using the patient-perceived COC importance as an IV, we examined a strong significant association between the level of patient-reported COC and patient satisfaction. It is necessary to adjust for unobserved confounders to obtain more accurate estimates of the relationship between patient-reported COC and patient satisfaction. However, the results and policy implications of this study should be cautiously interpreted because the possibility of other bias could not be ruled out. These findings support policies aimed at improving patient-reported COC among older adults.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: A mixed-mode survey

Objective

Routine measurement of patient safety from the patients’ perspective receives increasing attention as an important component of safety measurement systems. The aim of this study was to examine patients’ experience with patient safety in ambulatory care and the results’ implications for routine patient safety measurement in ambulatory care.

Design

Cross-sectional mixed-mode survey.

Setting

General practitioner and specialist practices.

Participants

Patients aged >18 years seeking care in ambulatory care practices between February and June 2020.

Methods

A 22-item-questionnaire was completed in the practice or at home either on paper or online. Multivariate logistic regression was used to analyse the influence of survey mode and patient characteristics on patient experience with patient safety.

Results

The overall response rate was 71.1%. Most patients completed the questionnaire on site (76.6%) and on paper (96.1%). Between 30.1% to 68.5% of the respondents report the most positive option for patient experience with the main domains of patient safety. A total of 2.9% of patients reported having experienced a patient-safety event (PSE) during the last 12 months. Patients who filled in the questionnaire off site were more likely to report negative experiences for the scales communication & information (OR 1.2, 95% CI 1.0–1.5), rapport & participation (OR 1.4, 95% CI 1.1–1.7) and access (OR 1.3, 95% CI 0.9–1.4) than those who completed it on site. Those who chose a paper questionnaire were more likely to report negative experiences for all five scales compared to web responders.

Conclusion

Routine measurement of patient experience with factors contributing to the occurrence of PSEs can achieve high response rates by offering flexible participation options. Results gained from mixed-mode surveys need to take mode-effects into account when interpreting and using the results. Further research is needed in how to adequately assess number and type of experienced events in routine measurements.

Assessing the Impact of Clinical Coordination Interventions on the Continuity of Care for Patients With Chronic Conditions: Participatory Action Research in Five Latin American Countries

Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care -i.e. from the patient perspective- particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five LA countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and of clinical management. Descriptive analyses were conducted and Poisson regression models with robust variance fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and of clinical management (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile, and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Association of Continuity of General Practitioner Care with Utilisation of General Practitioner and Specialist Services in China: A Mixed-Method Study

Background: Continuity of general practitioner (GP) care, widely known as the core value of high-quality patient care, has a positive association with health outcomes. Evidence about the relationship between continuity and health service utilisation has so far been lacking in China. This study aimed to analyse the association of continuity of GP care with utilisation of general practitioner and specialist services in China. Method: A cross-sectional mixed methods study was conducted in 10 urban communities in Hangzhou. Quantitative data were collected from a random sample of 624 residents adopting the self-developed questionnaire. Measurement of continuity of GP care included informational continuity (IC), managerial continuity (MC) and relational continuity (RC). With adjustment for characteristics of residents, multivariate regression models were established to examine the association of continuity of GP care with the intention to visit GP, frequency of GP and specialist visitations. Qualitative data were collected from 26 respondents using an in-depth interview, and thematic content analysis for qualitative data was conducted. Results: Quantitative analysis showed that the IC was positively associated with the intention to visit GP and frequency of GP visitations. Those people who gave a high rating for RC also used GP services more frequently than their counterparts. MC was negatively associated with frequency of specialist visitations. Qualitative analysis indicated that service capabilities, doctor-patient interaction and time provision were regarded as three important reasons why patients chose GPs or specialists. Conclusions: Overall, high IC and RC are independently associated with more GP service utilisation, but a high MC might reduce specialist visitations. Continuity of GP care should be highlighted in designing a Chinese GP system.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Care continuity across levels of care perceived by patients with chronic conditions in six Latin-American countries

OBJECTIVE

To analyse the care continuity across levels of care perceived by patients with chronic conditions in public healthcare networks in six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and to explore associated factors.

METHOD

Cross-sectional study by means of a survey conducted to a random sample of chronic patients in primary care centres of the study networks (784 per country) using the questionnaire Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA)©. Patients had at least one chronic condition and had used two levels of care in the 6 months prior to the survey for the same medical condition. Descriptive analysis and multivariable logistic regression were carried out.

RESULTS

Although there are notable differences between the networks analysed, the results show that chronic patients perceive significant discontinuities in the exchange of clinical information between primary care and secondary care doctors and in access to secondary care following a referral; as well as, to a lesser degree, regarding clinical coherence across levels. Relational continuity with primary care and secondary care doctors and information transfer are positively associated with care continuity across levels; no individual factor is systematically associated with care continuity.

CONCLUSIONS

Main perceived discontinuities relate to information transfer and access to secondary care after a referral. The study indicates the importance of organisational factors to improve chronic patients' quality of care.

Patients' perceptions of continuity of care across primary care level and emergency departments in Belgium: cross-sectional survey

OBJECTIVES

To assess patients' perceptions of continuity of care (COC) across primary care level and emergency departments (EDs) and to identify contextual and individual factors that influence this perception.

DESIGN

Cross-sectional multicentre survey.

SETTING

Five EDs in Brussels and Wallonia.

PARTICIPANTS

501 adult patients referred to the ED by their primary care physician (PCP). Patients with cognitive impairment or in critical condition were excluded.

RESULTS

Patients perceived high levels of the three types of COC. On an individual level, older patients showed a perception of higher levels of continuity. Lower levels of informational and management continuity were observed among patients suffering from chronic diseases and patients with a high level of education. Patients also perceived a redundancy of medical exams, in parallel to a high degree of accessibility between care levels. On an organisational level, three structural factors were identified as barriers to COC, namely, ED workload, suboptimal sharing information system and the current fee-for-service payment system that encourages competition and hinders coordination between actors.

CONCLUSION

Belgian healthcare services seem satisfying for patients and easily accessible. However, efforts need to be directed towards improving their efficiency. A stronger primary care level is also needed to benefit the healthcare system by reducing overuse of emergency services. On the individual level, a more enhanced patient-centred approach could be beneficial in improving patients experience of care.

Impact of different models of improvement of continuity of care on lipid control and the delay of visits to cardiology

Aims: To analyze the impact of implementing three different models of continuity of care on the delay of first visits to the cardiologist (management end point) and on LDL-cholesterol control rates among patients with atherosclerotic vascular disease (clinical end point). Methods: Observational, longitudinal and retrospective study of patients with cardiovascular disease and LDL-cholesterol ≥70 mg/dl attended in three hospitals (H1/H2/H3). In H1 and H2, a virtual system (telecardiology) was developed (in H1, internal audits and specific medical education were also performed). In H3 a cardiologist was integrated into the primary care center. Results: The delay of visits to cardiologist significantly improved from 66.5 ± 29.1 days to 34.1 ± 14.1 days (p < 0.001), as well as the intensification of lipid-lowering treatment and the achievement of lipid goals. LDL-cholesterol control rates were higher in H1 and the reduction of the delay of visits in H3. Conclusion: Continuity of care is associated with improvements in management and clinical end points.

Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China

BACKGROUND

This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors.

METHODS

A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity.

RESULTS

Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs.

CONCLUSION

Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.

Questionnaires that measure the quality of relationships between patients and primary care providers: a systematic review

Background

International guidance on models of care stress the importance of good quality, continuous patient-provider relationships to support high quality and efficient care and hospital avoidance. However, assessing the quality of patient-provider relationships is challenging due to its experiential nature. The aim of this study was to undertake a systematic review to identify questionnaires previously developed or used to assess the quality of continuous relationships between patients and their provider in primary care.

Methods

MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and SCOPUS databases were searched for English language studies published between 2009 and 2017. Key terms used identified studies conducted in the primary care setting examining relationships between patients and providers. Studies that focused on the conceptualisation, development, testing or review of a questionnaire, or studies that used a questionnaire for assessing the quality of continuous relationships between patients and providers were eligible. Studies that did not assess quality via a questionnaire, only assessed single aspects of relationships, only assessed single encounters, assessed transitions between settings or assessed relationships using an index were excluded. Information on validity testing of each relevant questionnaire identified from articles was reviewed to inform recommendations for future research and evaluation.

Results

Twenty-seven studies met the eligibility criteria, including 14 unique questionnaires. The questionnaires were diverse in length, scope, focus and level of validity testing. Five questionnaires were considered not feasible for future use due to size and lack of development work. Three questionnaires were considered strongest candidates for use in future work based on being relevant to the topic and primary care setting, freely available in English and not needing additional pilot work prior to use. These three questionnaires were the Care Continuity Across Levels of Care Scale, the Nijmegan Continuity Questionnaire and the Patient-Doctor Depth of Relationship Tool.

Conclusions

This study provides an overview of 14 unique questionnaires that have been used to assess the quality of continuous relationships between patients and primary care providers. The decision to use one of the questionnaires in future work requires careful consideration, including the scope, length, validation testing, accessibility of the questionnaires and their alignment with the initiative being evaluated.

The transitional risk and incident questionnaire was valid and reliable for measuring transitional patient safety from the patients' perspective

OBJECTIVE

This study describes the development and validation of the Transitional Risk and Incident Questionnaire (TRIQ), which measures transitional patient safety from the patients' perspective.

METHODS

The TRIQ was developed based on literature review, tested in the target group using a think-aloud procedure, and validated by a cross-sectional study among patients receiving health care at the interface between general practice and hospital care in two regions in the Netherlands. Exploratory factor analysis was performed, and internal consistency was assessed. The relationships between the occurrence of transitional safety incidents (TSIs) as measured by the TRIQ and relational continuity and those between TSI occurrence and overall rating of transitions were assessed.

RESULTS

In total, 451 questionnaires were completed for analysis. The exploratory factor analysis provided a four-factor solution: (1) personal relation with general practitioner, (2) personal relation with hospital physician, (3) information exchange, and (4) treatment consistency. Internal consistency was good (composite reliability, 0.75-0.95). An experienced TSI was related to a poorer relational continuity both with the general practitioner and hospital and with a lower overall rating of all transitions.

CONCLUSIONS

The TRIQ is a valid and reliable questionnaire measuring transitional patient safety from the patients' perspective.

Measurement tools and outcome measures used in transitional patient safety; a systematic review

BACKGROUND

Patients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed.

AIM AND METHODS

To identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection. First, publications about validation of measurement tools were appraised for quality following COSMIN criteria. Second, we inventoried all measurement tools and outcome measures found in our search that assessed current transitional patient safety or the effect of interventions targeting transitional patient safety.

RESULTS

The initial search yielded 8288 studies, of which 18 assessed validity of measurement tools of different aspects of transitional safety, and 191 assessed current transitional patient safety or effect of interventions. In the validated measurement tools, the overall quality of content and structural validity was acceptable; other COSMIN criteria, such as reliability, measurement error and responsiveness, were mostly poor or not reported. In our outcome inventory, the most frequently used validated outcome measure was the Care Transition Measure (n = 9). The most frequently used non-validated outcome measures were: medication discrepancies (n = 98), hospital readmissions (n = 55), adverse events (n = 34), emergency department visits (n = 33), (mental or physical) health status (n = 28), quality and timeliness of discharge summary, and patient satisfaction (n = 23).

CONCLUSIONS

Although no validated measures exist that assess all aspects of transitional patient safety, we found validated measurement tools on specific aspects. Reporting of validity of transitional measurement tools was incomplete. Numerous outcome measures with unknown measurement properties are used in current studies on safety of care transitions, which makes interpretation or comparison of their results uncertain.

Realist evaluation of a complex integrated care programme: protocol for a mixed methods study

INTRODUCTION

The lack of understanding of how complex integrated care programmes achieve their outcomes due to the lack of acceptable methods leads to difficulties in the development, implementation, adaptation and scaling up of similar interventions. In this study, we evaluate an integrated care network, the National University Health System (NUHS) Regional Health System (RHS), consisting of acute hospitals, step down care, primary care providers, social services and community partners using a theory-driven realist evaluation approach. This study aims to examine how and for whom the NUHS-RHS works to improve healthcare utilisations, outcomes, care experiences and reduce healthcare costs. By using a realist approach that balances the needs of context-specific evaluation with international comparability, this study carries the potential to address current research gaps.

METHODS AND ANALYSIS

This evaluation will be conducted in three research phases: (1) development of initial programme theory (IPT) underlying the NUHS-RHS; (2) testing of programme theory using empirical data; and (3) refinement of IPT. IPT was elicited and developed through reviews of programme documents, informal discussions and in-depth interviews with relevant stakeholders. Then, a convergent parallel mixed method study will be conducted to assess context (C), mechanisms (M) and outcomes (O) to test the IPT. Findings will then be analysed according to the realist evaluation formula of CMO in which findings on the context, mechanisms will be used to explain the outcomes. Finally, based on findings gathered, IPT will be refined to highlight how to improve the NUHS-RHS by detailing what works (outcome), as well as how (mechanisms) and under what conditions (context).

ETHICS AND DISSEMINATION

The National Healthcare Group, Singapore, Domain Specific Review Board reviewed and approved this study protocol. Study results will be published in international peer-reviewed journals and presented at conferences and internally to NUHS-RHS and Ministry of Health, Singapore.

Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil

Despite the fragmentation of healthcare provision being considered one of the main obstacles to attaining effective health care in Latin America, very little is known about patients' perceptions. This paper analyses the level of continuity of health care perceived by users and explores influencing factors in two municipalities of Colombia and Brazil, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had suffered at least one health problem within the previous three months (2163 in Colombia; 2167 in Brazil). An adapted and validated version of the CCAENA© (Questionnaire of care continuity across levels of health care) was applied. Logistic regression models were generated to assess the relationship between perceptions of the different types of health care continuity and sociodemographic characteristics, health needs, and organizational factors. The results show lower levels of continuity across care levels in information transfer and care coherence and higher levels for the ongoing patient-doctor relationship, albeit with differences between the two countries. They also show greater consistency of doctors in the Brazilian study areas, especially in primary care. Consistency of doctors was not only positively associated with the patient-doctor ongoing relationship in the study areas of both countries, but also with information transfer and care coherence across care levels. The study area and health needs (the latter negatively for patients with poor self-rated health and positively for those with at least one chronic condition) were associated with all types of continuity of care. The influence of the sex or income varied depending on the country. The influence of the insurance scheme in the Colombian sample was not statistically significant. Both countries should implement policies to improve coordination between care levels, especially regarding information transfer and job stability for primary care doctors, both key factors to guarantee quality of care.

Relationship preferences and experience of primary care patients in continuity of care: a case study in Beijing, China

Background

Continuity of care can bring a wide range of benefits to consumers, providers and health care systems. This study aimed to understand the relationship preferences of primary care patients and their associations with patient experience of continuity of care.

Methods

A questionnaire survey was conducted on 700 patients who sought medical care from a community health organisation in Beijing. The survey contained four items examining the relationship preferences of the respondents, and a modified Questionnaire of Continuity between Care Levels (CCAENA) measuring patient experience of continuity of care based on a three dimensional (relational, informational and managerial) model. The associations between the relationship preferences and the experience of respondents in continuity of care was tested using a linear regression model controlling for age, sex, education, medical insurance, personal income and servicing facilities.

Results

The respondents experienced relatively lower levels of informational and managerial continuity compared with relational continuity of care. More than 80% of respondents preferred free choice and a continuing relationship with doctors, compared with 59% who endorsed community facility control over hospital appointments. A preference for a continuing relationship with doctors was associated with all aspects of continuity of care. A preference in favour of community facility control over hospital appointments was a strong predictor of managerial continuity (β = 0.333, p < 0.001) and informational continuity (β = 0.256, p < 0.001). Patient preference for free choice of doctors was positively associated with relational continuity with specialists (p < 0.001), but not with primary care providers (p > 0.08). Perceived importance of information exchange was associated with relational and managerial continuity (p < 0.05), but not with informational continuity (p = 0.34).

Conclusions

Patients prefer a high level of freedom of choice and sustained individual relationship with doctors. Relationship preferences of patients are associated with their experience of continuity of care. But patient strong preference for free choice of doctors is not aligned with relational continuity with primary care, a desirable feature of cost-effective healthcare systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2536-1) contains supplementary material, which is available to authorized users.

Measuring parents' perspective on continuity of care in children with special health care needs

INTRODUCTION

Children with special health care needs are an exponentially growing population needing integrated health care programmes that involve primary, community, hospital and tertiary care services. The aims of the study are (1) to develop and validate the Special Needs Kids Questionnaire (SpeNK-Q) designed to measure parents' perspective on continuity of care for children with special health care needs and (2) to evaluate the continuity of care based on parental experiences in this population.

METHODS

SpeNK-Q was derived from a previous qualitative study and was based on Haggerty's constructs of informational, management and relational continuity. Parents of preterm birth children completed the 20-item SpeNK-Q at the second or subsequent planned follow-up visit after the child's hospital discharge. Principal component analysis was used to examine the structure of the instrument.

RESULTS

Principal component analysis of 101 questionnaires administered allowed us to identify five factors explaining 60.2% of item variance: informational continuity; coordination of care; continuity of family-paediatrician relationship; family support; information on care plan.

CONCLUSIONS AND DISCUSSION

SpeNK-Q proved to be a psychometrically promising instrument. Its utilisation could improve the identification of areas for service development, the delivery of coordinated care and support policy makers in redesigning integrated services.

Developing IntegRATE: a fast and frugal patient-reported measure of integration in health care delivery

BACKGROUND

Efforts have been made to measure integration in health care delivery, but few existing instruments have adopted a patient perspective, and none is sufficiently generic and brief for administration at scale. We sought to develop a brief and generic patient-reported measure of integration in health care delivery.

METHODS

Drawing on both existing conceptualisations of integrated care and research on patients' perspectives, we chose to focus on four distinct domains of integration: information sharing, consistent advice, mutual respect and role clarity. We formulated candidate items and conducted cognitive interviews with end users to further develop and refine the items. We then pilot-tested the measure.

RESULTS

Four rounds of cognitive interviews were conducted (n = 14) and resulted in a four-item measure that was both relevant and understandable to end users. The pilot administration of the measure (n = 15) further confirmed the relevance and interpretability of items and demonstrated that the measure could be completed in less than one minute.

CONCLUSIONS

This new measure, IntegRATE, represents a patient-reported measure of integration in health care delivery that is conducive to use in both routine performance monitoring and research. The psychometric properties of the measure will be assessed in the next stage of development.