Mortality and continuity of care - Definitions matter! A cohort study in diabetics.
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ABSTRACT:
SUBMITTER: Geroldinger A
PROVIDER: S-EPMC5774784 | biostudies-literature | 2018
REPOSITORIES: biostudies-literature
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Mortality and continuity of care - Definitions matter! A cohort study in diabetics.
Geroldinger Angelika A Sauter Simone Katja SK Heinze Georg G Endel Gottfried G Dorda Wolfgang W Duftschmid Georg G
PloS one 20180119 1
<h4>Objective</h4>To demonstrate that when investigating the relevance of continuity of care for patient outcomes, different definitions can lead to contradicting results.<h4>Methods</h4>We used claims data from the regional public health insurer of Lower Austria covering the period from 2008 to 2011. The study sample included subjects with repeated dispensings of anti-diabetic drugs. The continuity of care index was calculated firstly based on a patient's contacts with general practitioners (pr ...[more]
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Project description:ObjectiveContinuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.DesignSystematic review without meta-analysis.Data sourcesMEDLINE, Embase and the Web of Science, from 1996 to 2017.Eligibility criteria for selecting studiesPeer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients.ResultsOf the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors.ConclusionsThis first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important.Prospero registration numberCRD42016042091.
| S-EPMC6042583 | biostudies-literature
Project description:ObjectiveTo assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure.DesignRegistry-based, population-level longitudinal cohort study.SettingLinked data from Norwegian administrative healthcare registries, including 3989 GPs.Participants757 873 patients aged 60-90 years with ≥2 contacts with a GP during 2016 and 2017.Main outcome measureAll-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018.ResultsWe assessed COC using the conventional usual provider of care index (UPCpatient) and an alternative/supplementary index (UPCGP list) based on the COC for all other patients enlisted with the same preferred GP.For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPCGP list shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPCpatient and UPCGP list, respectively. Using UPCGP list, we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education.ConclusionsA continuity measure based on each patient's contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health.
| S-EPMC8640634 | biostudies-literature
Project description:BackgroundMany randomized controlled trials (RCTs) employ mortality at a given time as a primary outcome. There are at least three common ways to measure 90-day mortality: first, all-location mortality, that is, all-cause mortality within 90 days of randomization at any location. Second, ARDSnet mortality is death in a healthcare facility of greater intensity than the patient was in prior to the hospitalization during which they were randomized. Finally, in-hospital mortality is death prior to discharge from the primary hospitalization of randomization. Data comparing the impact of these different measurements on sample size are lacking. We evaluated the extent to which event rates vary by mortality definition.MethodsThis was a retrospective cohort study of 30,691 patients hospitalized at Veterans Affairs (VA) hospitals for sepsis during 2009. 12,727 (41.5%) received care in an ICU setting. For each patient, we measured event rates for three different 90-day mortality outcomes: all-location mortality, ARDSnet mortality, and in-hospital mortality. We also calculated sample sizes necessary to power an example RCT given those event rates.ResultsAt 90 days, all-location mortality was 26.4% (95% CI 25.9-26.9%), ARDSnet mortality was 19.2% (95% CI 18.8-19.7%), and in-hospital mortality was 13.4% (95% CI 13.0-13.8%) (p < 0.01 all comparisons). These respective event rates result in different required sample sizes to achieve a 20% relative reduction in mortality with 80% power and a 5% false positive rate. Such a trial of VA sepsis patients would require 2080 patients for all-location mortality, 3080 for ARDSnet mortality, and 4796 for in-hospital mortality. Among sepsis patients mechanically ventilated in an ICU, 2438 experienced all-location mortality (46.2% [95% CI 44.8-47.5%]), 2181 experienced ARDSnet mortality (41.3% [95% CI 40.0-42.6%]), and 1894 experienced in-hospital mortality (36.0% [95% CI 34.7-37.3%]).ConclusionsEvent rates vary substantially in sepsis patients based on the chosen 90-day mortality definition. This could have important implications for RCT design trade-offs.
| S-EPMC5870299 | biostudies-literature
Project description:BackgroundContinuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care.MethodsWe conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department.ResultsWe analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access.InterpretationChanges in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.
| S-EPMC7676991 | biostudies-literature
Project description:BackgroundPeople with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury.AimsWe set out to examine the relationship between the continuity of care of patients with schizophrenia, their mortality and cause of death.MethodPseudoanonymised community data from 5551 people with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index. These and demographic variables were related to death certifications of physical illness from the Office of National Statistics and mortal self-injury from clinical data. Data were analysed using generalised estimating equations.ResultsWe found no independent relationship between levels of continuity of care and overall mortality. However, lower levels of relationship continuity were significantly and independently related to death by self-injury.ConclusionsWe found no evidence that continuity of care is important in the prevention of physical causes of death in schizophrenia. However, there is evidence that declining relationship continuity of care has an independent effect on deaths as a result of self-injury. We suggest that there should be more attention focused on the improvement of continuity of care for these patients.
| S-EPMC8281257 | biostudies-literature
Project description:BackgroundIn 1997 the US Environmental Protection Agency (EPA) established the National Ambient Air Quality Standard (NAAQS) for fine particulate matter (PM2.5), largely because of its positive relationship to total mortality in the 1982 American Cancer Society Cancer Prevention Study (CPS II) cohort. Subsequently, EPA has used this relationship as the primary justification for many costly regulations, most recently the Clean Power Plan. An independent analysis of the CPS II data was conducted in order to test the validity of this relationship.MethodsThe original CPS II questionnaire data, including 1982 to 1988 mortality follow-up, were analyzed using Cox proportional hazards regression. Results were obtained for 292 277 participants in 85 counties with 1979-1983 EPA Inhalable Particulate Network PM2.5 measurements, as well as for 212 370 participants in the 50 counties used in the original 1995 analysis.ResultsThe 1982 to 1988 relative risk (RR) of death from all causes and 95% confidence interval adjusted for age, sex, race, education, and smoking status was 1.023 (0.997-1.049) for a 10 µg/m3 increase in PM2.5 in 85 counties and 1.025 (0.990-1.061) in the 50 original counties. The fully adjusted RR was null in the western and eastern portions of the United States, including in areas with somewhat higher PM2.5 levels, particularly 5 Ohio Valley states and California.ConclusionNo significant relationship between PM2.5 and total mortality in the CPS II cohort was found when the best available PM2.5 data were used. The original 1995 analysis found a positive relationship by selective use of CPS II and PM2.5 data. This independent analysis of underlying data raises serious doubts about the CPS II epidemiologic evidence supporting the PM2.5 NAAQS. These findings provide strong justification for further independent analysis of the CPS II data.
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Project description:BackgroundThe disease burden is increasing for chronic obstructive pulmonary disease (COPD) due to increasing of the growth rate of prevalence and mortality. But the empirical researches are a little for COPD that studied the association between continuity of care and death and about predictors effect on mortality.ObjectiveTo investigate the association between continuity of care (COC) and chronic obstructive pulmonary disease (COPD) mortality and to identify other mortality-related factors in COPD patients.MethodsWe conducted a longitudinal, population-based retrospective cohort study in adult patients with COPD from 2002 to 2012 using a nationwide health insurance claims database. The study sample included individuals aged 40 years and over who developed COPD in 2005 and survived until 2006. We performed a Cox proportional hazard regression analysis with COC analyzed as a time-dependent covariate.ResultsOf the 3,090 participants, 60.8% died before the end of study (N = 1,879). The median years of survival for individuals with high COC (COC index?0.75) was 3.92, and that for patients with low COC (COC index<0.75) was 2.58 in a Kaplan Meier analysis. In a multivariate, time-dependent analysis, low COC was associated with a 22% increased risk of all-cause mortality (HR, 1.22; 95% CI, 1.09-1.36). Not receiving oxygen therapy at home was associated with a 23% increased risk of all-cause mortality (HR, 1.23; 95% CI, 1.01-1.49). Moreover, the risk of all-cause mortality for individuals who admitted one time increased 38% (HR, 1.38; 95% CI, 1.21-1.59), two times was 63% (HR, 1.63; 95% CI, 1.34-1.99) and 3+ times was 96% (HR, 1.96; 95% CI, 1.63-2.36) relative to the reference group (no admission).ConclusionsHigh COC was associated with a decreased risk of all-cause mortality. In addition, home oxygen therapy and number of hospital admissions may predict mortality in patients with COPD.
| S-EPMC4631362 | biostudies-literature
Project description:BackgroundPrior studies have shown that, compared to patients with a low level of interpersonal continuity of care, patients with a high level of continuity of care have a lower likelihood of hospital admission and emergency department visits, and a higher likelihood of patient satisfaction. We sought to determine whether higher levels of continuity of care are associated with medication persistence and compliance among new users of oral antidiabetic treatment.MethodsWe conducted a medicoadministrative cohort study of new users of oral antidiabetics aged 18 years or more among people covered by the Quebec public drug plan. We excluded people with fewer than 730 days of treatment and those who had been in hospital for 275 days or more in the first or second year after initiation of antidiabetic treatment. We categorized continuity of care observed in the first year after treatment initiation as low, intermediate or high. The association between continuity of care and medication persistence and compliance was assessed using generalized linear models.ResultsIn this cohort of 60?924 new users of oral antidiabetic treatment, compared to patients with a high level of continuity of care, those with an intermediate and a low level of continuity of care were less likely to be persistent (adjusted prevalence ratio 0.97 [95% confidence interval (CI) 0.96-0.98] and 0.96 [95% CI 0.95-0.97], respectively) and compliant (adjusted prevalence ratio 0.98 [95% CI 0.97-0.99] and 0.95 [0.94-0.97], respectively) with their antidiabetic treatment.InterpretationA higher level of interpersonal continuity of care was associated with a higher likelihood of drug persistence and compliance. Since the strength of this association was weak, further research is required to determine whether continuity of care plays a role in medication adherence.
| S-EPMC5498180 | biostudies-literature
Project description:BackgroundObesity affects nearly half of adults in the United States and is contributing substantially to a pandemic of obesity-associated chronic conditions such as type 2 diabetes, hypertension, and arthritis. The obesity-associated chronic condition pandemic is particularly severe in low-income, medically underserved, predominantly African-American areas in the southern United States. Little is known regarding the impact of geographic, income, and racial disparities in continuity of care on major health outcomes for patients with obesity-associated chronic conditions.ObjectiveThe aim of this study is to assess, among patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes, (1) whether continuity of care is associated with lower overall and potentially preventable emergency department and hospital utilization, (2) the effect of geographic, income, and racial disparities on continuity of care and on health care utilization, (3) whether continuity of care particularly protects individuals at risk for disparities from adverse health outcomes, and (4) whether characteristics of health systems are associated with higher continuity of care and better outcomes.MethodsUsing 2015-2018 data from 4 practice-based research networks participating in the Southern Obesity and Diabetes Coalition, we will conduct a retrospective cohort analysis and distributed meta-analysis. Patients with obesity-associated chronic conditions and with type 2 diabetes will be assessed within each health system, following a standardized study protocol. The primary study outcomes are overall and preventable emergency department visits and hospitalizations. Continuity of care will be calculated at the facility level using a modified version of the Bice-Boxerman continuity of care index. Race will be assessed using electronic medical record data. Residence in a low-income area or a health professional shortage area respectively will be assessed by linking patient residence ZIP codes to the Centers for Medicare & Medicaid Services database.ResultsIn 4 regional health systems across Tennessee, Mississippi, Louisiana, and Arkansas, a total of 53 adult hospitals were included in the study. A total of 147,889 patients with obesity-associated chronic conditions who met study criteria were identified in these health systems, of which 45,453 patients met the type 2 diabetes criteria for inclusion. Results are expected by the end of 2020.ConclusionsThis study should reveal whether health system efforts to increase continuity of care for patients with obesity and diabetes have potential to improve outcomes and reduce costs. Analyzing disparities in continuity of care and their effect on major health outcomes can help demonstrate how to improve care and use of health care resources for vulnerable patients with obesity-associated chronic conditions, and within this group, patients with type 2 diabetes. Better understanding of the association between continuity and health care utilization for these vulnerable populations will contribute to the development of higher-value health systems in the southern United States.International registered report identifier (irrid)DERR1-10.2196/20788.
| S-EPMC7511855 | biostudies-literature
Project description:BackgroundLittle is known about how continuity of care for hospitalized patients varies among hospitals. We describe the number of different general internal medicine physicians seeing hospitalized patients during a medical admission and how that varies by hospital.MethodsWe conducted a retrospective study of a national 20% sample of Medicare inpatients from 01/01/16 to 12/31/18. In patients with routine medical admissions (length of stay of 3-6 days, no Intensive Care Unit stay, and seen by only one generalist per day), we assessed odds of receiving all generalist care from one generalist. We calculated rates for each hospital, adjusting for patient and hospital characteristics in a multi-level logistic regression model.ResultsAmong routine medical admissions with 3- to 6-day stays, only 43.1% received all their generalist care from the same physician. In those with a 3-day stay, 50.1% had one generalist providing care vs. 30.8% in those with a 6-day stay. In a two-level (admission and hospital) logistic regression model controlling for patient characteristics and length of stay, the odds of seeing just one generalist did not vary greatly by patient characteristics such as age, race/ethnicity, comorbidity or reason for admission. There were large variations in continuity of care among different hospitals and geographic areas. In the highest decile of hospitals, the adjusted mean percentage of patients receiving all generalist care from one physician was > 84.1%, vs. < 24.1% in the lowest decile. This large degree of variation persisted when hospitals were stratified by size, ownership, location or teaching status.ConclusionsContinuity of care provided by generalist physicians to medical inpatients varies widely among hospitals. The impact of this variation on quality of care is unknown.
| S-EPMC8180074 | biostudies-literature