Dataset Information

Association between continuity and access in primary care: a retrospective cohort study.

ABSTRACT: BACKGROUND:Continuity 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. METHODS:We 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. RESULTS:We 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. INTERPRETATION:Changes 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.

SUBMITTER: Cook LL

PROVIDER: S-EPMC7676991 | biostudies-literature | 2020 Oct-Dec

REPOSITORIES: biostudies-literature

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Association between continuity and access in primary care: a retrospective cohort study.

Cook Lisa L LL Golonka Richard P RP Cook Charles M CM Walker Robin L RL Faris Peter P Spenceley Shannon S Lewanczuk Richard R Wedel Robert R Love Rebecca R Andres Cheryl C Byers Susan D SD Collins Tim T Oddie Scott S

CMAJ open 20201001 4

<h4>Background</h4>Continuity 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.<h4>Methods</h4>We 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 continu ...[more]

PMID: 33199505

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Project description:ObjectivesTo investigate whether better continuity of care is associated with increased prescribing of clinically relevant medication and improved medication adherence.SettingRandom sample of 300 000 patients aged 30+ in 2017 within 83 English general practitioner (GP) practices from the Clinical Practice Research Datalink.DesignPatients were assigned to a randomly selected index date in 2017 on which medication use and continuity of care were determined. Adjusted associations between continuity of care and the prescribing and adherence of five cardiovascular medication groups were examined using logistic regression.ParticipantsContinuity of Care Index was calculated for 173 993 patients with 4+ GP consultations 2 years prior to their index date and divided into five categories: absence of continuity, below-average continuity, average, above-average continuity and perfect continuity.Main outcome measures(A) Prescription for statins (primary or secondary prevention separately), anticoagulants, antiplatelet agents and antihypertensives covering the patient's index date. (B) Adherence (>80%) estimated using medication possession ratio.ResultsThere was strong evidence (p<0.01) that prescription of all five cardiovascular medication groups increased with greater continuity of care. Patients with absence of continuity were less likely to be prescribed cardiovascular medications than patients with above-average continuity (statins primary prevention OR 0.73, 95% CI 0.59 to 0.85; statins secondary prevention 0.77, 95% CI 0.57 to 1.03; antiplatelets 0.55, 95% CI 0.33 to 0.92; antihypertensives 0.51, 95% CI 0.39 to 0.65). Furthermore, patients with perfect continuity were more likely to be prescribed cardiovascular medications than those with above-average continuity (statins primary prevention OR 1.23, 95% CI 1.01 to 1.49; statins secondary prevention 1.37, 95% CI 1.10 to 1.71; antiplatelets 1.37, 95% CI 1.08 to 1.74; antihypertensives 1.10, 95% CI 0.99 to 1.23). Continuity was generally not associated with medication adherence, except for adherence to statins for secondary prevention (OR 0.75, 95% CI 0.60 to 0.94 for average compared with above-average continuity).ConclusionBetter continuity of care is associated with improved prescribing of medication to patients at higher risk of cardiovascular disease but does not appear to be related to patient's medication adherence.

Project description:BackgroundAn important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging.MethodsThe aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013-October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis.ResultsInterviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions.ConclusionsIn contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting.

Project description:ObjectivesThe existing evidence for the impacts of continuity of care (COC) in patients with chronic obstructive pulmonary disease (COPD) is low to moderate. This study aimed to investigate the associations between relational COC within primary care and COPD-related hospitalisations using a robust methodology.DesignPopulation-based cohort study.SettingNational Health Insurance Service database, South Korea.Participants92 977 adults (≥40 years) with COPD newly diagnosed between 2015 and 2016 were included. The propensity score (PS) matching approach was used. PSs were calculated from a multivariable logistic regression that included eight baseline characteristics.ExposureCOC within primary care.Main outcome measuresThe primary outcome was the incidence of COPD-related hospitalisations. Cox proportional hazard models were used to estimate HRs and 95% CIs.ResultsOut of 92 977 patients, 66 677 of whom were cared for continuously by primary doctors (the continuity group), while 26 300 were not (the non-continuity group). During a 4-year follow-up period, 2094 patients (2.25%) were hospitalised; 874 (1.31%) from the continuity group and 1220 (4.64%) from the non-continuity group. After adjusting for confounding covariates, patients in the non-continuity group exhibited a significantly higher risk of hospital admission (adjusted HR (aHR) 2.43 (95% CI 2.22 to 2.66)). This risk was marginally reduced to 2.21 (95% CI 1.99 to 2.46) after PS matching. The risk of emergency department (ED) visits, systemic corticosteroid use and costs were higher for patients in the non-continuity group (aHR 2.32 (95% CI 2.04 to 2.63), adjusted OR 1.25 (95% CI 1.19 to 1.31) and expβ=1.89 (95% CI 1.82 to 1.97), respectively). These findings remained consistent across the PS-matched cohort, as well as in the sensitivity and subgroup analyses.ConclusionsIn patients with COPD aged over 40, increased continuity of primary care was found to be associated with less hospitalisation, fewer ED visits and lower healthcare expenditure.

Dataset Information

Association between continuity and access in primary care: a retrospective cohort study.

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Association between continuity and access in primary care: a retrospective cohort study.

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