1. Does Continuity of Care Matter? The Issues and the Evidence Doug Kutz MD

2. Definition “the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease” “an implicit contract of clinical responsibility on the part of the provider, and loyalty on the part of the patient” (BMJ 11/2003, 327:1219) Informational -> Longitudinal -> Interpersonal (Saultz,JW 2004 Ann Fam med 2(5);445-451)

3. How is it measured Indirectly – Patient demographics: travel, wait or pay. – Physician turnover Directly – Encounter data and ranking for degree of consistency in provider of record and billing – Patient surveys

4. Why does it matter ? Intuition – Sense that someone understands my views (IE the medical record is the map not the territory) – Sense that someone in the system cares – Sense that someone with expertise will be my advocate when I need them. Improved patient satisfaction? Improved clinical outcomes and/or costs?

5. The problems with continuity Diminished urgent access Multiple viewpoints can be beneficial in difficult cases Patients themselves may or may not value continuity (Coulter, A BMJ 11/05 331;1199)

6. Outpatient Satisfaction and Continuity Wasson studied 776 male veterans age >54 who were randomly assigned to a continuity clinic or clinic without continuity. After 18 months satisfaction with overall care, perception of clinician thoroughness and perception of patient education were significantly higher in the CC group. (Wasson JH, JAMA 1984;252:2413-2417)

7. Outpatient Satisfaction….. Review of 22 articles between 1966 and 2002 that addressed continuity and patient satisfaction (4 randomized, 4 cohort, and 14 “correlative”) 19/22 had a statistically significantly higher level of satisfaction that correlated with measurements of continuity (Saultz,JW 2004 Ann Fam med 2(5);445-451)

8. Outpatient Outcomes and Continuity Wasson studied 776 male veterans age > 54 After 18 months significant findings in the continuity group: – Less like to be admitted (20% vs. 39%) (P=.02) – Fewer ICU days (0.4 vs. 1.4 days) (P=.01) – Fewer hospital days (5.7 vs. 9.1) (P=.02) (Wasson JH, JAMA 1984;252:2413-2417)

9. Outpatient Outcomes…. Systematic review found 18 studies (12 cross sectional, 5 cohort, 1 randomized) – 7 studies showed decreased hospitalizations and ER visits, particularly in patients with chronic disease – 5 studies showed improved receipt of preventative care (Cabana J Fam Practice 12/04 53(12);974)

10. Inpatient continuity and Satisfaction Rural health system in Mississippi telephone surveyed 10% of 443 patients cared for by “hospitalists” vs. 10% of 1681 patients cared for by primary care internists in 1998. There was no difference in the response to: – How well were you informed in medical decisions – Friendliness of doctor that cared for you – Ability of hospital staff and MD to work together (Davis,K Am J Med 2000; 108:621)

11. Inpatient continuity and Satisfaction Summary of 19 studies done through 2002 which shows that hospitalist patients had satisfaction levels no lower than that of patients cared for by primary care In 4/5 studies that looked at this, the studies were done in academic medical centers. (Wachter, RM JAMA 2002;287:487)

12. Inpatient Outcomes and Continuity 5308 patients at an urban teaching hospital in San Francisco were evaluated in a retrospective cohort fashion in the first 2 years of implementing a hospitalist service there. After 2 years the hospitalist patients: – Had shorter LOS (0.61 days shorter (P=.002)) – Reduced costs ($822 less (P=.002)) – Lower inpt. mortality (4.8% vs. 7.2% (P=.03)) (Auerbach,A Ann Int Med 2002 137;11:859)

13. Inpatient Outcomes…. Wachter published a review of the 19 articles that had looked at outcomes with patients cared for by hospitalists in 2002. – Average of 13.4% lower costs (15/19 studies) – Average of 16.6% shorter stay (17/19 studies) – Hospitalist mortality data inconsistent (11/19 no difference, 1/19 increased, 2/19 decreased) – Hospitalist readmit data inconsistent (9/19 no difference, 1/19 increased, 2/19 decreased) (Wachter, RMJAMA 2002;287;487-494)

14. Hospitalists and outcomes: Mission accomplished? Most outcome studies have examined single hospitals, and small numbers of hospitalists in the initial years of a program. Are the decreased costs of hospitalization from early discharge being shifted? Quality studies have been rudimentary looking only at mortality and readmission rather than more sensitive disease related indicators. (The hospitalist movement Mission Accomplished? NEJM 2004 350(19):1935)

15. Other issues with continuity and Hospitalists “The time of transition out of the hospital is a very vulnerable one and hospitalist programs need look at how to improve communication. “ (Forster,A CMAJ 2004; 170:345) The “continuity” visit – 73 patients surveyed 78% of patients who were contacted by PCP were very satisfied vs. 60% of those who were not contacted. (Hruby, J Dis Mon 2002 48(4);230)

16. My Summary of the Evidence Outpatient Continuity appears to increase patient satisfaction (19/22 studies) Outpatient Continuity might improve outcomes and preventative services (7/18 and 5/18 studies) Inpatient Continuity may or may not improve patient satisfaction (5/19 studies no difference) Inpatient Continuity improves efficiency (17/19 studies) and probably doesn’t impact mortality (11/19 studies)

17. Why should we as GIM Care ? “Whither Continuity of Care” (Manian, FA NEJM 1999 340(17):1362-1363) Primary Care IM is in a unique position Physician career choices