A cluster of articles tackles important questions about continuity of care. It is important to clinicians, but does it matter to patients? If so, which patients value it and when? Does continuity affect important health-care outcomes? Does it affect health-care costs or utilization? Collectively, the authors challenge policy makers to pay attention to the current crisis in continuity and to create systems that encourage long-term, trusting, healing patient-physician relationships.
In This Issue:
Health Plan Switches Adversely Affect Patients
* A full-length press release detailing this study can be found at the bottom of this tip sheet.*
With health insurance premiums on the rise and insurance turnover at an all-time high, there is increasing concern about the possible adverse clinical and financial implications associated with changing insurance plans. Franks and colleagues validate these concerns with their newly released findings, which suggest that the first year in an insurance plan is associated with a significantly higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician and higher expenditures, especially for testing. The authors also found that adverse effects, including less prevention, higher costs and more avoidable hospitalizations, lasted up to three years from enrollment in a health plan. Together with studies showing decreased patient satisfaction with forced health-plan switches, the findings suggest that there are likely pervasive adverse consequences of the frequent re-bidding of insurance contracts by employers.
On Being New to an Insurance Plan: Health Care Use Associated with the First Years in a Health Insurance Plan
Peter Franks, M.D., et al
Provider Continuity Associated with Lower Total Health-care Costs
In a study of 4,800 adults in the Belgian health-care system, De Maeseneer and colleagues found that patients who always saw the same family physician over a two-year period had significantly lower health-care costs than those who saw multiple family physicians. The findings of this micro-level analysis add strong evidence to the conclusion that provider continuity with a family physician may reduce costs. The authors suggest that the findings indicate a financial incentive for health plans to strive to achieve continuity of care. They assert that policy makers working to develop a cost-effective health policy should choose systems that allow for provider continuity through structured primary health-care systems.
Provider Continuity in Family Medicine: Does it Make a Difference for Total Healthcare Costs?
By Jan De Maeseneer, M.D., Ph.D.
Diabetes Management Not Enhanced by Provider Continuity
It is often assumed that continuity of care should lead to improved quality of care, especially for people with chronic conditions such as diabetes mellitus, which require significant medical management. Contrary to expectation, however, continuity of care does not result in improved quality of care for diabetic patients, according to findings by Gill and colleagues. In this study, the researchers found that diabetic patients who concentrated their outpatient visits with the same health-care provider were no more likely to have received standard monitoring tests recommended by the American Diabetes Association, including an annual glycosylated hemoglobin test, lipid test and retinal eye exam. The authors suggest that while continuity may have many health benefits, it may not improve all aspects of quality of care and probably does not have a positive impact on the frequency of testing for chronic conditions.
Impact of Provider Continuity on Quality of Care for Persons with Diabetes Mellitus
By James M. Gill, M.D., M.P.H., et al
Vulnerable Patients Value Continuity of Physician Care More than Other Patients
Continuity of care is not universally important to patients, according to this study by Nutting and colleagues. The researchers find that continuity is more important to more vulnerable populations, including those who are at either end of the age spectrum, less educated, have Medicare or Medicaid coverage, have more health problems, require more medication and report lower health status. Based on these findings, the authors suggest that policy makers should encourage systems that enhance the provision of continuous, relationship-centered care particularly for those vulnerable populations who most value and appear to benefit from it - but who, in turn, may experience greater difficulty achieving it.
Continuity of Primary Care: To Whom Does it Matter and When?
By Paul A. Nutting, M.D., M.S.P.H., et al
New Definition of Continuity of Care Aims to Make Concept Clearer for Researchers
Researchers who have long struggled without an agreed upon definition of "continuity of care" may now be able to generalize findings from one study with another thanks to a new definition proposed by John W. Saultz, M.D. After undertaking a comprehensive review of the medical literature on continuity of care, Saultz proposes a new conceptual definition of continuity of care as a hierarchy of three dimensions - informational, longitudinal and interpersonal continuity. In his discussion, Saultz suggests that the dimension of interpersonal continuity, which leads to trust and mutual respect, is of particular interest for primary care and that future inquiry in family medicine should focus on better understanding this important variable.
Defining and Measuring Interpersonal Continuity of Care
By John W. Saultz, M.D.
Teachers Are Most Common Source of Referral for Attention-Deficit Hyperactivity Disorder
In light of the substantial increase in the prescribing of medication for ADHD over the past decade, Sax and Kautz researched the extent to which teacher recommendations and parental preferences play a role in the diagnosis and treatment of the disorder. The researchers found that teachers and other school personnel are often the first to suggest the diagnosis of ADHD. That fact may be one explanation for the large regional variations in the prescribing of medication for the disorder. In their discussion, the authors suggest that clinicians need to understand the culture and training of teachers at local schools, in order to understand what prompts teachers to suggest the diagnosis. They explain that knowing the source of referral might have important implications for preventing overdiagnosis.
Who First Suggests the Diagnosis of Attention-Deficit/Hyperactivity Disorder?
By Leonard Sax, M.D., Ph.D., and Kathleen Kautz, R.N., B.S.N.
Forced Health-Plan Switches Have Adverse Affect on Patients
Research Shows Less Prevention, Higher Costs and More Avoidable Hospitalizations Associated with First Year in an Insurance Plan
LEAWOOD, Kan. - With health insurance premiums on the rise and insurance turnover at an all-time high, there is increasing concern about the possible adverse clinical and financial implications associated with changing insurance plans. A new study published in the September/October issue of Annals of Family Medicine validates these concerns with findings suggesting that the first year in an insurance plan is associated with less prevention, a higher risk of avoidable hospitalization and higher expenditures, especially for testing.
"When coupled with studies showing decreased patient satisfaction with forced health-plan switches, our findings indicate that there are likely pervasive adverse consequences of the frequent re-bidding of insurance contracts by employers," commented the study's lead author, Peter Franks, M.D., from the University of California, Davis.
Discontinuity in health insurance is a growing phenomenon in the United States. According to background information provided in the study, recent research from the Center for Studying Health System Change found that one out of six consumers with private coverage changed health plans over a one-year period, with 68 percent of those changes due to either employers changing plan offerings or individuals switching jobs. The study was based on a household survey conducted between 1996 and 1997.
Recognizing the prevalence and possible costs of discontinuity, Franks and colleagues set out to assess the impact of changing insurance by comparing health-care indicators for people newly enrolled in a health plan with those in subsequent years of being insured in the same health plan. Using a multivariate analysis, the researchers analyzed four years of claims data involving 335,547 adult patients enrolled in the largest managed care organization in the Rochester, N.Y., area to determine the relationship between the first year of health insurance and a number of health-care indicators, including whether women received a PAP test, whether women over 40 had a mammogram, whether members had a physician visit, whether members had an avoidable hospitalization and members' health-care expenditures.
The researchers found that the first year of insurance was associated with a higher risk of not getting a mammogram, a higher risk of avoidable hospitalization, greater likelihood of visiting a physician and higher expenditures, especially for testing. They found no significant relationship between year of enrollment and the likelihood of receiving a PAP test. The authors surmise that the absence of effect for PAP tests contrasted with the effect for mammograms because PAP tests may be a more established part of women's health care and a routine that patients carry with them from one insurance status to the next more easily than getting mammograms.
The researchers found that adverse effects, including less prevention, higher costs and more avoidable hospitalizations, lasted up to three years from initial enrollment in a health plan.
The complete study can be accessed on the Annals of Family Medicine Web site at www.annfammed.org.
Access to this and other articles contained in the journal is free of charge.
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.