In 1948, W. Eugene Smith published "Country Doctor" in Life Magizine. 1 This landmark photo essay highlighted continuity of care in rural America by showing Dr Ceriani delivering babies, examining children, performing emergency surgery, and caring for the dying in Kremmling, Colorado. However, a half century of medical progress has brought us to a world filled with robotic surgery, MRI machines, DNA tests, electronic medical records, and handheld ultrasound devices that Dr Ceriani would barely recognize. Medical care has become more fragmented and specialized with an emphasis on convenience and care teams. 2-4 Despite these amazing medical advances, patients with chronic diseases still desire a relationship with their physician. 5-7 The Institute of Medicine defines continuity of care to be longitudinal care coupled with effective and timely communication of health information. 8 Continuity of care has been associated with lower mortality, fewer hospitalizations, fewer ED visits, improved preventative services, lower costs, decreased healthcare utilization, and improved patient satisfaction. 9-11 However, there is little agreement on an accepted measure of continuity of care. 12,13 Continuity of care measures have traditionally been classified into five categories that measure density of visits, dispersion of visits, sequence of visits, duration of relationships, and subjective patient
Background: Chronic diseases such as type 2 diabetes place a large burden on the health care system and are associated with increased morbidity and mortality. A team-based multidisciplinary approach that organizes care to improve chronic disease management may actually decrease traditional continuity of care metrics. Visit entropy (VE) provides a novel measure of care organization produced by teambased approaches. Higher VE, reflecting more disorganized care, has been associated with more hospital readmissions. We hypothesized that higher VE was also associated with reduced adherence to the D5 quality criteria. Methods: A retrospective study of 6590 adult diabetic patients in 5 established medical home practices was conducted. Multivariate logistic regression was used to determine if VE was associated with the dependent variable of D5 control. Separate models for usual provider continuity, continuity of care index, and sequence continuity were also constructed. Results: Less organized care with a higher VE was associated with decreased odds of D5 control (odds ratio ؍ 0.88; 95% confidence interval, 0.80 to 0.97). The other continuity measures were not significant. Age, education level, and initial HgA1c were significant covariates, but sex, race, endocrine consults, and Charlson comorbidity were not significant. The Number Needed to be Exposed to more organized care to produce 1 more controlled diabetic was 32.5. Conclusions: More organized care reflected by a lower VE is associated with improved odds of D5 diabetic control. VE represents a better measure of care organization in team-based medical home environments than traditional continuity of care metrics.
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