PURPOSE Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients' experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity.METHODS From an initial list of 514 potential studies (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), 33 met our criteria of using qualitative methods and exploring patients' experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes.RESULTS For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians.CONCLUSION Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confi dence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity. Ann Fam Med 2013;11:262-271. doi:10.1370/afm.1499. INTRODUCTIONC ontinuity of care is the extent to which a series of health care services is experienced as connected and coherent and is consistent with a patient's health needs and personal circumstances.1 As patients increasingly receive care from multiple professionals and organizations, improving continuity of care has become a research priority. Although continuity of care is understood differently across health disciplines, an interdisciplinary review of concepts and measures of continuity of care found all disciplines would recognize 3 types of continuity. 1,2 Relational continuity is the therapeutic relationship between a patient and 1 or more clinicians that bridges episodes of care and provides coherence through clinicians' growing comprehensive knowledge of the patient. It is most valued in primary care and family medicine. Informational continuity ensures connectedness and coherence by the uptake of information on past events and is most emphasized in the nursing sciences.3-6 Management continuity refers to consistent and coherent management by different clinicians 263 CONT INUIT Y O F C A R E WIT H MULT IPL E CLINICIANSthrough coordinated and timely delivery of complemen...

Background: People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas. Methods:We conducted a cross-sectional study using information for a random sample of 95 173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an amergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care. Results:After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41-1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44-1.48, and 1.27, 95% CI 1.25-1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.Interpretation: Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas. Abstract CMAJ 2007;177(11):1362-8From the

PURPOSE Patients who regularly see more than one clinician for health problems risk discontinuity and fragmented care. Our objective was to develop and validate a generic measure of management continuity from the patient perspective. METHODSThemes from 33 qualitative studies of patient experience with care from various clinicians were matched to existing instruments to identify potential measures and measurement gaps. Adapted and new items were tested cognitively, and the instrument was administered to 376 adult patients consulting in primary care for a variety of health conditions but seeing clinicians in a variety of settings. After initial psychometric analysis, the instrument was modifi ed slightly and readministered after 6 months. The analysis identifi ed reliable subscales and their association with indicators of continuity. RESULTSObserved factors correspond to 8 intended constructs, with good reliability. Three subscales (12 items) relate to the principal clinician and cover management and relational continuity. Four subscales (13 items) are related to multiple clinicians and address team relational continuity and problems with coordination and gaps in information transfer. Two (11 items) pertain to the patient's partnership in care. Subscales correlate well and in expected directions with indicators of discontinuity (wanting to change clinicians, suffering, and sense of being abandoned, medical errors) and degree of care organization. CONCLUSIONThe instrument reliably assesses both positive and negative dimensions of continuity of care across the entire system, and the subscales correlate with continuity effects. It supports patient-centered and relationship-based care and can be used as a whole or in part to assess coordination and continuity in primary care.

BACKGROUND-The diagnosis-specific Graded Prognostic Assessment (GPA) was published to clarify prognosis for patients with brain metastases. This study refines the existing Breast-GPA by analyzing a larger cohort and tumor subtype.

The scale can be used by physicians or primary health care units and has a wide range of applications.

BackgroundWith 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada.MethodsWe based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014.ResultsDuring the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = −0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators.ConclusionsCentralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0573-1) contains supplementary material, which is available to authorized users.

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Background Reform of primary healthcare (PHC) organisations is underway in Canada. The capacity of various types of PHC organizations to respond to populations’ needs remains to be assessed. The main objective of this study was to evaluate the association of PHC affiliation with unmet needs for care. Methods Population-based survey of 9205 randomly selected adults in two regions of Quebec, Canada. Outcomes Self-reported unmet needs for care and identification of the usual source of PHC. Results Among eligible adults, 18 % reported unmet needs for care in the last six months. Reasons reported for unmet needs were: waiting times (59 % of cases); unavailability of usual doctor (42 %); impossibility to obtain an appointment (36 %); doctors not accepting new patients (31 %). Regression models showed that unmet needs were decreasing with age and was lower among males, the least educated, and unemployed or retired. Controlling for other factors, unmet needs were higher among the poor and those with worse health status. Having a family doctor was associated with fewer unmet needs. People reporting a usual source of care in the last two-years were more likely to report unmet need for care. There were no differences in unmet needs for care across types of PHC organisations when controlling for affiliation with a family physician. Conclusion Reform models of primary healthcare consistent with the medical home concept did not differ from other types of organisations in our study. Further research looking at primary healthcare reform models at other levels of implementation should be done.