Future inquiry in family medicine should focus on better understanding the interpersonal dimension of continuity of care.

PURPOSE We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care.METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to fi nd original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence.RESULTS Forty-one research articles reporting the results of 40 studies were identifi ed that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were signifi cantly improved and only 2 were signifi cantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported signifi cantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity.CONCLUSIONS Although the available literature refl ects persistent methodologic problems, it is likely that a signifi cant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specifi c and measurable outcomes and more direct costs and should seek to defi ne and measure interpersonal continuity more explicitly. Ann Fam Med INTRODUCTIONC ontinuity of care traditionally is considered one of the core principles of family medicine, 1,2 and it is a core element of the Institute of Medicine defi nition of primary care. 3 Recently there has been a resurgence of interest in this subject, and the Annals of Family Medicine has devoted a theme issue to the topic. 4 This resurgence has occurred in part because of the growing sophistication of research in family medicine and because of changes in American health care that many believe have undermined continuity in the relationship between physicians and their patients.5-11 A central question facing the future of family medicine is the degree to which we will provide personal health care based on the individual doctor-patient relationship, or whether we will seek to provide a medical home for patients based on an interdisciplinary team with less emphasis on personal care. 12Continuity has proved to be a diffi cult variable to defi ne and measure. Several previous reviews of this subject have noted major limitations to its research foundation because of inconsistent defi nitions and complex methodologic challenges. [13][14][15][16][17][18] In early 2002, we undertook a comprehensive review of the medical literature to examine one aspect of continuity 160INTERPERSONAL CONTINUITY AND...

PURPOSE We wanted to review the medical literature regarding the relationship between interpersonal continuity of care and patient satisfaction and suggest future strategies for research on this topic.METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted to fi nd articles focusing on interpersonal continuity of patient care. The resulting articles were screened to select those focusing on the relationship between interpersonal continuity in the doctor-patient relationship and patient satisfaction. These articles were systematically reviewed and analyzed for study method, measurement technique, and the quality of evidence.RESULTS Thirty articles were found that addressed the relationship between interpersonal continuity and patient satisfaction with medical care. Twenty-two of these articles were reports of original research. Nineteen of the 22, including 4 clinical trials, reported signifi cantly higher satisfaction when interpersonal continuity was present.CONCLUSIONS Although the available literature refl ects persistent methodologic problems, a consistent and signifi cant positive relationship exists between interpersonal continuity of care and patient satisfaction. Future research in this area should address whether the same is true for all patients or only for those who seek ongoing relationships with physicians in primary care. INTRODUCTIONC ontinuity of care is considered to be a core principle of family medicine 1,2 and primary care, 3 but conclusive proof regarding its value has eluded primary care and health policy researchers. The fi rst step in establishing this proof requires a specifi c defi nition of the most important elements of continuity. Previous authors have addressed different aspects of continuity and have proposed defi nitions with multiple dimensions. 1,[4][5][6][7][8][9][10] Recently, 3 of these dimensions were organized into a hierarchy ranging from the availability of accurate information from one health care encounter to another (informational continuity), through a pattern of health care utilization at a particular site of care (longitudinal continuity), to a personal doctor-patient relationship characterized by loyalty and trust (interpersonal continuity).11 For family physicians the concept of interpersonal continuity holds particular importance. 12 Interpersonal continuity refers to a special type of longitudinal continuity in which an ongoing personal relationship between the patient and clinician is characterized by personal trust and responsibility.11 Changes in the American health care system during the past decade have made it increasingly diffi cult to establish such long-term trusting relationships between physicians and patients. [13][14][15][16][17][18][19] Some authors have questioned whether a personal model of care is feasible, as health plans increasingly have required provider changes for economic reasons. 20 As these changes occur, health policy planners are looking for evidence supporting the value of interpersonal continuity...

The current focus on increasing access makes it more difficult for patients to see the same doctor. But Bruce Guthrie and colleagues argue that relationships between doctors and patients are central to good care

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Introduction Recent health care reform policies focus on finding the best medical home for everyone. Less is known about how the stability of a usual source of care (USC) over time impacts on structural access to care. Objectives To examine the prevalence of USC changes among a low-income population of children, and how these changes were associated with unmet need. Design and Methods Cross-sectional, multivariable analyses of mail-return survey data from Oregon's food stamp program in January 2005. Results from 2,681 completed surveys were weighted back to a population of 84,087 families with adjustments for oversampling and non-response. The independent variable: whether a child had ever been required to change USC for insurance reasons. Dependent variables included: parents report of unmet medical need, unmet prescription need, missed medication doses, delayed urgent care, no ambulatory visits; and problems obtaining dental care, specialty care and counseling. Results Nearly 23% of children had changed their USC due to insurance reasons, and 10% had no current USC. Compared to children who had maintained a stable USC, children who had changed their USC due to insurance reasons had higher rates of unmet medical need (unadjusted odds ratio [OR] 2.69, 95% confidence interval [CI] 1.83, 3.29); unmet prescription need (OR 1.85, 95% CI 1.31, 2.61); delayed care (OR 1.87, 95% CI 1.21, 2.89); and reported more problems obtaining dental care (OR 1.66, 95% CI 1.20, 2.31) and counseling (OR 3.22, 95% CI 1.53, 6.77). Conclusions This study highlights the importance of ensuring stability with a USC. In our zeal to move people into new medical homes, we need to be wary of harming quality by disturbing existing care relationships, thus merely creating “temporary housing.”

Purpose: Becoming certified as a patient-centered medical home now requires practices to measure how effectively they provide continuity of care. To understand how continuity can be improved, we studied the association between provider practice characteristics and interpersonal continuity using the Usual Provider Continuity Index (UPC).Methods: We conducted a mixed-methods study of the relationship between provider practice characteristics and UPC in 4 university-based family medicine clinics. For the quantitative part of the study, we analyzed data extracted from monthly provider performance reports for 63 primary care providers (PCPs) between July 2009 and June 2010. We tested the association of 5 practice parameters on UPC:(1) clinic frequency; (2) panel size; (3) patient load (ratio of panel size to clinic frequency); (4) attendance ratio; and (5) duration in practice (number of years working in the current practice). Clinic, care team, provider sex, and provider type (physicians versus nonphysician providers) were analyzed as covariates. Simple and multiple linear regressions were used for statistical modeling. Findings from the quantitative part of the study were validated using qualitative data from provider focus groups that were analyzed using sequential thematic coding.Results: There were strong linear associations between UPC and both clinic frequency (␤ ‫؍‬ 0.94; 95% CI, 0.62-1.27) and patient load (␤ ‫؍‬ ؊0.37; 95% CI, ؊0.48 to ؊0.26). A multiple linear regression including clinic frequency, patient load, duration in practice, and provider type explained more than 60% of the variation in UPC (adjusted R 2 ‫؍‬ 0.629). UPC for nurse practitioners and physician assistants was more strongly dependent on clinic frequency and was at least as high as it was for physicians. Focus groups identified 6 themes as other potential sources of variability in UPC.Conclusions: Variability in UPC between providers is strongly correlated with variables that can be modified by practice managers. Our study suggests that patients assigned to nurse practitioners and physician assistants have continuity similar to those assigned to physicians. (J Am Board Fam Med 2013; 26:356 -365.)