Maintaining Continuity in Service: An Empirical Examination of Primary Care Physicians

Abstract

Problem definition: In many service operations, customers have repeated interactions with service providers. This creates two important questions for service design. First, how important is it to maintain the continuity of service for individuals? Second, because maintaining continuity is costly and, at times, operationally impractical for both the organization (because of potentially lower utilization) and providers (because of high effort required), should certain customer types, such as those with complex needs, be prioritized for continuity? These questions are particularly important in healthcare services where patients with chronic conditions visit primary care offices repeatedly. Therefore, we explore these questions in the context of diabetes, a chronic disease. Academic/practical relevance: Although the operations management (OM) and healthcare literatures suggest that higher continuity is better for health outcomes, the possibility that one could have too much continuity has not been explored. We draw on literature on continuity of care from the healthcare literature and learning effects from the OM literature to theorize and then show a curvilinear relationship. In addition, we further the literature on continuity by examining different categories for prioritization. Methodology: We use a detailed and comprehensive data set from the Veterans Health Administration, the largest integrated healthcare delivery system in the United States, which permits us to control for potential sources of heterogeneity. We analyze over 300,000 patients over an 11-year period who suffer from diabetes, a chronic disease whose successful management requires continuity of care, as well as kidney disease, a major complication of diabetes. We use an empirical approach to quantify the relationship between continuity of care and three important health outcomes: inpatient visits, length of stay, and readmission rate. We conduct extensive robustness checks and sensitivity analyses to validate our findings. Results: We find that continuity of care is related to improvements in all three health outcomes. Moreover, we find that the gains are not linearly improving in continuity, but rather the relationship is curvilinear, whereby outcomes improve and then decline in increasing continuity of care, suggesting that there may be value in having multiple providers. Additionally, we find that continuity of care is even more important for patients suffering from more complex conditions. Managerial implications: Identifying the amount of continuity of care to provide and determining which individuals to prioritize are both of interest to practitioners and policymakers because they can help in designing appropriate policies for staffing and work allocation.

Curbing the Opioid Epidemic at Its Root: The Effect of Provider Discordance After Opioid Initiation

“…Meanwhile, researchers have recently started to explore the potential benefits of variation when introduced within the care pathway of an individual patient (Ahuja et al 2020, Chan et al 2019, Kuntz et al 2019. Especially for medical conditions where multiple viable treatment options exist, patients may benefit from exposure to a variety of providers and treatment options as they search for the best solution to their problems (Christensen et al 2009).…”

“…This concept of routing during the early stages of opioid use is also related to studies on continuity of care. Such work typically focuses on the long-term management of patients who are already suffering from specific chronic conditions, e.g., heart failure (Senot 2019), diabetes (Ahuja et al 2020), or opioid dependence (Hallvik et al 2018). While most studies in these chronic settings find that patients benefit from repeated appointments with the same practitioner, we focus on patients prior to chronicity.…”

“…In medical settings, clinician discordance is generally recognized to confer two main advantages. First, combining the knowledge pools of two clinicians enlarges the information base used in decision-making (Ahuja et al 2020, the patient that proves important in weighing the trade-offs between potential treatments. This new perspective may be particularly important for the early stages of opioid use given the array of clinically viable treatment options available for pain management (Owen et al 2018).…”

“…For those patients who continue seeking treatment in the primary care setting after opioid initiation, we therefore ask: who should revisit the treatment plan with the patient, the original prescriber (i.e., provider concordance) or another clinician (i.e., provider discordance)? 1 While a different clinician can expose the patient to a "fresh perspective" and prevent anchoring to the original opioid treatment course, it may also lead to more fragmented care and reduce physician "ownership" of the long-term health of the patient (Ahuja et al 2020, Ariely et al 2003, Senot 2019. Although prescriber continuity is typically recommended for patients already dependent on opioids (Hallvik et al 2018, Jena et al 2014, the overall impact of exposing a patient to variation in providers in the initial stages of opioid use is not immediately clear.…”

Perceptions of Australian remote area nurses about why they stay or leave: A qualitative study

“…The term ‘remote health’ is often combined with the term ‘rural health’, but remote health has distinct characteristics (Ahuja et al, 2020). Compared with rural health, remote health refers to settings with greater distances and geographical isolation, less access to health care, less availability of services, and smaller and more mobile populations with a higher percentage of Indigenous residents.…”