Using an integrated COC index and multilevel measurements to verify the care outcome of patients with multiple chronic conditions

Abstract

BackgroundThe increasing prevalence of multiple chronic conditions has accentuated the importance of coordinating and integrating health care services. Patients with better continuity of care (COC) have a lower utilization rate of emergency department (ED) services, lower hospitalization and better care outcomes. Previous COC studies have focused on the care outcome of patients with a single chronic condition or that of physician-patient relationships; few studies have investigated the care outcome of patients with multiple chronic conditions. Using multi-chronic patients as subjects, this study proposes an integrated continuity of care (ICOC) index to verify the association between COC and care outcomes for two scopes of chronic conditions, at physician and medical facility levels.MethodsThis study used a dataset of 280,840 subjects, obtained from the Longitudinal Health Insurance Database (LHID 2005), compiled by the National Health Research Institutes, of the National Health Insurance Bureau of Taiwan. Principal Component Analysis (PCA) was used to integrate the indices of density, dispersion and sequence into ICOC to measure COC outcomes - the utilization rate of ED services and hospitalization. A Generalized Estimating Equations model was used to verify the care outcomes.ResultsWe discovered that the higher the COC at medical facility level, the lower the utilization rate of ED services and hospitalization for patients; by contrast, the higher the COC at physician level, the higher the utilization rate of ED services (odds ratio > 1; Exp(β) = 2.116) and hospitalization (odds ratio > 1; Exp(β) = 1.688). When only those patients with major chronic conditions with the highest number of medical visits were considered, it was found that the higher the COC at both medical facility and physician levels, the lower the utilization rate of ED services and hospitalization.ConclusionsThe study shows that ICOC is more stable than single indices and it can be widely used to measure the care outcomes of different chronic conditions to accumulate empirical evidence. Concentrated care of multi-chronic patients by a single physician often results in unsatisfactory care outcomes. This highlights the need for referral mechanisms and integration of specialties inside or outside medical facilities, in order to optimize patient-centered care.

Effects of Continuity of Care on Medication Duplication Among the Elderly

“…The rates of subjects receiving duplicated medications ranged from 40.38% to 43.50% with 1.45-1.62 duplicated medications per year during the study period without an obvious trend. 28 Moreover, the present investigation also 30 showed that the patients with high continuity at the facility level experienced favorable outcomes (emergency department visit and hospitalization), but the patients with high continuity at the physician level experienced poor outcomes. We also found that physician continuity had a stronger effect on medication duplication compared with site continuity.…”

“…However, higher physician continuity scores may indicate more concentrated or less dispersed physician visits by patients and continuous ongoing interpersonal relationships and information sharing between physicians and their patients. 30 Our findings suggest that the protective effect of COC against medication duplication is greater in elderly patient groups with MCCs than it is in other groups with a single or no chronic condition. Furthermore, ongoing interpersonal continuity is also associated with greater trust between physicians and patients, [46][47][48] which facilitates better medication management.…”

“…21,22 COC has been examined at the physician level in some studies and at the site level in other investigations. 18,28,29 However, Chan et al 30 concluded that patients with high continuity at the facility level experienced favorable health care outcomes but that patients with high continuity at the physician level experienced poor health care outcomes. Most of the studies have demonstrated that physician continuity is more influential than site continuity on health care outcomes.…”

“…21,22 However, medication management is a crucial issue for elderly patients with MCCs. 30 Little is known about whether COC has different impacts on medication duplication in patients without chronic conditions, with a single chronic condition or with MCCs. However, there is limited evidence regarding the effects of COC on medication duplication in elderly MCCs patients.…”

Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care

“…Continuity of care is a key component of quality of care [1,2] that becomes increasingly important for complex and vulnerable patients [3,4], including elderly patients [5], patients at end of life [2,6], those with chronic conditions [7,8], and those who transition through the greater healthcare system [9-11]. Continuity is central to many health disciplines, including family medicine [12,13] and nursing [14,15] and is an important national issue in several countries [16-18].…”