A comprehensive analysis of patients' perceptions of continuity of care and their associated factors.

OBJECTIVE: To determine the patients' perceived degree of continuity of care between primary and secondary care and to identify contextual and individual factors that influence patients' perceptions of continuity of care. DESIGN: Cross-sectional study by means of a survey of patients attended to in primary and secondary care. SETTING: Three health-care areas of the Catalonian public health-care system. PARTICIPANTS: A random sample of 1500 patients. MAIN OUTCOME MEASURES: Relational, informational and managerial continuity of care measured by means of Likert scales, using the CCAENA questionnaire. RESULTS: Overall, 93.8 and 83.8% of patients perceived an ongoing relationship with primary and secondary care physicians, respectively (relational continuity), 71.2% perceived high levels of information transfer (informational continuity) and 90.7% perceived high levels of consistency of care (managerial continuity). Patients from health-care areas where primary and secondary care were managed by a single organization and the elderly tended to perceive higher levels of all three types of continuity. Foreign-born patients were less likely to perceive relational continuity with primary care physicians; those with higher educational levels were less likely to perceive high levels of informational continuity and patients with worse health status were less likely to report high levels of managerial and relational continuity with secondary care physicians. CONCLUSIONS: Study results suggest high levels of perceived continuity of care, especially for relational and managerial continuity. The adopted comprehensive approach proves to be useful to properly understand the phenomenon because perceptions and associated factors vary according to the type of continuity.

Creation of a synthetic indicator of quality of care as a clinical management standard in primary care.

INTRODUCTION: The development of electronic medical records has allowed the creation of new quality indicators in healthcare. Among them, synthetic indicators facilitate global interpretation of results and comparisons between professionals. METHODS: A healthcare quality standard (EQA, the Catalan acronym for Estàndard de Qualitat Assistencial) was constructed to serve as a synthetic indicator to measure the quality of care provided by primary care professionals in Catalonia (Spain). The project phases were to establish the reference population; select health problems to be included; define, select and deliberate about subindicators; and construct and publish the EQA. RESULTS: Construction of the EQA involved 107 healthcare professionals, and 91 health problems were included. In addition, 133 experts were consulted, who proposed a total of 339 indicators. After systematic paired comparison, 61 indicators were selected to create the synthetic indicator. The EQA is now calculated on a monthly basis for more than 8000 healthcare professionals using an automated process that extracts data from electronic medical records; results are published on a follow-up website. Along with the use of the online EQA results tool, there has been an ongoing improvement in most of the quality of care indicators. CONCLUSIONS: Creation of the EQA has proven to be useful for the measurement of the quality of care of primary care services. Also an improvement trend over 5 years is shown across most of the measured indicators. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/2193-1801-2-51) contains supplementary material, which is available to authorized users.

A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire.

BACKGROUND: The CCAENA questionnaire was developed to assess care continuity across levels from the patients' perspective. The aim is to provide additional evidence on the psychometric properties of the scales of this questionnaire. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care in three health care areas of the Catalan health care system. Data were collected in 2010 using the CCAENA questionnaire. To assess psychometric properties, an exploratory factor analysis was performed (construct validity) and the item-rest correlations and Cronbach's alpha were calculated (internal consistency). Spearman correlation coefficients were calculated (multidimensionality) and the ability to discriminate between groups was tested. RESULTS: The factor analysis resulted in 21 items grouped into three factors: patient-primary care provider relationship, patient-secondary care provider relationship and continuity across care levels. Cronbach's alpha indicated good internal consistency (0.97, 0.93, 0.80) and the correlation coefficients indicated that dimensions can be interpreted as separated scales. Scales discriminated patients according to health care area, age and educational level. CONCLUSION: The CCAENA questionnaire has proved to be a valid and reliable tool for measuring patients' perceptions of continuity. Providers and researchers could apply the questionnaire to identify areas for health care improvement.

Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system.

OBJECTIVE: To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out. RESULTS: Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration. CONCLUSION: Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

[Design and validation of a questionnaire to measure continuity between care levels from the user's perspective]. / Diseño y validación de un cuestionario para medir la continuidad asistencial entre niveles desde la perspectiva del usuario: CCAENA.

OBJECTIVES: To design and validate an instrument that measures continuity between levels of care from the user's perspective to be applied in any healthcare system providing a continuum of care. METHODS: 1) A questionnaire for the measurement of continuity of care was designed, based on a literature review, and 2) the questionnaire was validated using an expert group, two pretests and a pilot test to a sample of 200 healthcare users. We assessed the questionnaire's comprehensibility, content validity and interviewer burden, as well as the reliability and construct validity of the scale. RESULTS: The instrument encompasses three types of continuity (management, information and relational) and is divided in two complementary parts. The first part addresses the patients' care pathways and the continuity of care for a particular episode that occurred in the last 3 months. The second part measures patients' perception of the continuity between levels of care. The experts agreed that all dimensions of continuity were represented and the interviewees found the questionnaire easy to understand. The mean time required to apply the instrument was 33.9 min. Cronbach's alpha was acceptable (>0.7) in all subscales except one, which was then removed. The multiple correspondence analyses showed associations among theoretically related items. CONCLUSIONS: The questionnaire (CCAENA) seems to be an useful, valid and reliable instrument to assess comprehensively continuity between levels of care from the user's perspective. Further information about the questionnaire's psychometric properties will be obtained by applying it to a larger population.