Reexamining the association of care continuity and health care outcomes.

OBJECTIVES: This study examined the relationship between claims-based and patient-reported continuity of care (COC) measures and investigated the effects of the 2 types of COC measures on subjective and objective health care outcomes. STUDY DESIGN: A prospective, cross-sectional, correlational survey design was used. A nationwide face-to-face interview survey of community-dwelling older adults was conducted, and the survey participants' health claims records were retrieved and linked under the universal health insurance system of Taiwan in 2018. METHODS: Health care outcomes were measured subjectively (patient satisfaction and perceived lack of coordination) and objectively (likelihood of hospital admissions and emergency department [ED] visits). COC was measured using claims-based and multidimensional patient-reported COC. Ordered logit and logit models were used to examine the relationship between the 2 types of COC measures, and health care outcomes were measured subjectively and objectively. Average marginal effects with bootstrapped SEs were computed for health care outcomes. RESULTS: This study demonstrated that the correlations of claims-based and patient-reported COC measures were quite low and mainly insignificant. A higher claims-based COC was significantly associated with a lower likelihood of hospital admissions, ED visits, and perceived lack of coordination. No significant relationship was identified between claims-based COC and patient satisfaction. Participants reporting higher COC had better patient satisfaction and less perceived lack of coordination. However, no relationship was identified between patient-reported COC and the likelihood of hospital admissions and ED visits. CONCLUSIONS: The correlation between claims-based and patient-reported COC measures is low, and claims-based and patient-reported COC measures are associated with different subjective and objective health care outcomes. We suggest that claims-based COC indicators representing the pattern of physician visits might be considered a unique dimension of COC.

Longitudinal care continuity and avoidable hospitalization: the application of claims-based measures.

BACKGROUND: Longitudinal continuity between a patient and his/her primary care physician is an important aspect in measuring continuity of care (COC). The majority of previous studies employed questionnaire surveys to patients to measure the continual relationship between patients and their physicians. This study aimed to construct a provider duration continuity index (PDCI) by using longitudinal claims data and to examine its agreement with commonly used COC measures. Then, this study investigated the effects of the various types of COC measure on the likelihood of avoidable hospitalization while considering the level of comorbidity. METHODS: This study constructed a 4-year panel (from 2014 to 2017) of the nationwide health insurance claims data in Taiwan. In total, 328,044 randomly selected patients with 3 or more physician visits per year were analyzed. Two PDCIs were constructed to measure the duration of interaction between a patient and his/her physicians over time. The agreement between the PDCIs and three commonly used COC indicators, the Usual Provider of Care index, the Continuity of Care Index, and the Sequential Continuity Index, were examined. Generalized estimating equations were conducted to examine the association between COC and avoidable hospitalization by the level of comorbidity. RESULTS: The results showed that the correlations among the three commonly used COC indicators were high (γ = 0.787 ~ 0.958) and the correlation between the two longitudinal continuity measures was moderate (γ = 0.577 ~ 0.579), but the correlations between the commonly used COC indicators and the two PDCIs were low (γ = 0.001 ~ 0.257). All COC measures, both the PDCIs and the three commonly used COC indicators, showed independent protective effects on the likelihood of avoidable hospitalization in three comorbidity groups. CONCLUSION: The duration of interaction between patients and physicians is an independent domain in measuring COC and has a significant effect on health care outcomes.

Does continuity of care improve patient satisfaction? An instrumental variable approach.

Numerous studies have investigated the relationship between continuity of care (COC) and patient satisfaction. However, COC and patient satisfaction were measured simultaneously; therefore, the direction of causality remains understudied. This study examined the effect of COC on the patient satisfaction of elderly individuals using an instrumental variable (IV) approach. Nationwide survey data acquired using a face-to-face interview were used to measure the patient-reported COC experiences of 1,715 participants. We applied an ordered logit model controlled for observed patient characteristics and a two-stage residual inclusion (2SRI) ordered logit model that accounted for unobserved confounding factors. Patient-perceived COC importance was used as an IV for patient-reported COC. The ordered logit models indicated that patients with high or intermediate patient-reported COC scores were more likely to perceive more patient satisfaction than those with low COC scores. Using the patient-perceived COC importance as an IV, we examined a strong significant association between the level of patient-reported COC and patient satisfaction. It is necessary to adjust for unobserved confounders to obtain more accurate estimates of the relationship between patient-reported COC and patient satisfaction. However, the results and policy implications of this study should be cautiously interpreted because the possibility of other bias could not be ruled out. These findings support policies aimed at improving patient-reported COC among older adults.

Continuity of Care and Coordination of Care: Can they Be Differentiated?

Introduction: Both care continuity and coordination are considered essential elements of health care system. However, little is known about the relationship between care continuity and coordination. This study aimed to differentiate the concepts of care continuity and coordination by developing and testing the reliability and validity of the Combined Outpatient Care Continuity and Coordination Assessment (COCCCA) questionnaire under the universal coverage health care system in Taiwan from a patient perspective. Methods: Face-to-face interviews were conducted nationwide with community-dwelling older adults selected via stratified multistage systematic sampling with probability-proportional-to-size process. A total of 2,144 subjects completed the questionnaire, with a response rate of 44.67%. Results: The 16 items of the COCCCA questionnaire were identified via item analysis and principal component analysis (PCA). The PCA generated five dimensions: three continuity-oriented (interpersonal, information sharing and longitudinal between patients and physicians) and two coordination-oriented (information exchange and communication/cooperation among multiple physicians). The second-order confirmatory factor analysis supported the factor structure and indicated that distinct constructs of care continuity and coordination can be identified. Conclusion: The COCCCA instrument can differentiate the concepts of care continuity and care coordination and has been demonstrated to be valid and reliable in outpatient care settings from a patient perspective.

Examining the Long-term Spillover Effects of a Pay-for-Performance Program in a Healthcare System That Lacks Referral Arrangements.

BACKGROUND: Several studies have examined the intended effects of pay-for-performance (P4P) programs, yet little is known about the unintended spillover effects of such programs on intermediate clinical outcomes. This study examines the long-term spillover effects of a P4P program for diabetes care. METHODS: This study uses a nationwide population-based natural experimental design with a 3-year follow-up period under Taiwan's universal coverage healthcare system. The intervention group consisted of 7688 patients who enrolled in the P4P program for diabetes care in 2017 and continuously participated in the program for three years. The comparison group was selected by propensity score matching (PSM) from patients seen by the same group of physicians. Each patient had four records: one pertaining to one year before the index date of the P4P program and the other three pertaining to follow-ups spanning over the next three years. Generalized estimating equations (GEEs) with difference-in-differences (DID) estimations were used to consider the correlation between repeated observations for the same patients and patients within the same matched pairs. RESULTS: Patients enrolled in the P4P program showed improvements in incentivized intermediate clinical outcomes that persisted over three years, including proper control of glycated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C). We found a slight positive spillover effect of the P4P program on the control of non-incentivized triglyceride [TG]). However, we found no such effects on the non-incentivized high-density lipoprotein cholesterol (HDL-C) control. CONCLUSION: The P4P program has achieved its primary goal of improving the incentivized intermediate clinical outcomes. The commonality in production among a set of activities is crucial for generating the spillover effects of an incentive program.

Development and Validation of an Integrated Healthy Workplace Management Model in Taiwan.

Background: Impacts of exposure are generally monitored and recorded after injuries or illness occur. Yet, absence of conventional after-the-effect impacts (i.e., lagging indicators), tend to focus on physical health and injuries, and fail to inform if workers are not exposed to safety and health hazards. In contrast to lagging indicators, leading indicators are proactive, preventive, and predictive indexes that offer insights how effective safety and health. The present study is to validate an extended Voluntary Protection Programs (VPP) that consists of six leading indicators. Methods: Questionnaires were distributed to 13 organizations (response rate = 93.1%, 1,439 responses) in Taiwan. Cronbach α, multiple linear regression and canonical correlation were used to test the reliability of the extended Voluntary Protection Programs (VPP) which consists of six leading indicators (safe climate, transformational leadership, organizational justice, organizational support, hazard prevention and control, and training). Criteria-related validation strategy was applied to examine relationships of six leading indicators with six criteria (perceived health, burnout, depression, job satisfaction, job performance, and life satisfaction). Results: The results showed that the Cronbach's α of six leading indicators ranged from 0.87 to 0.92. The canonical correlation analysis indicated a positive correlation between the six leading indicators and criteria (1st canonical function: correlation = 0.647, square correlation = 0.419, p < 0.001). Conclusions: The present study validates the extended VPP framework that focuses on promoting safety and physical and mental health. Results further provides applications of the extended VPP framework to promote workers' safety and health.

Care Continuity and Care Coordination: A Preliminary Examination of Their Effects on Hospitalization.

Both care continuity and care coordination are important features of the health care system. However, little is known about the relationship between care continuity and care coordination, their effects on hospitalizations, and whether these effects vary across patients with various levels of comorbidity. This study employed a panel study design with a 3-year follow-up from 2007 to 2011 in Taiwan's universal health coverage system. Patients aged 18 years or older who were newly diagnosed with diabetes in 2007 were included in the study. We found that the correlation between care continuity and care coordination was low. Patients with higher levels of care continuity or care coordination were less likely to experience hospitalization for diabetes-related conditions. Furthermore, both care continuity and care coordination showed stronger effects for patients with higher comorbidity scores. Improving care continuity and coordination for patients with multiple chronic conditions is the right direction for policymakers.

A psychometric analysis of a short form of the Chinese version of the ISPCAN child abuse screening tools - Children's home version (SC-ICAST-CH) using multidimensional item response theory.

BACKGROUND: The development of measures of child maltreatment for the Chinese population were limited until the Chinese version of the ISPCAN Child Abuse Screening Tools - Children's Home version (ICAST-CH-C) was proposed. Although the ICAST-CH-C was found to be effective in assessing the scope and prevalence of child maltreatment, it has several potential drawbacks. The time that is required to complete the ICAST-CH-C scale is longer than usual for a 36-item scale, because many of its items have one or more follow-up questions. Moreover, each item requires child victims to recall unpleasant experiences. Both phenomena can cause increases in invalid responses and in turn damage the data quality. OBJECTIVE: The goal of this study was to propose a short form of the ICAST-CH-C (called the SC-ICAST-CH) to reduce the test length and response time in order to improve the measurement quality. PARTICIPANTS AND SETTING: A dataset from a national survey of 5236 adolescents in Taiwan was used. METHODS: A multidimensional version of the rating scale model (MRSM) was fitted to the data. The model parameters were estimated with the ConQuest software. RESULTS: The results indicated the reliability of the SC-ICAST-CH was fairly good, with only 61 % of the original test length. Disordered thresholds were found in all five subscales; the underlying reasons for this phenomenon need further investigation. Specific cultural differences related to item retention/removal decisions were also discussed. CONCLUSION: The efficient, shorter SC-ICAST-CH was shown to be a valid and reliable instrument for assessing the prevalence of child maltreatment.

Keeping up with guideline recommendations: does patient volume matter in diabetes care?

OBJECTIVES: To examine the association between service volume and guideline adherence via multiyear observations. STUDY DESIGN: Repeated cross-sectional study. METHODS: This study employed nationwide claims data from Taiwan's National Health Insurance scheme and identified patients with newly diagnosed type 2 diabetes from 2001, 2005, and 2009; a new prescription guideline for diabetes care was introduced in 2006. Physician service volume was measured by the number of total outpatients with diabetes. The outcome variable indicated whether a patient was receiving metformin, the guideline-recommended antihyperglycemic agent, at the index date. RESULTS: Patients visiting physicians who had high or medium volumes of patients with diabetes were more likely to receive metformin than patients visiting physicians who had low volumes; the odds ratios (ORs) were 2.48 (95% CI, 2.03-3.04) and 1.76 (95% CI, 1.45-2.13), respectively. Patients with newly diagnosed diabetes in 2009 and 2005 were more likely to receive metformin than their counterparts in 2001, with ORs of 12.00 (95% CI, 11.19-12.86) and 2.44 (95% CI, 2.30-2.59), respectively. We also found that patients who visited younger physicians, physicians with fewer practice years, physicians practicing in large-scale hospitals, or physicians practicing in urban areas were more likely to receive metformin than their counterparts. CONCLUSIONS: In the process of implementing a new practice guideline for treating patients with diabetes, physicians with higher patient volumes are more likely to adhere to the guideline recommendation.

An Exploratory Strategy to Identify and Define Sources of Differential Item Functioning.

The sources of differential item functioning (DIF) items are usually identified through a qualitative content review by a panel of experts. However, the differential functioning for some DIF items might have been caused by reasons outside of the experts' experiences, leading to the sources for these DIF items possibly being misidentified. Quantitative methods can help to provide useful information, such as the DIF status and the number of sources of the DIF, which in turn help the item review and revision process to be more efficient and precise. However, the current quantitative methods assume all possible sources should be known in advance and collected to accompany the item response data, which is not always the case in reality. To this end, an exploratory strategy, combined with the MIMIC (multiple-indicator multiple-cause) method, that can be used to identify and name new sources of DIF is proposed in this study. The performance of this strategy was investigated through simulation. The results showed that when a set of DIF-free items can be correctly identified to define the main dimension, the proposed exploratory MIMIC method can accurately recover a number of possible sources of DIF and the items that belong to each. A real data analysis was also implemented to demonstrate how this strategy can be used in reality. The results and findings of this study are further discussed.

Escalating utilization of inpatient surgery for pelvic floor dysfunction in the elderly in Taiwan.

AIMS: The direct cost of operations and health care expenditure for treating pelvic floor dysfunction are substantial. In this study, we evaluate the number of inpatient surgical procedures and direct expenditures for treating pelvic organ prolapse and urinary incontinence under the coverage of National Health Insurance (NHI) in Taiwan. METHODS: Thirteen years of population-based NHI inpatient claims were used in this study. The number of surgical procedures and the average direct cost of inpatient fees for treating pelvic floor dysfunction for each patient from 1999 to 2011 were calculated. The patients were stratified based on age into a younger than 65 years group and 65 years or older group for comparisons. RESULTS: The number of patients per year increased by 27%, increasing from 5278 patients in 1999 to 6706 patients in 2011. The total direct cost of inpatient (surgical and admission) fees for pelvic floor dysfunction increased by 57.2%, increasing from $6 674 968 USD in 1999 to $10 494 894 USD in 2011. However, while the expenditures for women 65 years or older increased by 102.2% from 1999 to 2011, there was only a 38.3% increase for those younger than 65 years when we stratified the patients by age. CONCLUSION: The increasing expenditures for inpatient surgery for pelvic floor dysfunction are mainly due to the escalating utilization of inpatient surgical procedures, especially those for pelvic organ prolapse in women aged 65 or older.

Reimbursement changes and drug switching: are severe patients more affected?

Objectives To examine the long-term effects of drug reimbursement adjustments on drug-switching decisions and to investigate whether patients with complicated or severe conditions are more affected. Methods A population-based, longitudinal study with a before-and-after design. Analysis of 141,703 patients with type 2 diabetes covered by the universal health insurance program in Taiwan. Observation of five 6-month phases before and after a drug reimbursement adjustment implemented in October 2009. Drug switching was defined as a brand change within the same anatomical therapeutic chemical group between two consecutive physician visits. Generalized estimating equations were employed to control for the random subject effect. Results The drug-switching rates in the five phases were 10.85% and 13.71% before implementation and 31.53%, 28.29% and 15.61% after implementation. Results from the regression model revealed a higher likelihood of receiving switched drugs in phases 3, 4 and 5, with odds ratios of 3.16, 2.72 and 1.44 (with 95% confidence interval 3.04-3.29, 2.61-2.84 and 1.38-1.51), respectively, compared with phase 1. Patients with complicated or severe conditions were more likely to have their drugs switched after the reimbursement adjustment. Conclusions The drug reimbursement adjustment under the health insurance program resulted in an increase in drug-switching decisions, and patients were not exempt from medication switching regardless of the complications or the severity level of their illness.

Half-Managed Care: A Preliminary Assessment of a Capitation Program in a Health Care System Without Gatekeepers.

In 2011, a novel capitation program was launched in Taiwan under its universal health insurance plan. This study aimed to assess the short-term impact of the program. Two hospitals in the greater Taipei area, one participating in the "loyal patient" model (13,319 enrollees) and one in the "regional resident" model (13,768 enrollees), were analyzed. Two comparison groups were selected by propensity score matching. Generalized estimating equation models with differences-in-differences analysis were used to examine the net effects of the capitation program on health care utilization, expenses, and outcomes. Enrollees in the loyal patient model had fewer physician visits in the host hospital, but more physician visits outside that hospital during the program year than they had the year before. Compared with non-enrollees, the loyal patient model enrollees incurred fewer physician visits (ß = -0.042, p < .001), fewer emergency department visits, (ß = -0.140, p < .001), and similar total expenses and outcome. For the regional resident model, no differences were found in the number of physician visits, expenses, or outcomes between enrollees and non-enrollees. The novel capitation models in Taiwan had minimal impact on health care utilization after 1 year of implementation and the health care outcome was not compromised.

Continuity of care and changes in medication adherence among patients with newly diagnosed diabetes.

OBJECTIVES: Recent studies have revealed significant variation in medication adherence among patients with chronic conditions. Little is known about the effect of continuity of care (COC) on changes in medication adherence. This study aims to identify medication adherence trajectories among patients with newly diagnosed diabetes, as well as to examine the association of COC and medication adherence among various adherence trajectories. METHODS: This study utilized a longitudinal design with a 6-year follow-up, from 2002 to 2008, under a universal health insurance program in Taiwan. Subjects 18 years or older with type 2 diabetes that was newly diagnosed in 2002 were included in the study. The main outcome was medication adherence measured by medication possession ratio each year. Group-based trajectory models were used for analysis. RESULTS: Four medication adherence trajectories were identified: persistent adherence (39.9%), increasing adherence (27.5%), decreasing adherence (12.0%), and nonadherence (20.6%). Patients with high or medium COC index scores were more likely to be adherent to medications than those with low COC index scores in all of the trajectory adherence groups. CONCLUSIONS: This study demonstrated the heterogeneity in patients' medication adherence and identified 4 distinct trajectories of medication adherences among those with newly diagnosed type 2 diabetes. Improving COC may lead to better medication adherence in all of the adherence trajectory groups.

Potentially Inappropriate Medication and Health Care Outcomes: An Instrumental Variable Approach.

OBJECTIVE: To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach. DATA SOURCES/STUDY SETTING: Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010. STUDY DESIGN: We employed a panel study design to examine the relationship between PIM and hospitalization. We applied both the naive generalized estimating equation (GEE) model, which controlled for the observed patient and hospital characteristics, and the two-stage residual inclusion (2SRI) GEE model, which further accounted for the unobserved confounding factors. The PIM prescription rate of the physician most frequently visited by each patient was used as the IV. PRINCIPAL FINDINGS: The naive GEE models indicated that patient PIM use was associated with a higher likelihood of hospitalization (odds ratio [OR], 1.399; 95 percent confidence interval [CI], 1.363-1.435). Using the physician PIM prescribing rate as an IV, we identified a stronger significant association between PIM and hospitalization (OR, 1.990; 95 percent CI, 1.647-2.403). CONCLUSIONS: PIM use is associated with increased hospitalization in elderly individuals. Adjusting for unobserved confounders is needed to obtain unbiased estimates of the relationship between PIM and health care outcomes.

Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system.

INTRODUCTION: Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension. METHODS: This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme. RESULTS: Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. CONCLUSION: This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Medication supply, healthcare outcomes and healthcare expenses: longitudinal analyses of patients with type 2 diabetes and hypertension.

INTRODUCTION: Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses. METHODS: This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses. RESULTS: The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses. CONCLUSION: Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

Effects of continuity of care on medication duplication among the elderly.

BACKGROUND: The effects of continuity of care on health care outcomes are well documented. However, little is known about the effect of continuity at the physician or the site level on the process of care for patients with multiple chronic conditions (MCCs). OBJECTIVE: The objective of this study was to examine the effects of physician continuity versus site continuity on duplicated medications received by patients with and without MCCs. RESEARCH DESIGN AND SUBJECTS: This study utilized a longitudinal design with an 8-year follow-up from 2004 to 2011 of patients aged 65 or older under a universal health insurance program in Taiwan (55,573 subjects and 389,011 subject-years). Generalized estimating equation models with propensity score method were conducted to assess the association between continuity and medication duplication. RESULTS: The rates of subjects receiving duplicated medications ranged from 40.38% to 43.50% with 1.45-1.62 duplicated medications during the study period. The findings revealed that better continuity, either at the physician level or the site level, was significantly associated with fewer duplicated medications. This study also indicated that the physician continuity had a stronger effect on medication duplication than did site continuity. Furthermore, the magnitude of the protective effect of continuity against duplicated medications increased when the patients had more chronic conditions [physician continuity: the marginal effect ranged from -10.7% to -52.9% (all P<0.001); site continuity: the marginal effect ranged from -0.4% (P=0.063) to -31.4% (P<0.001)]. CONCLUSION: Improving either physician continuity or site continuity may result in fewer duplicated medications, particularly for patients with MCCs.

Does medication adherence lead to lower healthcare expenses for patients with diabetes?

OBJECTIVES: To examine the relationship between medication adherence and healthcare outcomes and expenses and to investigate whether the duration of type 2 diabetes mellitus (T2DM) has a role in the aforementioned relationship. DATA SOURCE/STUDY SETTING: Health insurance claims data under a universal coverage system in Taiwan. STUDY DESIGN: Seven years of longitudinal analysis was performed to examine the association between medication adherence of oral antihyperglycemic drugs and outcomes among patients with newly diagnosed T2DM. Generalized estimating equations were conducted to assess the temporal relationship while controlling for unobserved characteristics of patients. RESULTS: Better medication adherence was associated with decreased hospitalization and emergency department (ED) visits for diabetes or related conditions. The results also revealed that medication adherence was negatively associated with the expenses of hospitalization and ED visits for diabetes or related conditions, but medication adherence was positively associated with patients' total healthcare expenses. However, the adherence-related differences in total healthcare expenses began to decrease 5 years after the time of diabetes onset. CONCLUSIONS: Adherence to medication can improve healthcare outcomes but is associated with higher total healthcare expenses, especially during the years immediately following the onset of diabetes. Long-term follow-up is needed for further investigation.

Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis.

BACKGROUND: The effects of continuity of care (COC) on health care outcomes are well established. However, the mechanism of this association is not fully understood. OBJECTIVE: The objective of this study was to examine the relationship between COC and medication adherence, as well as to investigate the mediating effect of medication adherence on the association between COC and health care outcomes, in patients with newly diagnosed type 2 diabetes. RESEARCH DESIGN AND SUBJECTS: This study utilized a longitudinal design and included a 7-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. Patients aged 18 years or older who were first diagnosed with type 2 diabetes in 2002 were included in the study. Random intercept models were conducted to assess the temporal relationship between COC, medication adherence, and health care outcomes. RESULTS: Patients with high or intermediate COC scores were more likely to be adherent to medications than those with low COC scores [odds ratio (OR), 3.37; 95% confidence interval (CI), 3.15-3.60 and OR, 1.84; 95% CI, 1.74-1.94, respectively]. In addition, the association between COC and health care outcomes was partly mediated by better medication adherence in patients with newly diagnosed type 2 diabetes. CONCLUSIONS: Improving the COC for patients with type 2 diabetes may result in higher medication adherence and better health care outcomes.