How unique is continuity of care? A review of continuity and related concepts.

BACKGROUND: The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear. OBJECTIVE: In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management. METHODS: We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary. RESULTS: Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective. CONCLUSIONS: The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

Heart failure patients' experiences with continuity of care and its relation to medication adherence: a cross-sectional study.

BACKGROUND: A growing number of health care providers are nowadays involved in heart failure care. This could lead to discontinuity and fragmentation of care, thus reducing trust and hence poorer medication adherence. This study aims to explore heart failure patients' experiences with continuity of care, and its relation to medication adherence. METHODS: We collected data from 327 primary care patients with chronic heart failure. Experienced continuity of care was measured using a patient questionnaire and by reviewing patients' medical records. Continuity of care was defined as a multidimensional concept including personal continuity (seeing the same doctor every time), team continuity (collaboration between care providers in general practice) and cross-boundary continuity (collaboration between general practice and hospital). Medication adherence was measured using a validated patient questionnaire. The relation between continuity of care and medication adherence was analysed by using chi-square tests. RESULTS: In total, 53% of patients stated not seeing any care provider in general practice in the last year concerning their heart failure. Of the patients who did contact a care provider in general practice, 46% contacted two or more care providers. Respectively 38% and 51% of patients experienced the highest levels of team and cross-boundary continuity. In total, 14% experienced low levels of team continuity and 11% experienced low levels of cross-boundary continuity. Higher scores on personal continuity were significantly related to better medication adherence (p < 0.01). No clear relation was found between team- or cross-boundary continuity and medication adherence. CONCLUSIONS: A small majority of patients that contacted a care provider in general practice for their heart failure, contacted only one care provider. Most heart failure patients experienced high levels of collaboration between care providers in general practice and between GP and cardiologist. However, in a considerable number of patients, continuity of care could still be improved. Efforts to improve personal continuity may lead to better medication adherence.

Changes in the pattern of service utilisation and health problems of women, men and various age groups following a destructive disaster: a matched cohort study with a pre-disaster assessment.

OBJECTIVES: Female gender and young age are known risk factors for psychological morbidity after a disaster, but this conclusion is based on studies without a pre-disaster assessment. The aim of this study in family practice was to investigate if these supposed risk factors would still occur in a study design with a pre-disaster measurement. METHODS: A matched cohort study with pre-disaster (one year) and post-disaster (five years) data. Community controls (N = 3164) were matched with affected residents (N = 3164) on gender, age and socioeconomic status. Main outcome measures were utilization rates measured by family practice attendances and psychological, musculoskeletal and digestive health problems as registered by the family practitioner using the International Classification of Primary Care (ICPC). RESULTS: Affected residents of female and male gender and in five age groups all showed increases in utilization rates in the first post-disaster year and in psychological problems when compared to their pre-disaster baseline levels. The increases showed no statistically significant changes, however, between women and men and between all age groups. CONCLUSION: Gender and age did not appear to be disaster-related risk factors in this study in family practice with a pre-disaster base line assessment, a comparison group and using existing registries. Family practitioners should not focus specifically on these risk groups.

Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors.

BACKGROUND: Most studies on the incidence of the carpal tunnel syndrome and the relation of this disorder with occupation are population-based. In this study we present data from general practice. AIM: To compare incidence rates of carpal tunnel syndrome in 1987 with those in 2001, and to study the relationship between carpal tunnel syndrome and occupation. DESIGN OF STUDY: Analysis of the data of the first and second Dutch National Survey of General Practice, conducted in 1987 and 2001, respectively. SETTING: General practices in The Netherlands. METHOD: One hundred and three general practices in 1987 with 355 201 listed patients, and 96 practices with 364 998 listed patients in 2001, registered all patients who presented with a new episode of carpal tunnel syndrome. Patient and GP populations were representative for The Netherlands. RESULTS: The crude incidence rate was 1.3 per 1000 (95% confidence interval [CI] = 1.0 to 1.5) in 1987, and 1.8 per 1000 (95% CI = 1.7 to 2.0) in 2001. In males it was 0.6 (95% CI = 0.5 to 0.7) and 0.9 (95% CI = 0.8 to 1.0) respectively; in females 1.9 (95% CI = 1.7 to 2.1) and 2.8 (95% CI = 2.6 to 3.1). At both study periods, peak incidence rate occurred in the 45-64-year age group: in 2001 this peak reached 4.8 per 1000 (95 CI = 4.1 to 5.4) for females and 1.6 (95 CI = 1.2 to 2.0) for males. Women who performed unskilled and semi-skilled work had 1.5 times greater risk of acquiring carpal tunnel syndrome than women with higher-skilled jobs (P <0.001). In men no relationship of this kind was found. CONCLUSION: In 2001 the crude incidence rate of carpal tunnel syndrome was 1.5 times higher than in 1987, but the difference was not statistically significant after subdividing by age and sex. In both years the female:male ratio was 3:1. Incidence rates were related to the job level of women, but not of men.

Changes in the sociodemographic composition of the lowest socioeconomic group over time, 1987-2001.

BACKGROUND: When comparing health differences of groups with equal socioeconomic status (SES) over time, the sociodemographic composition of such a SES group is considered to be constant. However, when the periods are sufficiently spaced in time, sociodemographic changes may have occurred. The aim of this study is to examine in which respects the sociodemographic composition of lowest SES group changed between 1987 and 2001. METHODS: Our data were derived from the first and second Dutch National Survey of General Practice conducted in 1987 and 2001. In 1987 sociodemographic data from all listed patients (N = 334,007) were obtained by filling out a registration form at the practice (response 78.3%, 261,691 persons), in 2001 these data from all listed patients (385,461) were obtained by postal survey (response 76.9%, 296,243 persons). Participants were primarily classified according to their occupation into three SES groups: lowest, middle and highest. RESULTS: In comparison with 1987, the lowest SES group decreased in relative size from 34.9% to 29.5%. Within this smaller SES group, the relative contribution of persons with a higher education more than doubled for females and doubled for males. This indicates that the relation between educational level and occupation was less firmly anchored in 2001 than in 1987. The relative proportion of some disadvantaged groups (divorced, unemployed) increased in the lowest SES group, but the size of this effect was smaller than the increase from higher education. Young people (0-24 years) were proportionally less often represented in the lowest SES group. Non-Western immigrants contributed in 2001 proportionally less to the lowest SES group than in 1987, because of an intergenerational upward mobility of the second generation. CONCLUSION: On balance, the changes in the composition did not result in an accumulation of disadvantaged groups in the lowest SES group. On the contrary, the influx of people with higher educational qualifications between 1987 and 2001 could result in better health outcomes and health perspectives of the lowest SES group.

Striking variations in consultation rates with general practice reveal family influence.

BACKGROUND: The reasons why patients decide to consult a general practitioner vary enormously. While there may be individual reasons for this variation, the family context has a significant and unique influence upon the frequency of individuals' visits. The objective of this study was to explore which family factors can explain the differences between strikingly high, and correspondingly low, family consultation rates in families with children aged up to 21. METHODS: Data were used from the second Dutch national survey of general practice. This survey extracted from the medical records of 96 practices in the Netherlands, information on all consultations with patients during 2001. We defined, through multilevel analysis, two groups of families. These had respectively, predominantly high, and low, contact frequencies due to a significant family influence upon the frequency of the individual's first contacts. Binomial logistic regression analyses were used to analyse which of the family factors, related to shared circumstances and socialisation conditions, can explain the differences in consultation rates between the two groups of families. RESULTS: In almost 3% of all families, individual consultation rates decrease significantly due to family influence. In 11% of the families, individual consultation rates significantly increase due to family influence. While taking into account the health status of family members, family factors can explain family consultation rates. These factors include circumstances such as their economic status and number of children, as well as socialisation conditions such as specific health knowledge and family beliefs. The chance of significant low frequencies of contact due to family influences increases significantly with factors such as, paid employment of parents in the health care sector, low expectations of general practitioners' care for minor ailments and a western cultural background. CONCLUSION: Family circumstances can easily be identified and will add to the understanding of the health complaints of the individual patient in the consulting room. Family circumstances related to health risks often cannot be changed but they can illuminate the reasons for a visit, and mould strategies for prevention, treatment or recovery. Health beliefs, on the other hand, may be influenced by providing specific knowledge.

All in the family: headaches and abdominal pain as indicators for consultation patterns in families.

PURPOSE: Headaches and abdominal pain are examples of minor ailments that are generally self-limiting. We examined the extent to which patterns of visits to family physicians for minor ailments, such as headaches or abdominal pain, cluster within families. METHODS: Using information from the Second Dutch National Survey of General Practice for 96 family practices, we analyzed the visits of families with at least 1 child aged 12 years or younger during a period of 12 months. RESULTS: Family patterns were clearest in the visits of mothers and children. A large part of the similarity in the frequencies of contact by mothers and daughters could be attributed to shared family factors. This finding was especially true for families with a child who had a headache or abdominal pain as the presenting symptom, rather than physical trauma or chronic disease. Within families, we did not find any specific patterns of diagnoses. Diagnoses were recorded by family physicians. In the case of young children, family similarity may have been overestimated because parents initiated the visits and put their child's health problem into words. CONCLUSIONS: Visits to family physicians for headaches or abdominal pain can be seen as indicators of consultation patterns in families. Family patterns related to minor ailments are likely to be a result of socialization. Family consultation patterns might point toward specific needs of families and consequently at a different approach to treatment.

Why does it run in families? Explaining family similarity in help-seeking behaviour by shared circumstances, socialisation and selection.

Why do contact frequencies with general practice of family members resemble each other? Many aspects related to the clustering of health-care utilisation within families have been studied, but the underlying mechanisms have not been addressed. This article considers whether family similarity in contact frequency with general practice can be explained as (a) a result of shared circumstances, (b) through socialisation, and (c) through homogeneity of background characteristics. Data from the second Dutch national survey of general practice were used to test these mechanisms empirically. This survey recorded all consultations in 2001 for 104 general practices in the Netherlands, serving 385,461 patients. Information about socio-demographic characteristics was collected by means of a patient survey. In a random sample, an extended health interview took place (n=12,699). Overall, we were able to show that having determinants in common through socialisation and shared circumstances can explain similarity in contact frequencies within families, but not all hypotheses could be confirmed. In specific terms, this study shows that resemblances in contact frequencies within families can be best explained by spending more time together (socialisation) and parents and children consulting a general practitioner simultaneously (circumstances of the moment). For general practitioners, the mechanisms identified can serve as a framework for a family case history. The importance of the mechanism of socialisation in explaining similarities in help-seeking behaviour between family members points to the significance of knowledge and health beliefs underlying consultation behaviour. An integrated framework including these aspects can help to better explain health behaviour.

Treatment of heart failure in Dutch general practice.

BACKGROUND: To study the relation between the prescription rates of selected cardiovascular drugs (ACE-inhibitors and Angiotensin receptor blockers, beta-blockers, diuretics, and combinations), sociodemographic factors (age, gender and socioeconomic class) and concomitant diseases (hypertension, coronary heart disease, cerebrovascular accident, heart valve disease, atrial fibrillation, diabetes mellitus and asthma/COPD) among patients with heart failure cared for in general practice. METHODS: Data from the second Dutch National Survey in General Practice, conducted mainly in 2001. In this study the data of 96 practices with a registered patient population of 374.000 were used. Data included diagnosis made during one year by general practitioners, derived from the electronic medical records, prescriptions for medication and sociodemographic characteristics collected via a postal questionnary (response 76%) RESULTS: A diagnosis of HF was found with 2771 patients (7.1 in 1000). Their mean age was 77.7 years, 68% was 75 years or older, 55% of the patients were women. Overall prescription rates for RAAS-I, beta-blockers and diuretics were 50%, 32%, 86%, respectively, whereas a combination of these three drugs was prescribed in 18%. Variations in prescription rates were mainly related to age and concomitant diseases. CONCLUSION: Prescription is not influenced by gender, to a small degree influenced by socioeconomic status and to a large degree by age and concomitant diseases.

Outcomes of audit-enhanced monitoring of patients with type 2 diabetes.

OBJECTIVE: To assess the outcome of diabetes care in a practice-based research network after the introduction of an audit-enhanced monitoring system (AEMS). STUDY DESIGN: An AEMS was introduced into family practices participating in the academic research network of Nijmegen University, Nijmegen, the Netherlands. One and 7 years later, a cross-sectional analysis was performed on the outcome of care in all type 2 diabetes patients under treatment by their family physicians. POPULATION: Approximately 42,000 patients in 1993 and approximately 46,000 patients in 1999 at 10 family practices participating in the university's academic research network. OUTCOMES MEASURED: Targets of care were HbA1c < 8.5% and blood pressure < 150/85 mm Hg. Targets for lipids depended on age, cardiovascular morbidity, and smoking status. RESULTS: In 1993, 540 type 2 diabetes patients were included; in 1999, 851 such patients were included, representing a prevalence of 1.3% and 2.0%, respectively. Glycemic control improved statistically significantly by the percentage of patients with HbA1c < 8.5% (87% vs 59%, P =.0001) and the mean HbA1c (7.1% vs 8.2%, P =.0001) from the first to the second cohort. Mean blood pressure and the percentage of patients above the target blood pressure did not change. The mean cholesterol (207 mg/dL vs 238 mg/dL [5.4 mmol/L vs 6.2 mmol/L], P =.0001) and the percentage of patients who met their target lipid levels (72% vs 52%, P =.001) also improved between 1993 and 1999. In addition, an increased percentage of patients attended an annual review in the past year (73% vs 84%). CONCLUSIONS: Outcomes of diabetes care in a family practice research setting using an AEMS were comparable with those reported under randomized controlled trial conditions.

Experienced continuity of care in patients at risk for depression in primary care.

BACKGROUND: Existing studies about continuity of care focus on patients with a severe mental illness. OBJECTIVES: Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure. METHODS: Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as ( 1 ) number of care providers contacted (personal continuity); ( 2 ) collaboration between care providers in general practice (team continuity) (six items, score 1-5); and ( 3 ) collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1-5). RESULTS: Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01). CONCLUSION: The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.

Measurement properties of questionnaires measuring continuity of care: a systematic review.

BACKGROUND: Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties. METHODS: We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including 'continuity of care', 'coordination of care', 'integration of care', 'patient centered care', 'case management' and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist. RESULTS: We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties. CONCLUSIONS: Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.

Nijmegen Continuity Questionnaire: development and testing of a questionnaire that measures continuity of care.

OBJECTIVE: To develop and pilot test a generic questionnaire to measure continuity of care from the patient's perspective across primary and secondary care settings. STUDY DESIGN AND SETTING: We developed the Nijmegen Continuity Questionnaire (NCQ) based on a systematic literature review and analysis of 30 patient interviews. The questionnaire consisted of 16 items about the patient-provider relationship to be answered for five different care providers and 14 items each on the collaboration between four groups of care providers. The questionnaire was distributed among patients with a chronic disease recruited from general practice. We used principal component analysis (PCA) to identify subscales. We refined the factors by excluding several items, for example, items with a high missing rate. RESULTS: In total, 288 patients filled out the questionnaire (response rate, 72%). PCA yielded three subscales: "personal continuity: care provider knows me," "personal continuity: care provider shows commitment," and "team/cross-boundary continuity." Internal consistency of the subscales ranged from 0.82 to 0.89. Interscale correlations varied between 0.42 and 0.61. CONCLUSION: The NCQ shows to be a comprehensive, reliable, and valid instrument. Further testing of reliability, construct validity, and responsiveness is needed before the NCQ can be more widely implemented.

Trends in COPD prevalence and exacerbation rates in Dutch primary care.

BACKGROUND: Changes in the burden of chronic obstructive pulmonary disease (COPD) and its exacerbations on primary health care are not well studied. AIM: To identify trends in the prevalence of physician-diagnosed COPD and exacerbation rates by age, sex, and socioeconomic status in a general practice population. DESIGN OF STUDY: Trend analysis of COPD data from a 27-year prospective cohort of a dynamic general practice population. SETTING: Data were taken from the Continuous Morbidity Registration Nijmegen. METHOD: For the period 1980-2006, COPD and COPD exacerbation data were extracted for patients aged ≥40 years. Data were standardised for the composition of the Continuous Morbidity Registration population in the year 2000. Regression coefficients for trends were estimated by sex, age, and socioeconomic status. Rate ratios were calculated for prevalence differences in different demographic subgroups. RESULTS: During the study period, the overall COPD prevalence decreased from 72.7 to 54.5 per 1000 patients per year. The exacerbation rate decreased from 44.1 to 31.5 per 100 patients, and the percentage of patients with COPD who had exacerbations declined from 27.6% to 21.0%. The prevalence of COPD increased significantly in women, in particular those aged ≥65 years with low socioeconomic status. Decreases in exacerbation rates and percentages of patients with exacerbations were independent of sex, age, and socioeconomic status. CONCLUSION: The decline in COPD prevalence and exacerbation rates suggests a reduction of the burden on Dutch primary care. The increase of the prevalence in women indicates a need to focus on this particular subgroup in COPD management and research.

Health problems presented to family practices in the Netherlands 1 year before and 1 year after a disaster.

BACKGROUND: Disasters often have negative health consequences. Studies of health problems presented in family practice before and after a disaster are rare. The present study analyzed health problems before and after a disaster and predictors of increased morbidity after the disaster as presented in family practice. METHODS: A matched cohort study design with measurements 1 year before the disaster and 1 year after the disaster. Victims (N = 9183) and matched controls (N = 7066) were surveyed in the electronic medical records of 30 family practices after the explosions of a fireworks depot in The Netherlands. All health problems were registered using the International Classification of Primary Care. RESULTS: Victims showed significantly higher prevalence rates for psychological problems after the disaster than before the disaster (422 vs133 per 1000 person-years; P < .001) and for problems of the musculoskeletal system (450 vs 401 per 1000 person-years; P < .05). Relocation because of the disaster (odds ratio, 10.65; 95% confidence interval, 8.15-13.94) and, to a lesser degree, psychological morbidity before the disaster (odds ratio, 2.31; 95% confidence interval, 1.42-3.76) were the strongest predictors of psychological problems after the disaster. CONCLUSION: The results suggested that forced relocation and a history of psychological problems were risk factors to post-disaster psychological problems of victims presenting to a family practice.

The course of post-disaster health problems of victims with pre-disaster psychological problems as presented in general practice.

BACKGROUND: Survivors of disaster with pre-disaster psychological problems are believed to be at risk for presenting post-disaster psychological and physical morbidity. Up till now this statement is based on cross-sectional studies with self-reported data and without pre-disaster measurement. OBJECTIVE: To monitor post-disaster health care utilization and morbidity presented in general practice after a man-made disaster by victims and controls with and without pre-disaster psychological problems. METHODS: A controlled cohort study with pre-disaster (1 year) and post-disaster (two-and-a-half years) data. Victims (N = 2518) of an exploding fireworks depot in a residential area and matched controls (N = 2512), representing patients in 30 general practices, were included. Main outcome measures were utilization measured by GP attendances, and psychological and physical problems registered by the GP using the International Classification of Primary Care. RESULTS: Only victims without pre-disaster psychological problems demonstrated a significant increase in utilization in the first half year post-disaster. Victims with pre-disaster psychological problems did not. Being a victim (OR = 6.13; 95% CI = 4.84-7.77) had a greater effect than pre-disaster psychological problems (OR = 4.96; 95% CI = 3.96-6.21) on presenting post-disaster psychological problems. Pre-disaster psychological problems had more effect (OR = 1.93; 95% CI = 1.79-2.08) than the effect of being a victim (OR = 1.25; 95% CI = 1.18-1.32) on the development of post-disaster physical symptoms. CONCLUSION: Post-disaster increases in utilization and psychological morbidity were observed. Post-disaster psychological problems were more influenced by the disaster, while post-disaster physical symptoms were more influenced by pre-disaster psychological problems. GPs should concentrate on the pre-disaster health history of victims of man-made disasters in their practices.