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About the Project

Understanding relational continuity of care

There is no funding for this project. It is for self-funded students.

Background

Relational continuity of care is ongoing affiliation between clinician and a patient across many illness episodes.[i]

Patients value continuity of care, especially older patients and those with chronic conditions and it is strongly linked to positive patient experience.[ii],[iii]

It is also valued by GPs, who identify continuity of care as the most essential feature of general practice.[iv] 

Systematic review of qualitative research has identified a high degree of congruence between doctors’ and patients’ views of continuity of care. Both doctors and patients see it as enabling person-centred care; increasing quality of care; and giving patients greater confidence in medical decision-making. Both groups also identify some drawbacks (access, overfamiliarity, physician burden). Both see absence of continuity of care leading to harm (misdiagnosis, patients withdrawing from care) and loss of trust in the care team.[v] Doctors see continuity as particularly important for patients with serious, chronic, complex, or psychological problems.5 They also say it brings joy and meaning to their work.5

Longstanding evidence shows continuity of care is associated with reduced emergency care consultations, unplanned admissions and even mortality.[vi],[vii],[viii] Natural experiments provide further evidence of causation: disruption of continuity of care by departure of a physician is followed by increased use of specialty, urgent, and emergency care by older patients.[ix],[x] Systematic reviews of continuity of care in both primary care and specialist settings, have found an association with reduced mortality.[xi],[xii]

Relational continuity of care can be measured subjectively, (patient experience of continuity) or quantitatively (e.g. Usual Provider of Care index or Bice-Boxerman index).

Continuity of care is lower in larger general practices and varies by patient age and sex. It is also higher in practices with personal list systems. Efforts have been made to improve continuity of care in general practices. In 2019, five Health Foundation funded projects were undertaken to improve continuity of care through within-practice changes in organisation.[xiii] In the Netherlands the TOOL study is evaluating an intervention to improve continuity of care among older patients.[xiv]

We are planning to undertake a research project investigating continuity of care in UK primary care. This is will include several parts.

  • Developing a consensus on quantitative approaches to measurement of continuity of care.
  • Analysis of a large dataset of electronic primary care records (3.5 million individuals) to determine the practice characteristics associated with relational continuity of care (e.g. practice size, staff turnover, patient turnover).
  • An economic analysis of the effects of continuity of care in primary care using econometric methods and causal inference.
  • Case studies (interviews and focus groups) of general practices which maintain high quality of care

Research proposal

Applications are invited from prospective students with an interest in relational continuity of care. There may be opportunities to build on and contribute to research into measurement of continuity of care; the general practice-related factors associated with continuity of care; the economics of continuity of care; or investigation of the ways in which continuity of care affects general practices.

Students should either have an interest in continuity of care and either skills in quantitative analysis of large datasets of health care records (statistical or econometric skills) or have qualitative research skills (undertaking and analysing interviews and focus groups). Clinical knowledge would also be an advantage.

[i] Haggerty JL et al. Continuity of care: a multidisciplinary review. BMJ. 2003 Nov 22;327(7425):1219-21. doi: 10.1136/bmj.327.7425.1219.

[ii] Saultz JW et al. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med 2004; 2: 445–451.

[iii] Waibel S et al. What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies. Int J Qual Health Care 2012; 24, 39-48.

[iv] Pereira Gray D et al Towards a theory of continuity of care J R Soc Med 2003;96:160–166

[v] Nowak DA et al. Why does continuity of care with family doctors matter? Review and qualitative synthesis of patient and physician perspectives. Can Fam Physician. 2021 Sep;67(9):679-688.

[vi] Tammes, P et al. Continuity of primary care and emergency hospital admissions among older patients in England. Ann Fam Med 2017; 15, 515-522.

[vii] Barker I et al. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data BMJ 2017;356:j84

[viii] Sandvik H et al. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. BJGP. 2021 Aug 26:BJGP.2021.0340.

[ix] Sabety AH et al. Changes in health care use and outcomes after turnover in primary care. JAMA Intern Med. 2021 1; 181:186-194.

[x] Skarshaug LJ et al. How does general practitioner discontinuity affect healthcare utilisation? An observational cohort study of 2.4 million Norwegians 2007-2017. BMJ Open. 2021 16; 11:e042391.

[xi] Pereira Gray DJ et al. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. 2018 BMJ Open, 8, e021161.

[xii] Baker R, et al Primary medical care continuity and patient mortality: a systematic review. BJGP 10 August 2020; bjgp20X712289.

[xiii] The Health Foundation. Increasing Continuity of care in General Practice 2020 [Accessed 13th March 2020]

[xiv] Groot LJJ et al. Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial. BMC Fam Pract. 2021 Oct 20;22(1):207.


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