Association of Lower Continuity of Care With Greater Risk of Emergency Department Use and Hospitalization in Children
TL;DR: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization and efforts to improve and maintain continuity may be warranted.
Abstract: Context. The benefits of continuity of pediatric care remain controversial. Objective. To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. Design. Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. Main Exposure Variable. A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. Main Outcome Measures. ED utilization and hospitalization. Results. Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20–1.36]) and more likely to be hospitalized (HR: 1.22 [1.09–1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49–1.66]) and to be hospitalized (HR: 1.54 [1.33–1.75]). These risks were even greater for children on Medicaid and those with asthma. Conclusions. Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.
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TL;DR: It is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization and future research in this area should seek to define and measure interpersonal continuity more explicitly.
Abstract: PURPOSE We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to fioriginal English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence. RESULTS Forty-one research articles reporting the results of 40 studies were identifi ed that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were signifi cantly improved and only 2 were signifi cantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported signifi cantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity. CONCLUSIONS Although the available literature refl ects persistent methodologic problems, it is likely that a signifi cant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specifi c and measurable outcomes and more direct costs and should seek to defi ne and measure interpersonal continuity more explicitly.
556 citations
Journal Article•
TL;DR: SCOC is associated with patient satisfaction, decreased hospitalizations and emergency department visits, and improved receipt of preventive services, and this association is consistently documented for patients with chronic conditions.
Abstract: Objective Continuity of care is a cornerstone of primary care that has been promoted by recent trends in medical education and in the way health care delivery is organized. We sought to determine the effect of sustained continuity of care (SCOC) on the quality of patient care. Data sources We conducted a systematic review of all articles in Medline (January 1966 to January 2002), Educational Resources Information Center (ERIC), and PSYCH INFO using the terms "continuity of care" or "continuity of patient care." We identified additional titles of candidate articles by reviewing the bibliographies of articles from our original MEDLINE search, contacting experts in primary care, health care management, and health services research, and by reviewing bibliographies of textbooks of primary care and public health. Study selection and data extraction Two investigators (MDC, SHJ) independently reviewed the full text to exclude articles that did not fulfill search criteria. Articles excluded were those that focused on physicians-in-training, on SCOC in a non-primary care setting, such as an inpatient ward, or on transitions from inpatient to the outpatient setting. We also excluded articles that did not correlate SCOC to a quality of care measure. Data synthesis From 5070 candidate titles, we examined the full text of 260 articles and found 18 (12 cross-sectional studies, 5 cohort studies and 1 randomized controlled trial) that fulfilled our criteria. Five studies focused on patients with chronic illness (eg, asthma, diabetes). Results No studies documented negative effects of increased SCOC on quality of care. SCOC is associated with patient satisfaction (4 studies), decreased hospitalizations and emergency department visits (7 studies), and improved receipt of preventive services (5 studies). Conclusions SCOC improves quality of care, and this association is consistently documented for patients with chronic conditions. Programs to promote SCOC may best maximize impact by focusing on populations with chronic conditions.
468 citations
Cites background from "Association of Lower Continuity of ..."
...Half of the studies focused on patients with chronic conditions (asthma or diabetes).(33,34,37) Medicaid claims data analyses suggest that...
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TL;DR: These studies validate the belief that increased provider continuity is associated with improved patient outcomes and satisfaction and further research is required to determine whether information or management continuity improves outcomes.
Abstract: Background Numerous studies have tried to determine the association between continuity and outcomes. Studies doing so must actually measure continuity. If continuity and outcomes are measured concurrently, their association can only be determined with time-dependent methods.
Objective To identify and summarize all methodologically studies that measure the association between continuity of care and patient outcomes.
Methods We searched MEDLINE database (1950–2008) and hand-searched to identify studies that tried to associate continuity and outcomes. English studies were included if they: actually measured continuity; determined the association of continuity with patient outcomes; and properly accounted for the relative timing of continuity and outcome measures.
Results A total of 139 English language studies tried to measure the association between continuity and outcomes but only 18 studies (12.9%) met methodological criteria. All but two studies measured provider continuity and used health utilization or patient satisfaction as the outcome. Eight of nine high-quality studies found a significant association between increased continuity and decreased health utilization including hospitalization and emergency visits. Five of seven studies found improved patient satisfaction with increased continuity.
Conclusions These studies validate the belief that increased provider continuity is associated with improved patient outcomes and satisfaction. Further research is required to determine whether information or management continuity improves outcomes.
455 citations
01 Jan 2010
428 citations
TL;DR: The evidence provides moderate support for the hypothesis that medical homes provide improved health-related outcomes for children with special health care needs, and the preponderance of evidence supported a positive relationship between the medical home and desired outcomes.
Abstract: CONTEXT. The receipt of health care in a medical home is increasingly touted as a fundamental basis for improved care for persons with chronic conditions, yet the evidence for this claim has not been systematically assessed. OBJECTIVE. Our goal was to determine the evidence for the federal Maternal and Child Health Bureau recommendation that children with special health care needs receive ongoing comprehensive care within a medical home. METHODS. We searched the nursing and medical literature, references of selected articles, and requested expert recommendations. Search terms included children with special health care needs, medical home-related interventions, and health-related outcomes. Articles that met defined criteria (eg, children with special health care needs, United States–based, quantitative) were selected. We extracted data, including design, population characteristics, sample size, intervention, and findings from each article. RESULTS. We selected 33 articles that reported on 30 distinct studies, 10 of which were comparison-group studies. None of the studies examined the medical home in its entirety. Although tempered by weak designs, inconsistent definitions and extent of medical home attributes, and inconsistent outcome measures, the preponderance of evidence supported a positive relationship between the medical home and desired outcomes, such as better health status, timeliness of care, family centeredness, and improved family functioning. CONCLUSIONS. The evidence provides moderate support for the hypothesis that medical homes provide improved health-related outcomes for children with special health care needs. Additional studies with comparison groups encompassing all or most of the attributes of the medical home need to be undertaken.
333 citations
References
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Book•
01 Jan 1985
TL;DR: Clinical Epidemiology is a book dedicated to H.L. Mencken, Kurt Vonnegut, Jr., Douglas Adams, and the Emperor's New Clothes and Physicians and others who wish to recognize key clinical epidemiologic features of the diagnosis and management of patients will benefit from reading.
Abstract: I might have guessed that a book dedicated to "H.L. Mencken, Kurt Vonnegut, Jr., Douglas Adams, and the Emperor's New Clothes" would be fun to read. It was! Readers will sense the authors' enthusiasm for their subject on each page, from the preface to the final chapter. The authors prepared this book for "users" rather than "doers" of clinical research. Physicians and others who wish to recognize key clinical epidemiologic features of the diagnosis and management of patients will benefit from reading Clinical Epidemiology. Those who wish to conduct actual research studies will need to look elsewhere for a detailed discussion of clinical epidemiologic methodology. In this review, I will mention
3,791 citations
Book•
15 Jan 1987
TL;DR: The core of the subject remains essentially simple, and a good epidemiological study should be capable of describing in such a way that all who are interested in the cause of disease can follow the argument and decide for themselves the validity of the conclusions as mentioned in this paper.
Abstract: Epidemiology is the simplest and most direct method of studying the causes of disease in humans, and many major contributions have been made by studies that have demanded nothing more than the ability to count, to think logically, and to have an imaginative idea. With the accumulation of knowledge, however, its has become harder for individuals working alone to make effective contributions, and epidemiological research is becoming increasingly a matter of teamwork, not only because of the large number of people that may have to be studied and the large amount of data that have to be collected and analyzed, but also because of the need to bring together for the design and conduct of the study clinical experience, biological understanding, statistical expertise, and many other special skills that vary from one study to another. But if, in this sense, epidemiological research is becoming more complex, the core of the subject remains essentially simple, and a good epidemiological study should be capable of description in such a way that all who are interested in the cause of disease can follow the argument and decide for themselves the validity of the conclusions.
2,797 citations
Book•
05 Aug 1993
TL;DR: This self-contained account of the statistical basis of epidemiology has been written specifically for those with a basic training in biology, therefore no previous knowledge is assumed and the mathematics is deliberately kept at a manageable level.
Abstract: Statistical models in epidemiology , Statistical models in epidemiology , کتابخانه مرکزی دانشگاه علوم پزشکی تهران
1,527 citations
Book•
29 Oct 1998
TL;DR: A comparison of primary care practices in the United States and Europe over the past 50 years shows improvements in both quality and quantity of treatment and the number of patients and populations has increased.
Abstract: I. PRIMARY CARE AND HEALTH II. PRIMARY CARE PRACTICE III. ACCOUNTABILITY IN PRIMARY CARE IV. PATIENTS AND POPULATIONS V. HEALTH POLICY AND PRIMARY CARE
1,051 citations
TL;DR: Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases, and improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.
Abstract: Objective. —To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style. Design. —Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas. Setting. —Community based. Participants. —A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities. Main Outcome Measures. —We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style. Results. —Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions ( R 2 =0.50; P P P Conclusion. —Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions. ( JAMA . 1995;274:305-311)
878 citations