Improving primary care

What is continuity?

Reid and colleagues⁵ defined 2 core elements and 3 types of continuity. The 2 core elements of continuity include the experience of care between a patient and a provider, and care that continues over time. The 3 types of continuity are informational continuity, management continuity, and relational or interpersonal continuity.⁵ Informational continuity is sharing “information on prior events and circumstances to make current care appropriate for the individual and his or her condition.”⁵ The focus is on the transfer of information about the patient and the patient’s care (current and historical) between care providers and between visits to ensure clear communication of and consistency in the course of care. Management continuity focuses on “the provision of timely and complementary services within a shared management [or care] plan”⁵ and is most vulnerable during care transitions.⁶ Case management, care navigation, and clinical care guidelines are posited as strategies to enhance management continuity, and a disease-specific approach is typical. Evidence tells us that although management continuity can lead to better outcomes in the context of a particular disease, it can also lead to poorer overall outcomes for individual patients.⁷

According to Reid and colleagues, relational or interpersonal continuity refers to an ongoing therapeutic relationship between a patient and one or more providers that supports present care by linking it to the past and to the future.⁵ McWhinney described longitudinality of contact as only one part of relational continuity, and explained that relational continuity was also about the trusting relationship and shared history between the patient and provider, as well as the accountabilities and mutual commitment embedded in the relationship.⁸ We believe that these elements are too often overlooked when relational continuity is considered and measured. We will return to this notion later.

In terms of outcomes, the evidence suggests that longitudinality as a feature of relational continuity makes a difference, particularly for those with chronic conditions. In a systematic review of literature related to the outcomes of continuity in primary care published between 1966 and 2002, Cabana and Jee found that sustained continuity of care between a physician and a patient was associated with an improvement in quality of care, a decrease in hospitalizations and use of emergency departments, and improvement in receipt of preventive care services.⁹ More recent evidence supports these findings: longitudinality has been associated with improved use of other health care resources such as specialty, laboratory, and diagnostic services; improved preventive and proactive care; more comprehensive whole-person care; and improved adherence to medical treatment.^10–17 Some have argued that the value of this continuity over time is lost on many primary care patients—namely those who just want to get in, get seen, and have their immediate (and infrequent) problems addressed in a timely manner. We would counter with the observation that this is the public expectation that has been nurtured by our medical system—we have taught the public to expect that the only purpose of primary care is to solve acute medical problems. Therefore, questioning the value of something we have taught the public not to value is a somewhat circular argument with a predictable outcome. We would argue that if a primary care relationship over time can contribute to the prevention of medical complexity, then it is worth exploring and measuring. Additionally, to argue that continuity is not as valuable as many suggest—and premise that argument on the assertion that it only makes a difference to those with chronic conditions—seems at odds with the observation that roughly 16 million Canadians live with 1 or more chronic diseases,¹⁸ 80% of primary care physician visits are related to chronic disease, and more than two-thirds of all medical costs involve chronic disease.¹⁹

Conceptual clarity, evidence, and measurement

Despite the evidence suggesting the value of continuity of care over time, and a disease burden that has shifted considerably toward chronic conditions, we have observed little emphasis on improving relational continuity in Canada. We suggest that this might be for several interrelated reasons: a lack of conceptual clarity; measurement challenges; and an interpretation, or misinterpretation, of relational continuity that makes it seem contradictory to team-based care or at odds with good access to primary care. It must also be said that most studies on continuity and its value are cross sectional and correlational—telling us nothing about cause or about the strength of associations over time. Existing evidence also relies heavily on the measurement of longitudinality (as noted above), and the data used are typically administrative. In our own primary care organization we also measure longitudinality and have added the element of consistency (at several levels) to the metric. This allows a high-level determination of the number of times a patient seeks care from different providers in different places across our organization. We capture and measure differences in outcomes as a function of longitudinality and consistency with a single provider, with a single team, with an overall primary care practice, and across a network of practices. This metric includes instances of deflection to the emergency department for an ambulatory care sensitive condition or a family practice sensitive condition,^20,21 and enables us to associate this continuity measure with system outcomes such as hospitalization and emergency department use. Providing this metric annually over a few years has increased our understanding of how patients are using the health care system, and has allowed for the adoption of practices and processes to better meet these calls for care in primary care, resulting in diminished deflections. We have also seen improvements in guideline- concordant screening for patients who have the highest levels of continuity with their primary physicians; ie, these patients were more likely to be screened for colorectal and breast cancer and more likely to receive their pneumococcal and influenza immunizations.

Although we think this is a more robust approach to measurement, we still do not think that measuring longitudinality and consistency (or “attachment”) is the whole picture in measuring relational continuity. In Greenhalgh and Heath’s²² penetrating look at the measurement of the quality of therapeutic relationships, they describe measurable structural preconditions that increase the likelihood of a therapeutic relationship forming, including the necessity of sufficient time for consultation and an ability for patients to ask for their preferred provider. Similarly, we suggest that it might well be that longitudinality and consistency are the structural preconditions that make the development of relational continuity more likely. Therefore, we view these as necessary but insufficient measures of relational continuity. Similarly, the core element of relational continuity described by Reid and colleagues⁵ as “the experience of care” is most often reduced to measures of patient satisfaction.⁶ It is our assertion that this retrospective, single-dimensional measure misses the co-constructed nature of the relationship between providers and patients. We suggest that the dimensions of relational continuity are not well understood and as a result we default to what we can measure: patient visits to a particular provider over time and patient satisfaction.

Team-based care, access, and relational continuity

The assumption that there is value in sustaining a relationship between a core primary care physician and a patient over time is supported by the evidence, but is often met with at least 2 subsequent questions: Is this not a throwback to “the country doctor” and therefore no longer even possible if we want to maintain good access to primary care? Is this not untenable in an era of team-based care, and even disrespectful to the contributions of others beyond the physician? It is evident that no one primary provider can be available at all times; it is not even possible for one individual to provide all the care required, especially for patients with complex chronic conditions.²³ But if one accepts that relational continuity is an important contributor to comprehensive primary care, then one might ask different questions: How, in the current context, can an ongoing relationship between a primary provider and a patient be preserved in a way that protects access to care? As to considerations around team-based care, evidence shows that the physician might not be the most appropriate provider to manage complex care. For example, it has been demonstrated that complex care management conducted by registered nurses with additional education²⁴ or by nurse practitioners²⁵ can produce superior outcomes at equivalent or reduced cost to the health system.²⁶ Therefore, the questions one needs to ask should be less about how continuity with a core provider might affect the team and more about how it affects the care. Do outcomes improve if relational continuity is preserved with a core provider as part of a consistent team of providers who share accountability for good overall care? How do we measure relational continuity in a way that captures the contributions of all team members, including the patient?

So where to from here?

The value of relational continuity needs to be explored in further research, and informed by better definition and measurement of all the attributes of the concept. The value of relational continuity from the patient and family’s perspective is needed, especially in terms of its importance in enabling patients to reach their health goals, and particularly in the case of chronic disease. Relational continuity also needs to be explored in the context of its potential value for those who do not typically access primary care. Does a trusting mutual relationship over time assist in preventing complexity in otherwise healthy people? We would suggest that this is at least plausible, but acknowledge that, currently, this is largely an open empirical question.