Continuity of Care

Contents

1. Three kinds of continuity
2. Counting a relationship
3. What the mortality reviews found
4. Hospital use and cost
5. A decline despite the evidence

Office based gynecology and preventive women’s healthcare made up a growing part of Candace Cooley’s later years in practice, and that kind of care is rarely a single event. It runs as a course. A first visit opens a record, a return a year later adds to it, and over a decade the same clinician may see a patient through several stages of life. Researchers who study this pattern call it continuity of care, and their studies run on the same kind of timeline. In the review of mortality studies published in the British Journal of General Practice in 2020, data collection periods ranged from a few weeks to 17 years.² The patients in the review that prompted it, reported by the BBC, had kept contact with the same doctor over an average of two years.⁴

Three kinds of continuity

The 2020 review defines continuity as the care of an individual, rather than a population, over time, and separates it into three types.² Relationship continuity is a trusting bond between a patient and at least one clinician. Informational continuity means her records are available to everyone involved. Management continuity is the coordination among the groups who share her care.² An editorial in the Annals of Family Medicine recalls the view of the primary care researcher Barbara Starfield that continuity needs both the relational and the informational kind to work.⁵

Figure

The three kinds of continuity

1. 01
   RelationshipA trusting bond between one patient and at least one clinician who knows her.
2. 02
   InformationalRecords that are available to everyone involved in her care.
3. 03
   ManagementCoordination and communication among all the groups who treat her.

Counting a relationship

A relationship is hard to measure, so most studies count visits instead. The 2020 review calls this concentration of care: the share of a patient’s contacts that land on the same professional.² The reviewers point out the limit of the method. Seeing the same person is not the same as knowing her well, and indices built from appointment records are at best a stand in for the relationship itself; measures reported by patients may come closer.² A study of more than 47,000 patients with newly diagnosed heart risk factors in South Korea, summarized by AJMC, used three common indices side by side, including the share of visits with the most frequent provider.⁷

What the mortality reviews found

The first systematic review of continuity and the risk of dying appeared in BMJ Open in 2018. It gathered 22 studies from nine countries, including Canada, France, the Netherlands, South Korea, the United States and the United Kingdom, and The European Scientist reported that 18 of them linked steady contact with the same doctor to significantly lower mortality, three found no link and one gave mixed results.³ The effect was not limited to family doctors. New Scientist noted that it held for specialists, psychiatrists and surgeons as well, though differing measures made a single pooled estimate impossible.¹

The 2020 follow up narrowed the question to primary care. Of 12 studies measuring death from any cause, nine found a statistically significant protective effect, two found none, and one swung either way depending on the measure.² The authors proposed three mechanisms: a doctor’s growing knowledge of the patient, a patient’s trust and willingness to follow advice, and a stronger sense of clinical responsibility.² None of the studies tested those mechanisms directly, and the reviewers were plain that every study was observational, so reverse causation remains possible: patients at greater risk of dying may simply be less able to see one doctor.²

Figure

What the 22 studies in the 2018 review found

• Lower mortality with continuity18
• No association3
• Mixed results1

studies

Hospital use and cost

A second line of research looks at admissions. A Health Foundation analysis of more than 230,000 patients in England aged 62 to 82, described by The Guardian, found that those with high continuity had just over 12 percent fewer admissions for conditions a family doctor could usually manage, such as asthma flares, than those with low continuity.⁶ The Korean study tied lower continuity to more inpatient and outpatient days and higher costs.⁷ A critical review led by Andrew Bazemore, discussed in an interview with Healio, examined 83 articles published between 2002 and 2022 and concluded that continuous relationships go with lower costs and more appropriate use of care.⁸

Figure

Continuity and avoidable admissions

fewer avoidable admissions with medium continuity

almost 9 percent

fewer avoidable admissions with high continuity

just over 12 percent

patients aged 62 to 82 in the analysis

230,000

A decline despite the evidence

The Annals editorial lists the benefits that have accumulated: fewer admissions and emergency visits, better uptake of preventive care, better medication adherence and higher satisfaction for patients and physicians alike.⁵ It also records a sharp fall in continuity in family practice in both the United Kingdom and the United States, and cites an English analysis that traced about 45 percent of that fall to a more fragmented workforce and rising workload.⁵ New Scientist cited a study finding that the chance of seeing the same family doctor in England fell by 27 percent between 2012 and 2017.¹ The editorial suggests partial remedies, including a buddy system in which patients see their own physician or a named partner, and personal patient lists.⁵ Demand for continuity is uneven. The 2020 review observes that young and healthy patients may neither want nor need a single regular doctor, while older patients and those living with several conditions often do, and it suggests that the first trials of deliberately improved continuity should focus on them.² The BBC account of the 2018 review added that the benefit is thought to be greatest for people with chronic and complex needs.⁴

The research also has edges. The 2020 reviewers noted reports of delayed diagnosis and overfamiliarity, and warned that a simple verdict that continuity is good for every patient may hide a more complex picture.² Continuity is also only one of the conditions under which care unfolds; what happens at any particular visit is for a woman and the clinician caring for her to decide together. That decision has its own structure and its own body of research, set out in the next entry on shared decision making, and the record continuity builds is part of what a well woman visit draws on.