Project proposal Västra Götaland Region – draft outline (pre-1st draft)
Proposal for Position Paper of the European Forum for Primary Care (EFPC)
“Impact of continuity on quality of care within Primary Care”
Outlines for position paper on European Forum for Primary Care 2012
Time frame
Overall period: 18 months
From the start the following results will be achieved
Within 3 months the 1st
workshop is organized
– Achieved at Conference Graz –
presentation of outlines for draft,
engagement of interested participants
September 16th 2011
Within 6 months a 1st draft
version will be ready
Feb 2012
Within 10 months a 2nd
draft will be ready
June 2012
Within 14 months the 2nd
workshop is organised
Conference Gothenburg September
2012
September 3rd-4th
2012
Within 16 months a final
version of the PP will be
presented to the EFPC
Executive Committee
Nov 2012
Within 17 months the final
version is approved by the
EFPC Executive
Committee
December 2012
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Proposed Position paper authors
Cecilia Björkelund
Per Hjortdahl
Jan De Maeseneer
Anna Maria Murante
Suzana Nikolovska
Kathryn Hoffman
Gerrard Abi-Aad
From the VG-region:
Kristina Bengtsson Boström
Ulf Lindblad
Jörgen Thorn
Staffan Björk
Lars Björkman
Bo Palaszewski
Christer Andersson
Andy Maun
Carl Wikberg
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Disposition of EFPC Position Papers
1. Clarifying concepts and formulating a clear problem from a primary care approach.
2. Why a concern in/of primary care
3. Why it is (or should be) a concern at international (EU) level.
a. problems in disease mangement
b. organizational and financial problems
4. Experiences (both positive and negative) and developments in management, including
country or system characteristics that influence these experiences (this chapter should
include some clear practical examples or at least provide a short summary of these
examples & providing a link for further information.
5. Lessons learned and the conditions (policies) that favour positive experiences in terms
of access, equity, efficiency, and quality.
6. Recommendations of policy measures on national and European level
7. Identifying areas for further research.
8. Addressing primary care from a comprehensive, multi-disciplinary, patient centred
and community oriented approach
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“Impact of continuity on quality of care within Primary Care”
1. Clarifying concepts and formulating a clear problem from a primary care
approach.
Continuity of care has long been one of the cornerstones of primary care and is included in at
least two of the eleven characteristics of the discipline of general practice/family medicine
stated by WONCA and The European definition of General Practice/Family Medicine Short
Version EURACT 2005 (1):”d) has a unique consultation process, which establishes a
relationship over time, through effective communication between doctor and patient. Each
contact contributes to an evolving story, and each individual consultation can draw on this
prior shared experience. The value of this personal relationship is determined by the
communication skills of the family doctor and is in itself therapeutic”.
e) is responsible for the provision of longitudinal continuity of care as determined by the
needs of the patient. The approach of general practice must be constant from birth (and
sometimes before) until death (and sometimes afterwards). It ensures the continuity of care by
following patients through the whole of their life. The medical file is the explicit proof of this
constancy. It is the objective memory of the consultations, but only part of the common
doctor-patient history. Family doctors will provide care over substantial periods of their
patients' lives, through many episodes of illness. They are also responsible for ensuring that
healthcare is provided throughout the 24 hours, commissioning and coordinating such care
when they are unable to provide it personally.”
Initially, the concept continuity mostly corresponded to one care provider continuity between
doctor and patient, but today, health care processes and health care organizations have grown
and become more complex. Primary health care of today is mostly provided by different
professionals to fulfill patients' health care needs and therefore multidimensional models of
continuity have to be developed (2).
Continuity of care could be viewed from several different perspectives, and from the
perspective of the patient or the provider.
Continuity of care has been described in the following ways (3)





with a practice
interpersonal
informational continuity
relational continuity
management continuity
For primary care, most important relevant types of continuity seems to be what Starfield
defines as longitudinality, referring to longitudinality in the use of a regular source of care (4).
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She claimed that the concept continuity stands for a bridging mechanism between visits for a
specific condition or episode (4). In his article “Defining and measuring interpersonal
continuity of care” (5), Saultz defines three levels of continuity in a hierarchy of 3
dimensions, informational continuity, longitudinal continuity and interpersonal continuity,
where interpersonal continuity is the highest level and refers to a special type of longitudinal
continuity with an ongoing personal relationship between patient and care provider.
Longitudinal continuity per se does not automatically lead to interpersonal continuity.
There are several studies showing health effects and health economic effects of continuity in
primary care. Starfield showed that a primary care organization with high continuity of care
had lower rates of hospital admissions (6). High continuity of care was associated with more
effective prevention (7) and Hjortdahl showed association to higher patient satisfaction (8, 9).
Freeman, Olesen and Hjortdahl in 2003 stated that further evidence is needed to demonstrate
the added value of interpersonal continuity in general practice, and that continuity, especially
interpersonal continuity, is an important factor for future primary care development (10).
In 2010, a systematic review was published concerning relationship between patient
satisfaction and continuity (3). The authors concluded that no single measure of continuity of
care could be shown to be more valid, and that no clear relationship between patient
satisfaction and doctor continuity could be shown.
Concerning importance of continuity of care in mental problems, Solberg et al in 2006
published a study about what factors increased quality of care in primary care depression
treatment (11). They found, that increase in continuity increased accessibility, and with high
continuity, more patients received treatment for depression, more patients had a next visit in
14 days (from 55% - to 85%), and more patients continued depression treatment for 6
months. High accessibility, on the other hand, did not per se increase quality of care in these
respects. In the Norwegian Naturalistic Treatment Study of Depression in General Practice, a
24 week RCT with 3 arms; placebo, sertralin, and mianserin, the placebo arm consisted of
visits to general practitioner ten times during six months (12). No significant difference
concerning recovery was found between placebo arm and SSRI arms in patients with first
time depression. This could be interpreted as an indication of antidepressant effect of regular,
continuous visits and thus continuity of care in primary care.
Formulating a clear problem from a primary care approach
Most studies concerning continuity in primary care has been concentrated on i) one care
provider continuity between i.e. doctor and patient, while most nurse research has
concentrated on informational continuity, e.g. transmitted from shift from hospital to
nursing homes, availability to provide clinical information to any care
holder etc
(13), and ii) patient´s attitudes and patient satisfaction concerning interpersonal continuity.
So far research seems to show, that both patients (14) and caregivers (doctors and nurses)
value continuity in the form of regular sources of care, and that provider continuity is
related to lower total health care costs on the macro level. Evidence still seems to be
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lacking concerning added value of interpersonal continuity in general practice, and to
what extent continuity contributes to quality of care within primary care. Problems from a
primary care approach of today are especially:
i)
Does care with high interpersonal continuity of
(practitioner/nurse/team) lead to improved medical outcomes ?
care
ii)
Does interpersonal continuity of practitioner/nurse/team aid in the
management of problems?
iii)
Which organizational structures improve interpersonal continuity in
primary care of today?
The present position paper is proposed concentrate on these issues.
2. Why a concern in/of primary care
In 2004, the question was raised by Freeman et al whether primary care, and especially
British primary care, was aiming away from continuity of care, as more and more patients
registered with a practice, not a named GP (10). Further, a recent definition of general
practice did not mention continuing care. The authors also concluded that there still exists
confusion about the definition of continuity of care and that further evidence is needed to
demonstrate the added value of interpersonal continuity in primary care (10). Surveys on
GPs´ attitudes in 2005 showed that there was still high agreement of that personal
continuity remained an important aspect of good-quality care to GPs´ patients in European
countries (England, Wales, the Netherlands) and the US (15). Also patients rate continuity
of GPs and nurses high, but substantial evidence for continuity as promoting medical
results is still partly lacking concerning e.g. chronic diseases (16). In 2004, a review of 16
studies on effects of sustained continuity of care found associations between patient
satisfaction (4 studies), decreased hospitalization (7 studies) and improved receipt of
preventive services (5 studies) (17). In a report from EFPC and NIHDI (Belgian federal
institute for health and disability insurance) on Chronic Disease Management, one of
mentioned perceived strengths of the disease management approaches was more
continuity of care together with proactive and well-structured care processes,
multidisciplinary collaboration, and more attention to patient outcomes and satisfaction
(18).
A review on electronic consultation (e-consultation) concludes that direct benefits from econsultations include the continuity of care that results from keeping care more centered in
the patient’s medical home, greater convenience, and reduced cost (19).
A recent synthesis of research programs on continuity of care mainly concentrates on what
continuity of care is and how it is perceived (13). Most studies concerning continuity are
performed concerning special diagnoses, and few concerning primary care per se. Baker
2006 is the only study in this review that includes the whole primary care context. What
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is most interesting is what imposes on the performance of continuity; size of facility,
resources, staff turnover, hospital admission, possibility to sharing information,
arrangements, appointments, telephone organization. An important factor that influenced
experience of continuity was whether care was predominantly person-focused or disease
focused. Professionals do not deliver continuity ´to´ service users but work ´with´ them
and their carers/family to assess needs and preferences and facilitate contact and
continuity. The authors of this review conclude: “It is the conversations between
professionals, service users, family members and carers about what the service user needs,
and can have, within the constraints that are achievable, that are crucial to experienced
continuity. If professionals understand the components of continuity, and are able to act
on that understanding to deliver person-focused care, then these conversations can be
meaningful and ultimately fruitful” (13).
A survey of patients with complex care needs in eleven countries (Australia, Canada, France,
Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United
Kingdom, and the United States) found that in all of them, care is often poorly coordinated
(20). However, adults seen at primary practices with attributes of a patient-centered medical
home - where clinicians are accessible, know patients’ medical history, and help coordinate
care - gave higher ratings to the care they received and were less likely to experience
coordination gaps or report medical errors. The authors conclude: "Our study indicates a need
for improvement in all countries through redesigning primary care, developing care teams
accountable across sites of care, and managing transitions and medications well."
3. Why continuity of care should be a concern at international (EU) level.
Taken together, there seems to be a contradiction between growing primary care centres, with
a primary care encompassing many different competences and the sustention of continuity of
care. There also seems to be a contradiction between high accessibility and continuity of care,
though providing high continuity of care has been shown also to lead to high accessibility (8).
There seems to be evidence for increased patient satisfaction with high continuity of care, and
lower health care costs as well with provider continuity, but there still is rather frail evidence
concerning medical and other outcomes (e.g. sick listing). Providing continuity of care is
highly ranked among European as well as American general practitioners, as well as among
primary care nurses.
4. Experiences (both positive and negative) and developments in management,
including country or system characteristics that influence these experiences (this
chapter should include some clear practical examples or at least provide a short
summary of these examples & providing a link for further information.)
i)
Proposed study of medical effects of continuity of care in VG Region, Sweden
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As a way of describing experiences (both positive and negative) and developments in (case)
management, including country or system characteristics that influence these experiences, a
quality register based on the transfer of Electronic Patient Record data to the County Council
of West Gotaland, Sweden will be used to explore possible health effects related to continuity
of care. We plan to explore the possible association between continuity of care and





HbA1C levels
Blood pressure control
Medication
Mental health treatment
Patient satisfaction
in the primary care patient population with chronic diseases in cooperation with network R&B
units, university and region. September 2012, preliminary results will be presented.
ii)
Further inclusion of some clear practical examples or provision of a short
summary of these examples & a link for further information – please find free to
propose examples from own studies/experiences.
5. Formulating lessons learned and the conditions (policies) that favour positive
experiences in terms of access, equity, efficiency, and quality.
To be processed
6. Recommending policy measures on national and European level and identifying
areas for research.
To be processed
7. Addressing primary care from a comprehensive, multi-disciplinary, patient
centred and community oriented approach
To be processed
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References
1. Short Version EURACT 2005 at
http://www.woncaeurope.org/Web%20documents/European%20Definition%20of%20
family%20medicine/Definition%20EURACTshort%20version.pdf
2. Wierdsma A, Mulder C, de Vries S, Sytema S. Reconstructing continuity of care in
mental health services: a multilevel conceptual framework. J Health Serv Res Policy.
2009 Jan;14(1):52-7
3. Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient
satisfaction: a systematic review. Fam Pract 2010;27(2):171-8.
4. Starfield B. Continuous confusion. American Journal of Public Health 1980;70:117-9
5. Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med
2003;1(3):134-43
6. Starfield B. Primary care - balancing health needs, services and technology. New
York: Oxford University Press, 1998.
7. Koopman RJ, Mainous AG, 3rd, Baker R, Gill JM, Gilbert GE. Continuity of care and
recognition of diabetes, hypertension, and hypercholesterolemia. Arch Intern Med
2003;163(11):1357-61.
8. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient
satisfaction. BMJ 1992;304:1287-9
9. Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of
practice characteristics influencing patient satisfaction. Br J Gen Pract. 1995
Dec;45(401):654–659.
10. Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essential element of
modern general practice? Fam Pract 2003;20(6):623-7
11. Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, PJ. OC.
Effect of improved primary care access on quality of depression care. Ann Fam Med.
2006;4(1):69-74
12. Malt U, Robak OH, Madsbu HP, Bakke O, Loeb M. The Norwegian naturalistic
treatment study of depression in general practice (NORDEP)I: randomised double
blind study. BMJ 1999;318:1180-84.
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13. Parker G, Corden A, Heaton J. Experiences of and influences on continuity of care for
service users and carers: synthesis of evidence from a research programme. Health Soc
Care Community 2011;19(6):576-601
14. Waibel S, Henao D, Aller M-B, Vargas I, Vazquez M-L. What do we know about
patients' perceptions of continuity of care? A meta-synthesis of qualitative studies.
International Journal for Quality in Health Care 2011 doi =10.1093/intqhc/mzr068
15. Stokes T, Tarrant C, Mainous AG, Schers H, Freeman G, Baker, R. Continuity of
Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and
Family Physicians in England and Wales, the United States, and the Netherlands. Ann
Fam Med. 2005; 3(4):353–359
16. Gulliford MC, Naithani S, Morgan M. Continuity of care and intermediate outcomes
of type 2 diabetes mellitus. Fam Pract 2007;24(3):245-51
17. Cabana MD, Jee S. Does continuity of care improve patient outcomes? Family
Practice 2004;53:
18. Rijken P.M, Bekkema N. Chronic Disease Management Matrix 2010. Results of a
survey in ten European countries
http://calliope.nivel.nl/pdf/CHR028%20EUR015%20report%20CDM%20Matrix_fina
l%20version29-08.pdf
19. Harno K, Paavola T, Carlson C, Viikinkoski P. Patient referral by telemedicine:
effectiveness and cost analysis of an Intranet system. J Telemed Telecare
2000;6(6):320-9
20. Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 Survey
Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often
Poorly Coordinated. Health Aff November 2011 10.1377/hlthaff.2011.0923
? EFPC Position Paper on Chronic Disease Management by Stefan Gress et al yet not
accessible
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