Andrea M. Lee, M.S.
Robert G. Frank, Ph.D.
Zoe N. Swaine, M.S.
Natalie C. Blevins, M.S.
Heather Steingraber, B.S.

Continuity of Care
• Definition:
– healthcare events experienced as coherent and connected
– consistent with the patient’s medical needs and personal context
• In primary care:
– relationship between a single provider and a patient
– extends beyond specific episodes of illness or disease

Continuity of Care
• Patients who maintain a continuous relationship with a primary care provider are
– more satisfied with their care
(Gulliford et al., 2007)
– more likely to take medications correctly
(Becker et al.,
1974)
– more likely to be diagnosed early for chronic diseases
(Koopman et al., 2003)

Continuity of Care
• Lower health care utilization
– Reduced likelihood of emergency department utilization in children
(Christakis et al., 2001; Brousseau et al.,
2004)
– Reductions in hospitalizations, emergency department visits in the elderly
(Weiss & Blustein, 1996;
Wasson et al., 1984; Burge, Lawson, & Johnston, 2003)
• Lower health care expenditures
• No studies on psychological populations

Depression & primary care
• One of the most prevalent disorders in primary care
(Ballenger et al., 1999)
• Depressed individuals tend to have
(Simon et al.,
1995)
:
– lower overall physical functioning
– more disability days
– higher rates of health care utilization

• 13% of enrollees use Medicaid mental health benefits
(Mark et al., 2003)
• Medicaid’s spending for mental health services accounted for over 50% of all public mental health expenditures in 2003
(kff.org)
• Projected to increase up to 2/3 by 2013
(kff.org)

• Association between continuity of care and health care expenditures in depressed
Medicaid enrollees
• Higher continuity of care hypothesized to be associated with lower expenditures
• Florida Medicaid claims data
• Cross-sectional

• 8,680 participants
• Ages 18-65
• 78% female; 22% male
• 42% White, 14% Black, 38% other, 6%
Hispanic

• Modified, Modified Continuity Index
(MMCI)
MMCI




• Continuous variable, ranging from 0 to 1
– 1 indicates high continuity of care

60
50
40
Percentage of
30
Sample
20
10
0
0.0 - 0.19
0.2 - 0.39
0.4 - 0.59
0.6 - 0.79
0.8 - 1.0
Continuity of Care Index Scores

• Logistic regression for expenditures with large proportion of zeroes
– inpatient, outpatient, and emergency room expenditures
• Log-linear multiple regression
– inpatient, outpatient, emergency room, pharmacy, medical, and total expenditures
• Controlled for age, sex, race, number of medical comorbidities, and number of prescription drugs

• Higher continuity of care associated with:
– a lower likelihood of having any expenditures for:
• Inpatient (odds ratio: 0.20, p < .01)
• Outpatient (odds ratio: 0.69, p < .01)
• Emergency room (odds ratio: 0.58, p < .01)
– lower expenditures for total, medical, inpatient, outpatient, emergency room expenditures (p < .01)
– higher pharmacy expenditures (p < .01)

• Unable to differentiate between provider type and practice site in identifying primary care provider
• ICD-9 codes limited reliability – subject to error and only captures provider – identified depression (not undetected or undiagnosed depression)

• Improving continuity of care in depressed Medicaid recipients may impact overall health care spending
• Pharmacy expenditures were higher with higher continuity of care, which may be due to better medication management

• Relatively few enrollees with low continuity of care to target for policy change, but can have a measurable impact
60
50
40
Percentage of
30
Sample
20
10
0
0.0 -
0.19
0.2 -
0.39
0.4 -
0.59
0.6 -
0.79
0.8 - 1.0
Continuity of Care Index Scores
Depression

• Robert Frank
• Natalie Blevins
• Zoë Swaine
• Eleni Dimoulas
• Heather Steingraber
• Jianyi Zhang
• Allyson Hall