Patient Attitudes Toward Continuity of Care

Background  Concern has been raised about managed care's effects on continuity of patient care, but little is known about how much value patients place on continuity.

Methods  We surveyed 2500 adult patients of a large New England health maintenance organization about their attitudes toward continuity and their willingness to spend additional time or money to maintain continuity with their primary care physician (PCP).

Results  Among the 1171 (46.8%) of patients responding, 460 (39.6%) of 1162 patients had had more than one PCP in the previous 5 years. Nearly all patients (1068 [91.5%] of 1167) rated continuity as very important or important; only 26 (2.2%) rated continuity as unimportant or very unimportant. However, only 256 (22.2%) of 1152 patients were willing to drive more than 60 minutes to maintain continuity with their PCP, and only 200 (18.2%) of 1096 would be willing to spend an additional $20 to $40 per month to maintain it. In multivariable analyses, patients were more willing to drive if they were nonwhite (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.6), older than 50 years (OR, 1.7; 95% CI, 1.2-2.4), or had less than a college education (OR, 1.6; 95% CI, 1.2-2.2). Patients who had been forced to change PCPs when their physician moved away were less willing to drive (OR, 0.5; 95% CI, 0.3-0.8) or spend more money (OR, 0.7; 95% CI, 0.5-1.0) to maintain continuity.

Conclusions  Most patients in this sample indicated that continuity of care was important to them, but reported being unwilling to spend much additional personal time or money to maintain continuity with their current PCP. Nevertheless, an important subset of older and more vulnerable patients reported being more willing to pay to maintain continuity.

CONTINUITY OF CARE is ideal in the practice of medicine, and primary care practice embraces it as the foundation of the patient-physician relationship.^1-5 Continuity of patient care is a complex concept and has been defined and measured in several different ways. One element of this concept is the continuity of the site of care, which includes continuity of patient health information and continuity of access to care in a familiar setting. Continuity of the patient-physician relationship itself, however, involves a shared history of caregiver and patient. Despite efforts to ensure continuity of health information and practice in the event that patients cannot maintain continuity of physician, there is evidence^6-8 that patients are more satisfied when they have a continuous relationship with one primary care physician (PCP) and when they believe that their PCPs know them personally and remember their medical history.

Recent changes in the organization of health care services, coupled with increasing rates of PCP turnover, pose threats to the maintenance of a continuous patient-physician relationship over time.^9,10 However, to our knowledge, there are no studies that explore patient attitudes toward continuity of care with a PCP. The goal of this study was to survey patients about their attitudes toward continuity of care with a PCP and to ask them about their willingness to spend extra time or money to maintain this continuity.

The survey was performed among patients in Harvard Pilgrim Health Care, a large mixed-model health maintenance organization in New England. Patients were eligible if they were 25 years or older and had seen a clinician at least once during the previous year. From among all eligible patients, a random sample of 2500 was created: 1250 patients randomly drawn from a multispecialty group practice that formerly functioned as a staff-model health maintenance organization division of the health plan and 1250 patients randomly drawn from the division of the health plan composed of affiliated small group practices and solo practitioners. Surveys were mailed in February 2000.

Sociodemographic information was obtained from an administrative database of the health plan. The survey asked patients to describe their health as excellent, very good, good, fair, or poor. To identify patients with a chronic or persistent condition, we asked whether patients had seen a PCP 2 or more times for the same disease or condition during the previous 2 years.

Recent experience with continuity of care with a PCP was measured by asking patients how many PCPs they had had in the previous 5 years. In addition, patients were provided a list of potential reasons for a change of PCP and asked to select any that applied to their experience during that same period.

Attitudes about the importance of continuity with a PCP were measured by asking patients, "In general, how important to you is the idea of having the same primary care doctor take care of you over time?" Patients responded on a 5-point scale from very important to very unimportant. In reporting the results, we collapse very important and important together to compare with all other responses.

Patients' willingness to spend time or money to maintain continuity with a PCP was measured with 2 questions. The first question was as follows: "If you or your primary care doctor were to relocate so that it would take you 60 minutes on average to travel to your doctor's office, what would you be likely to do?" Patients' options were to keep their PCP, get a new PCP, or note that they already travel 60 to 90 minutes to visit their PCP. This time limit was chosen because informal questioning of laypeople determined that 60 minutes of driving time was an important threshold to separate important from less important commitments. The second question was as follows: "If you were asked to choose a new primary care doctor or pay more money out of your own pocket to keep your current doctor, what is the most that you would be willing to pay each month to keep your current doctor?" Patients could respond that they would switch PCPs or that they would be willing to pay a monthly fee ($5-$10, $20-$40, $50-$75, or $100-$125).

The χ² and t test statistics were used for univariate comparisons between patient characteristics and their rating of the importance of continuity with a PCP and between patient characteristics and their willingness to pay for continuity. Multiple logistic regression was used for multivariable analyses to model these associations. Variables were included in the multivariable model if they were associated with the outcome variable in univariate analyses (P<.10).

Of 2500 enrollees surveyed, 1171 (46.8%) responded. Respondents were older than nonrespondents (mean ± SD age, 49.0 ± 13.8 vs 46.0 ± 13.0 years; P<.01), but there was no significant difference in the proportion of women in the 2 groups (55.7% vs 52.3%; P = .07). The sociodemographic characteristics of respondents are shown in Table 1.

Among the respondents, 460 (39.6%) had had more than one PCP in the past 5 years. The most common reason reported for a change was that the physician had moved, cited by 200 patients. The relative frequencies of reasons for a change in PCP are listed in Table 2.

Patients overwhelmingly responded that continuity of care with a PCP was important to them. Among all patients, 1068 (91.5%) of 1167 rated continuity as very important or important, and only 26 (2.2%) rated continuity as unimportant or very unimportant. Women were more likely to consider continuity important (93.6% vs 86.8%; P<.01), as were patients who had been seen by their PCP at least twice for a chronic or persistent condition in the past 2 years (94.3% vs 87.6%; P<.01). Patient age (P = .31), race (P = .13), educational level (P = .86), income (P = .70), self-reported health status (P = .69), recent experience of discontinuity with their PCP (P = .50), and site of care (multispecialty group practice vs affiliated small group practices or solo practitioners) (P = .54) were not significantly associated with attitudes toward continuity of care: among all groups, more than 90% of patients believed continuity was very important or important.

Although most patients believed continuity with a PCP was very important or important, far fewer patients were prepared to spend substantial additional time or money to maintain continuity of care with their current PCP. Only 256 (22.2%) of 1152 patients believed they would be willing to drive more than 60 minutes to maintain continuity with their PCP, and 604 (55.1%) of 1096 respondents indicated they would be willing to pay $5 to $10 per month out of pocket to maintain continuity with their PCP. Only 200 (18.2%) of 1096 respondencts indicated that they would be willing to spend an additional $20 to $40 per month to maintain continuity.

Several patient characteristics were correlated with willingness to spend extra time or money to maintain continuity (Table 3). Patients older than 50 years were more willing to do either. Although patients with a chronic or persistent condition did not seem more willing to drive more than 60 minutes to maintain continuity of care, they were more likely to be willing to spend extra money to maintain it. Poor patients and less educated patients were more willing to drive more than 60 minutes to maintain continuity, although they were not more likely to pay extra money to maintain it. Patients whose PCPs had moved away from their practice in the previous 5 years were less willing to do either. Site of care (multispecialty group practice vs affiliated small group practices or solo practitioners) was not associated with willingness to spend extra time or money to maintain continuity.

In multivariable analyses, patients' age, race, level of education, and recent experience with a PCP leaving a practice remained significantly associated with their willingness to drive more than 60 minutes to maintain continuity with their PCP (Table 4). Race was the characteristic most highly correlated with willingness to drive to maintain continuity, with nonwhite patients more than twice as likely to be willing to drive. Patients older than 50 years were more likely to be willing to drive, as were patients with less than a college education. Patients whose PCP had moved away in the past 5 years were half as likely to be willing to drive. Patient characteristics were less strongly associated with willingness to spend money to maintain continuity.

When asked how important it was to have the same PCP take care of them over time, most patients responded that it was important or very important. However, many fewer patients were willing to spend substantial time or money to maintain continuity of care with their current PCP. Most were unwilling to drive more than 60 minutes to maintain continuity with their PCP, and likewise most were unwilling to pay more than a small additional monthly fee to maintain continuity.

This apparent contradiction between attitudes about continuity and willingness to spend time or money to maintain it may be due in part to a social response bias that led patients to rate continuity as more important than they truly believed it was. Another possible explanation, however, is that this large difference between attitudes and willingness to spend substantial time or money represents a true distinction: most patients believe that continuity with the same PCP is important as an abstract notion, but many are willing to change PCPs if continuity would require additional resources to maintain it. This distinction is consistent with previous work^11,12 that suggests that willingness to pay is a more stringent measure of perceived value than are expressed attitudes.

In this mobile society, patients may accept a lack of continuity in medical care as one consequence of changing jobs, moving, or having their physician move away.¹³ Also, patients who have already experienced discontinuity with a PCP may have experience that gives them confidence that their medical information and care can be successfully transferred to a new PCP. Of the patients we surveyed, 39.6% had had more than one PCP in the previous 5 years, and those patients whose PCPs had moved away from their practice were less likely to be willing to spend time or money to maintain personal continuity. However, while many patients were not willing to spend much additional time or money to maintain personal continuity of care, there were a significant few who were willing to drive more than 60 minutes or to pay a substantial out-of-pocket fee to maintain continuity with their PCP (22.2% and 18.2%, respectively). Personal continuity of care can be said to be highly valued by this significant minority of patients.

There are important limitations to this study. First, there were many nonresponders, and although we know they were older than the responders, it is not possible to predict whether they would be more or less likely than responders to value PCP continuity or to be willing to pay for it. Also, we surveyed patients from one region of the country insured by one health maintenance organization and, therefore, it is difficult to generalize these patients' attitudes and willingness to pay with time or money to a broader population. In particular, the urban setting may have affected patients' willingness to drive to maintain continuity with a PCP for, to our respondents, this may have implied leaving an urban practice and subspecialty support to follow a PCP to a different practice in a rural area. In addition, while it is intriguing that patients whom we defined as having a chronic or persistent condition were more willing to spend money to maintain continuity of care with a PCP, we are unable to better define the spectrum of patients within this group and cannot comment on whether having a chronic or persistent condition might affect a patient's willingness to spend time or money to maintain this continuity.

Despite these limitations, to our knowledge, this is the first report of patient attitudes toward and willingness to pay for personal continuity with a PCP. Future research should continue to explore the values placed on continuity of care with a PCP by patients in a wide variety of practice settings. Meanwhile, in the design of systems of care, it is important to recognize that there may be a significant few for whom personal continuity with a PCP is of key importance.

Corresponding author and reprints: Steven D. Pearson, MD, MSc, Department of Ambulatory Care and Prevention, Harvard Medical School, 133 Brookline Ave, Sixth Floor, Boston, MA 02215 (e-mail: steven_pearson@hphc.org).

Accepted for publication July 12, 2002.

Dr Pearson is a Robert Wood Johnson Foundation Generalist Faculty Scholar.