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Invited Commentary
Health Policy
March 24, 2021

Continuity of Care Matters in All Health Care Settings

Author Affiliations
  • 1Sealy Center on Aging, The University of Texas Medical Branch at Galveston
  • 2Department of Medicine, The University of Texas Medical Branch at Galveston
JAMA Netw Open. 2021;4(3):e213842. doi:10.1001/jamanetworkopen.2021.3842

Concern regarding declining continuity of medical care has been growing during the past 3 decades. Continuity of care has been threatened by an array of forces, including the decrease in primary care physicians, changes in health insurance, the growth of specialization, and the need to ensure easy and timely access to care.1 Most of the initial focus on continuity of care was in outpatient settings. Outpatient continuity with a primary care physician has been linked to decreased emergency department use and hospitalizations, lower costs, and higher patient and physician satisfaction.1 These findings contributed to a greater emphasis on team-based care and other chronic care management models.

Another setting that has experienced declines in continuity is the transition from the community to the hospital and back to the community.2 By 2006, most hospitalized Medicare patients received no care from a physician who had previously provided care for them.2 Several studies have found that such discontinuity is associated with higher postdischarge costs and readmission rates.3

Continuity of care received in the hospital has declined as well. Recent studies have suggested that patients admitted for medical illness are likely to be cared for by more than 1 general internist during their stay.4,5 Such discontinuity seems driven by the growth in care by hospitalists and the fact that many hospitalists have work schedules that do not allow for continuity of care.

Just as with outpatient medicine, we might expect that hospitalized patients who experience discontinuities in their care also have worse outcomes. That is the question posed in the study by Farid et al.6 The major challenge in asking whether continuity of care in the hospital affects outcomes is the potential for strong confounding. Patients with more severe illness are more likely to see multiple physicians and also more likely to have poor outcomes. A bias this strong is almost never eliminated by traditional approaches to controlling for severity of illness and other factors.7 Farid et al6 avoided this bias in a clever way. Using Medicare charge data, they identified hospitalists working at least 7 days in a row. They then identified patients who had a greater likelihood of poor continuity of care because they were admitted toward the end of a hospitalist’s 7-day shift. They compared these patients with those admitted during the initial few days in a 7-day shift who were therefore less likely to experience discontinuity. Farid et al6 found no difference in mortality in the 30 days after discharge among patients admitted early in the shift vs those admitted close to the end of the shift. However, among patients in the top quartile for risk of death, there was a 1.0% adjusted lower rate of mortality (27.8% vs 26.8%) among those admitted early in the shift.

We used an approach similar to that of Farid et al6 to indirectly identify patients at risk of discontinuity.5 We compared patients cared for by hospitalists who usually worked 5 or 7 days in a row with those cared for by hospitalists whose schedules were more intermittent, such as working every third day.4 Patients cared for by hospitalists with intermittent schedules were much more likely to see multiple hospitalists during their stay.4 Both the approach by Farid et al6 and our approach focused on the schedules of the treating hospitalists in determining risk of discontinuity, avoiding the strong selection biases that would occur if the patients were classified by how many different physicians actually provided care during their stay. In our study, patients cared for by hospitalists in the top quartile of continuous schedules had significantly lower postdischarge mortality, readmission rates, and costs and higher rates of discharge home compared with patients cared for by hospitalists with discontinuous schedules.5

What might be responsible for the somewhat discrepant results between the 2 studies? Both used indirect methods to identify discontinuities in care. However, the study by Farid et al6 required that the patients be taken care of by hospitalists who worked at least 7 consecutive days, which represents a small percentage of all admissions.4 This selection criterion would have placed all of the participants in the study by Farid et al6 in the highest quartile for continuity of care using the methods in our study.5 In other words, we were comparing outcomes across a wider range of continuity of care than that in the study by Farid et al.6 Indeed, according to our results, hospitalists working 5- or 7-day schedules were associated with the lowest level of discontinuities in care.

The phenomenon described by continuity of care has been given various names in the literature, such as fragmentation of care. Philosophers from the Presocratics to the phenomenologists and ordinary language philosophers have emphasized the potential confusion in thinking caused by the words we choose to identify abstract concepts. By using the term handoffs to discuss care continuity, Farid et al6 emphasize an aspect of discontinuity, ie, the process whereby a physician transfers information to another physician who is taking over care. However, the term may communicate more than the reality. What do we picture when we think of handoffs? Two physicians performing rounds together or sitting in a conference room? Two physicians talking on the telephone? Or a physician reading the note of the physician who just went off service? In my experience, all these realities occur.

More importantly, issues of continuity include more than handoffs, and efforts to standardize better handoffs will not eliminate all the problems engendered by discontinuity. It is unlikely that all relevant information communicated by patients and their families to a physician is included in the electronic medical record or is transmitted orally during handoffs. Information relevant to patient values and preferences and degree of family involvement can be key in medical and discharge decision-making. There is also the important issue of trust. Patients and their families may be less comfortable soliciting and following the advice of a physician they are seeing for the first time, particularly if the topic is value laden, such as end-of-life issues or discharge destination. Efforts to increase the exposure of hospitalized patients to physicians who work several days in a row, such as those studied by Farid et al,6 should lead to improved patient outcomes.

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Article Information

Published: March 24, 2021. doi:10.1001/jamanetworkopen.2021.3842

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Goodwin JS. JAMA Network Open.

Corresponding Author: James S. Goodwin, MD, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, 301 University Blvd, Route 0133, Galveston, TX 77555-0460 (jsgoodwi@utmb.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Willett  LL, Landefeld  CS.  The costs and benefits of hospital care by primary physicians: continuity counts.   JAMA Intern Med. 2017;177(12):1788-1789. doi:10.1001/jamainternmed.2017.5833PubMedGoogle ScholarCrossref
2.
Sharma  G, Fletcher  KE, Zhang  D, Kuo  YF, Freeman  JL, Goodwin  JS.  Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults.   JAMA. 2009;301(16):1671-1680. doi:10.1001/jama.2009.517PubMedGoogle ScholarCrossref
3.
Kuo  YF, Goodwin  JS.  Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study.   Ann Intern Med. 2011;155(3):152-159. doi:10.7326/0003-4819-155-3-201108020-00005PubMedGoogle ScholarCrossref
4.
Goodwin  JS, Zhou  J, Kuo  YF, Nattinger  AB.  Work schedules of hospitalists and continuity of care during hospital stays of Texas Medicare patients: an observational study.   J Gen Intern Med. 2019;34(4):489-491. doi:10.1007/s11606-018-4777-zPubMedGoogle ScholarCrossref
5.
Goodwin  JS, Li  S, Kuo  YF.  Association of the work schedules of hospitalists with patient outcomes of hospitalization.   JAMA Intern Med. 2020;180(2):215-222. doi:10.1001/jamainternmed.2019.5193Google ScholarCrossref
6.
Farid  M, Tsugawa  Y, Jena  AB.  Assessment of care handoffs among hospitalist physicians and 30-day mortality in hospitalized Medicare beneficiaries.   JAMA Netw Open. 2021;4(3):e213040. doi:10.1001/jamanetworkopen.2021.3040Google Scholar
7.
Giordano  SH, Kuo  YF, Duan  Z, Hortobagyi  GN, Freeman  J, Goodwin  JS.  Limits of observational data in determining outcomes from cancer therapy.   Cancer. 2008;112(11):2456-2466. doi:10.1002/cncr.23452PubMedGoogle ScholarCrossref
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