Interpersonal continuity of primary care of veterans with diabetes: a cohort study using electronic health record data

Christine M Everett,Valerie A Smith,Perri Morgan,Sandra Woolson,Brandolyn White,George L Jackson,Theodore Berkowitz,David Edelman,Cristina C Hendrix

doi:10.1186/s12875-018-0823-5

Abstract

BackgroundContinuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran’s Health Administration (VHA) primary care patients with diabetes.MethodsThis patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a “home” VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations.ResultsAmong VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75–0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07–0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69–0.97; reference least restrictive regulation).ConclusionsICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.

Highlights

A core function of primary care is continuity of care (CoC) [1, 2]
A panel of approximately 1200 primary care patients are assigned to a Patient-Aligned Care Team (PACT), which consists of one primary care provider (PCP) (physician, nurse practitioner (NP) or physician assistant (PA)), a registered nurse care manager, a clinical associate, and a clerk
Among the patients with diabetes that could be assigned to a PCP (N = 656,368) in 2012, 76% were assigned to an attending physician, 16% were assigned to an Nurse practitioner (NP), 6.2% were assigned to a Physician assistant (PA), and 1.7% were assigned to a resident physician

Summary

Introduction

A core function of primary care is continuity of care (CoC) [1, 2]. A cornerstone element of CoC in primary care is interpersonal continuity (ICoC), defined as a longitudinal relationship between a primary care provider (PCP) and patient that involves delivery of preventive care, treatment of multiple illness episodes, and a Patient, organizational, and community factors have been shown to impact CoC. This paper examines associations between patient, provider, organizational, and community factors with ICoC. Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran’s Health Administration (VHA) primary care patients with diabetes

Methods

Results

Conclusion