Transfer of Graduating Residents’ Continuity Practices

Abstract

To the Editors:— We applaud Caines et al.1 for addressing an important patient safety topic, year-end resident continuity clinic handoffs, that has received little attention thus far.2 The high percentage of patients lost to follow-up is astounding, highlighting that clinic handoffs are a vulnerable time for patients. Because very few patients who were lost to follow-up were in fact scheduled for an appointment, it is critical to explore if more effective scheduling may improve this transition of care. In addition to more effective scheduling, we wondered if patient factors or patterns of care may explain why patients did not follow up. For instance, among the 29% of patients lost to follow-up because they did not keep their appointment, it would be important to understand whether these patients had a history of missing appointments. In other words, did they miss the appointment because of the handoff or because they tend to miss appointments? The distinction is important since patients who miss appointments generally may require even more intense follow-up and coaching during the handoff to overcome barriers to visiting their physician. Patients deemed to be high risk may also be more likely to be lost to follow-up in their resident clinic because they present elsewhere to emergency departments or hospitals for acute care. Therefore, understanding the acute care utilization patterns of these patients both before and after the handoff is important to consider for future studies. Lastly, defining high-priority patients as those requiring follow-up within 1 year may be too crude a measure given the chronic illness burden of resident clinic patients. It has previously been demonstrated that US residents take care of underserved populations who are at risk for poor outcomes.3 Moreover, guidelines recommend that patients with certain conditions, such as diabetes, should be seen every 3 months, making certain high-risk patients in need of more frequent care than once a year. Understanding what constitutes a high-risk patient given the increasing complexity of primary care and already high illness burden for resident clinic patients is critical. Rebalancing case loads after a year-end clinic handoff to ensure appropriate workloads and illness burden has been a strategy used in other disciplines.4