Continuity In General Practice Research Articles

Absolute cardiovascular risk assessment by Australian early-career general practitioners: a cross-sectional study

ObjectiveTo determine the prevalence and associations of general practice registrars’ performing absolute cardio-vascular risk (ACVR) assessment (ACVRa).DesignA cross-sectional study employing data (2017–2018) from the Registrar Clinical Encounters in Training project,...

A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age

Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs).Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and ‘tinkering’ by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving—to a greater or lesser extent—continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations.Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity—of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.

Optimising personal continuity: a survey of GPs' and older patients' views.

Personal continuity - having a GP who knows their patients and keeps track of them - is an important dimension of continuity of care and is associated with lower mortality rates, higher quality of life, and reduced healthcare costs. In recent decades it has become more challenging for GPs to provide personal continuity owing to changes in society and health care. To investigate GPs' and older patients' views on personal continuity and how personal continuity can be improved. Cross sectional survey study in The Netherlands. A digital and postal survey was sent to 499 GPs and 1599 patients aged 65 years or older. Results were analysed using descriptive statistics for quantitative data and thematic analysis for open questions. In total, 249 GPs and 582 patients completed the surveys. A large majority of GPs (92-99%) and patients (91-98%) felt it was important for patients to see their own GP for life events or psychosocial issues. GPs and patients provided suggestions on how personal continuity can be improved. The thematic analysis of these suggestions identified nine themes: 1) personal connection, 2) GP accessibility and availability, 3) communication about (dis)continuity, 4) GP responsibility, 5) triage, 6) time for the patient, 7) actions by third parties, 8) team continuity, and 9) GP vocational training. Both GPs and older patients still place high value on personal continuity in the context of a changing society. GPs and patients provided a wide range of suggestions for improving personal continuity. The authors will use these suggestions to develop interventions for optimising personal continuity in general practice.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway.

BackgroundContinuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.AimTo analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.Design and settingRegistry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.MethodDuration of RGP–patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP–patient relationship was categorised as 1, 2–3, 4–5, 6–10, 11–15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.ResultsCompared with a 1-year RGP–patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2–3 years’ duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2–3 years’ duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2–3 years’ duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP–patient relationship of >15 years.ConclusionLength of RGP–patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose–response relationship between continuity and these outcomes indicates that the associations are causal.

Continuity in general practice and hospitalization patterns: an observational study

BackgroundHigh continuity of care is a key feature of strong general practice. This study aimed to assess the effect of a programme for enhancing strong general practice care on the continuity of care in Germany. The second aim was to assess the effect of continuity of care on hospitalization patterns.MethodsWe performed an observational study in Germany, involving patients who received a strong general practice care programme (n=1.037.075) and patients who did not receive this programme (n=723.127) in the year 2017. We extracted data from a health insurance database. The cohorts were compared with respect to three measures of continuity of care (Usual Provider Index, Herfindahl Index, and the Sequential Continuity Index), adjusted for patient characteristics. The effects of continuity in general practice on the rates of hospitalization, rehospitalization, and avoidable hospitalization were examined in multiple regression analyses.ResultsCompared to the control cohort, continuity in general practice was higher in patients who received the programme (continuity measures were 12.47 to 23.76% higher, P< 0.0001). Higher continuity of care was independently associated with lowered risk of hospitalization, rehospitalization, and avoidable hospitalization (relative risk reductions between 2.45 and 9.74%, P< 0.0001). Higher age, female sex, higher morbidity (Charlson-index), and home-dwelling status (not nursing home) were associated with higher rates of hospitalization.ConclusionHigher continuity of care may be one of the mechanisms underlying lower hospitalization rates in patients who received strong general practice care, but further research is needed to examine the causality underlying the associations.

Improving access and continuity in general practice: practical and policy lessons

BackgroundImproved access to general practice is seen by policy makers as essential to address patient expectations and reduce demand for A&amp;E, but little is known about its impact on continuity.AimThis study examined the impact of policies to improve access on continuity and described practical approaches to delivering both improved access and continuity. What is the evidence that continuity within general practice benefits patients, or is important to health professionals?Which primary care patients are more likely to want continuity of care, and how likely are they to report receiving it?How might policy initiatives to improve access affect continuity of care, and to what extent is there evidence of this?What factors might best support continuity of care in the context of improved access?MethodA rapid literature review, semi-structured interviews with providers and one commissioner, and two expert workshops were combined, with quantitative analysis of practice-level data and 2017 GP Patient Survey data.ResultsVarious sociodemographic and clinical factors shape patients’ desire for, and ability to obtain, continuity. We will present the limited evidence available on the impact of improved access on continuity and describe practical approaches to support continuity across three broad areas: service design, workforce development, and technology.ConclusionIt is possible to offer both improved access and continuity if this is an explicit objective of service redesign. Commissioners and policymakers should attach greater priority to continuity and commission further research to understand the longer-term impacts of improved access and working at scale on continuity, patient experience, and wider outcomes.

Fifty years of longitudinal continuity in general practice: a retrospective observational study.

Continuity of care has been defined as relational continuity between patient and doctor and longitudinal continuity describing the duration of the relationship. Measurement of longitudinal continuity alone is associated with outcomes including patient satisfaction, medical costs, hospital admissions and mortality. In one UK general practice, records were searched for patients with continuous registration for 50 or more years. Characteristics of these patients were analysed for age, gender, social deprivation, partner registration and length of registration. Trends in numbers and proportions of this group over the previous 14 years were determined. A comparison group of patients, aged 50 or more, and registered in the same practice within the last 2-4 years, was identified. Patients registered for 50 years or more with a median registration of 56.2 years numbered 190 out of a population of 8420 (2.3%). These patients increased in number by 35.3% (1.7-2.3%) over 14 consecutive years. There were no differences between groups for GP consultation rate, number of repeat medications and hospital use, despite the significantly higher prevalence of multi-morbidity, depression and diabetes in patients with high continuity. This is the first report of 50-year continuity in general practice. Numbers of such patients and proportions are increasing. Longitudinal continuity is easily measured in general practice and associated with important clinical outcomes.

Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey

Continuity of GP care is associated with reduced hospitalisations, but solid documentation of its relationship to use of outpatient specialist services is lacking. To test the association between continuity of GP care and use of inpatient and outpatient specialist services. A cross-sectional population-based study with questionnaire data from the sixth Tromsø Study (2007-2008). Descriptive statistics and two sample t-test were used to estimate specialist healthcare use according to duration of the GP-patient relationship. Logistic regression analysis was used to assess associations between duration and intensity of the GP-patient relationship and use of specialist care. Analyses were adjusted for sex, age, marital status, income, education, and self-rated health, and also stratified by self-rated health and age. Of 10,624 eligible GP users, 85% had seen the same GP for >2 years. The probability of visiting outpatient specialist services was significantly lower among these participants compared to those with a shorter GP relationship (odds ratio [OR] = 0.81, 95% confidence interval [95% CI] = 0.71 to 0.92). Similar findings were found for hospitalisations (OR = 0.76, 95% CI = 0.64 to 0.90). Stratified analyses revealed that these associations were not dependent on self-rated health or age. The probability of specialist use increased for the frequent GP users. Continuity of GP care is associated with reduced use of outpatient specialist services and hospitalisations. Healthcare providers and policymakers who wish to limit use of specialist health care may do well to perform and organise health services in ways that support continuity in general practice.

It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice.

BackgroundContinuity of care has traditionally been regarded as a core quality of general practice, but the long-term doctor-patient relationship has been put under pressure. In many places practices are expanding, with larger teams and more registered patients, thereby threatening the possibility of patients staying with their own general practitioner (GP). GPs often take it for granted that interpersonal continuity is valuable. However, little is known about how patient satisfaction is related to interpersonal continuity. The purpose of this study is to explore the creation of patient satisfaction or dissatisfaction in the interpersonal relation with the GP, and in a comprehensive way to investigate how this is related to continuity of care.MethodsQualitative study based on 22 interviews with patients from two practices in Denmark. A total of 12 patients saw a regular doctor and 10 saw an unfamiliar doctor. The patients were selected after an observed consultation and sampled purposefully according to reason for encounter, age and sex. Interpretative phenomenological analysis (IPA) was used to study how patients perceive meeting either a regular or an unfamiliar GP. The analysis explored the patients' perception of their interpersonal relationship with their GP, and interpreted the accounts by using social psychological theories.ResultsA long-term continuous relationship with the GP could be satisfactory, but it could also be the reverse. The same pattern was shown in case of an unfamiliar GP. Therefore, patient satisfaction and interpersonal continuity were not causally related. On the contrary, there was a general pattern of how the satisfactory and trustful doctor-patient relationship from the patients' point of view could be created, maintained or destroyed. A pattern where the process of recognition, by respecting and remembering, on the one hand created and maintained satisfaction while humiliation on the other hand destroyed satisfaction in the relationship.ConclusionIt was not valuable to have a continuous relationship unless the GP recognized the patient. The social psychological concept of recognition had two different meanings and the GP had to do both, respect and remember the patient, in order to create and sustain the trustful relationship. The added value of interpersonal continuity had to be combined with recognition.

Familiarity between patient and general practitioner does not influence the content of the consultation

BackgroundPersonal continuity in general practice is considered to be a prerequisite of high quality patient care based on shared knowledge and mutual understanding. Not much is known about how personal continuity is reflected in the content of GP – patient communication. We explored whether personal continuity of care influences the content of communication during the consultation.MethodsPersonal continuity was defined as the degree of familiarity between GP and patient, rated by both the GP and the patient. 394 videotaped consultations between GPs and patients aged 18 years and older were analyzed. GP – patient communication was evaluated with an observation checklist, which rated the following topics of conversation: (1) medical issues, (2) psychological themes, and (3) the social environment of the patient. For each of these topics we coded whether or not it received attention, and was built upon prior knowledge. Data were analyzed using multilevel logistic regression analyses.ResultsNo relationship was found between GP – patient familiarity and the discussion of medical issues, psychological themes, or the social environment of the patient. But if the patient and the GP knew each other very well, the GP more often displayed prior knowledge with the topic in question. Few patient and GP characteristics were associated with differences in content of communication.ConclusionGiven the relatively small sample size, we carefully conclude that familiarity between a GP and a patient does not influence the content of the communication (medical issues, psychological themes nor topics relating to the social environment). This is remarkable because we expected that familiarity would 'open up the communication' for more psychological and social themes. GPs seem to have the communication skills to put both familiar and non-familiar patients at ease enabling them to freely raise any issue they think necessary.

Continuity of care: an essential element of modern general practice?

For a variety of reasons, GPs are working more and more with unfamiliar patients. The proposed new British GP contract stipulates that in future patients will register with a practice, rather than with a named GP and a recent new definition of general practice did not mention continuing care. There has been persistent confusion about the definition of continuity of care. Evidence for the benefit of patients usually seeing the same doctor is still limited. In this paper we describe some discrete elements of continuity, emphasize the importance of interpersonal continuity and suggest how this may work. The contributions of informational continuity (especially good records) and of excellent consulting skills are put in context. We conclude that further evidence is needed to demonstrate the added value of interpersonal continuity in general practice and that this needs a clear theoretical basis. We propose that such a theory will define the concept of multi-dimensional diagnosis as the key strength of our discipline and that continuity, especially interpersonal continuity, is an important factor in achieving this economically and in a way which satisfies both patients and professionals.

Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey

Objectives: To examine patients' views on access and continuity in general practice to derive quality standards.Design: Secondary analysis of data from general practice research studies and routine quality assessment activities...

Does continuity in general practice really matter?

# Does continuity in general practice really matter? {#article-title-2} Continuity is an official core value of general practice in the United Kingdom,1 but there are at least two potentially conflicting...