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Continuity of Care and the Physician-Patient Relationship
BACKGROUND: We assessed the role and importance of continuity of care in predicting the perceptions of the physician-patient relationship held by patients with asthma.
METHODS: We analyzed the 1997 statewide probability survey of adult Kentucky Medicaid recipients. The participants included 1726 respondents with 2 or more visits to a physician’s office, clinic, or emergency department in the previous 12 months. Of these, 404 reported having asthma. The respondents used 5-point single-item scales to rate continuity of care, provider communication, and patient influence over treatment.
RESULTS: Multivariate linear regression analyses were used to assess the contribution of continuity of care to provider communication and patient influence in the presence of control variables. Those variables included age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. For persons with asthma, continuity of care was the only variable that significantly contributed to the provider communication model (P=.01) and the only variable other than life satisfaction that contributed to the patient influence model (P <.05 for each). For patients who did not have asthma, continuity of care was one of several variables contributing significantly (P <.05) to the provider communication and patient influence models.
CONCLUSIONS: Particularly for patients with asthma, continuity of care was linked to patient evaluations of their interaction with the physician. Because of this, changes in health care systems that promote discontinuity with individual physicians may be particularly disruptive for patients with chronic diseases.
Continuity of care has been shown to be associated with a variety of positive outcomes including patient satisfaction,1 compliance with medication regimens,2 and health services utilization.3 High continuity of physician care is also associated with a decreased likelihood of future hospitalization.4,5 One explanation for this finding is that continuity leads to increased knowledge and trust between the patient and the physician.6 This increased knowledge and trust may make it easier for the physician to manage medical problems in the office or over the phone and thereby avoid hospitalizing the patient. Similarly, having care continuity with a specific physician is significantly associated with a decreased likelihood of emergency department (ED) use.7
Although data are continually accumulating indicating that continuity between a patient and a clinician has positive benefits, it is clear that it is not always easy to achieve high continuity in practice.8 This is increasingly the case as physicians work in larger groups where there is likely to be less continuity with an individual provider.9 According to data from the 1987 National Medical Expenditure Survey, only half of all patients have high continuity with a physician.8 This situation may be worsening as more Americans are enrolled in managed health care plans that frequently change their panel of approved physicians.10 As a result, patients may be forced to change their physician on multiple occasions, which could have negative consequences on the management of their medical problems.
Since continuity between a patient and a physician has positive health benefits in the general population, it makes intuitive sense that these benefits would be greatest for persons with chronic conditions. Asthma is a common chronic disease affecting 14 to 15 million people in the United States and is the most common chronic disease of childhood, affecting nearly 5 million children in the United States.11 Asthma accounts for more than 470,000 hospitalizations and more than 5000 deaths annually.12 Rates of hospitalization for asthma have been increasing and reflect that it is the most common discharge diagnosis among children.13 In addition to the morbidity and mortality associated with this disease, some treatments have possible adverse effects.14 Thus, the benefits that could accrue from improved health care delivery are considerable.
Patients with asthma have a greater desire than the general population to maintain continuity with a physician, even when the visit is not for asthma.15 A possible reason continuity of care may be important is that the management of chronic conditions requires ongoing monitoring and decisions about when changes in therapy are appropriate. When a patient is seen by the same physician, that provider is more likely to know when tests and treatment changes are indicated. Effective physician-patient interaction is an important component of health care delivery. For patients with chronic illnesses, interaction processes that include the physician giving more information and the patient having greater control during the visit are associated with better health.15 Physician and patient roles in managing asthma differ across physician-patient relationships,16 but the relation between continuity of care and the physician-patient relationship has not been specified for patients with asthma.
It is important to determine the role and importance of continuity in the delivery of health care to patients with asthma. The purpose of our study was to examine the relationship between continuity of care and physician-patient interaction among patients with and without asthma.
Methods
The data for our study came from an omnibus survey of the patient satisfaction of recipients of the Kentucky Medicaid program. Our study is a secondary analysis of that large data set. In 1997 a survey was mailed to a stratified random sample of adult participants (aged Ž18 years) in the Kentucky Medicaid fee-for-service program. The design followed the Dillman method, using an initial wave of surveys with reminder postcards and 2 additional waves of surveys to nonresponders.17 The response rate to the survey was 60%, with a total sample of 2308.
The survey items were based on the Health Employer Data and Information Set (HEDIS 3.0) customer satisfaction survey,18 the Consumer Assessments of Health Plans Study (CAHPS)19 completed by the Agency for Health Care Policy and Research (AHCPR), and satisfaction surveys used in Kentucky during previous assessments in 1987, 1989, and 1991 (KENPAC program). The internal review board of the University of Kentucky approved the survey.
Our sample was limited to individuals who visited primary care physicians often enough to assess continuity. They reported utilization on a single survey item assessing outpatient visits. A total of 1726 respondents reported making 2 or more visits to a physician’s office, clinic, or ED during the previous 12 months. In this group 404 reported having asthma. The prevalence of asthma in this population is higher than in the general population but not exceptionally higher than that found in Medicaid programs.20 Continuity was measured by the question “Over the past 12 months, when you went for medical care, how often did you see the same doctor or provider?” The 4 response categories were “always,” “most of the time,” “sometimes,” and “rarely or never” (reverse scored from 1=”rarely or never” to 4=”always”). Although continuity can be measured in a variety of ways, patient self-reports have commonly been used.1,21 In the present context, perceptions of continuity may be no less important than actual continuity in predicting patients’ evaluative ratings of physician-patient interaction.
The outcome measures were patient assessments of the health care they had received in Medicaid programs during the past 12 months. They are consistent with other self-report measures and were created for the CAHPS by the AHCPR (now the Agency for Healthcare Research and Quality). The present survey reference to 12 months differed from the original CAHPS survey reference to 6 months. The measures included an item about provider communication (“Doctor or provider listened to you and talked with you about your care”) and an item about patient influence (“Your ability to influence the treatment you received from a doctor or provider for your health problems”). These were measured on 5-point scales (reverse scored from 1=poor to 5=excellent).
Analysis
We computed bivariate analyses comparing characteristics of the groups of patients with and without asthma and assessing the relation between continuity of care and physician-patient interaction for each group (chi-square, Student t test). Then the relation between continuity of care and physician-patient interaction was evaluated in multivariate linear regression analyses in the presence of the following control variables: age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. Among the variables available for analysis, these were identified as most likely to confound the relation between continuity of care and patient perceptions of the physician-patient relationship. General health (“In general, would you say your health is:”), health improvement (“Compared to one year ago, how would you rate your health in general now?”), and life satisfaction (“Overall, how satisfied or dissatisfied are you with how your life is going?”) were rated using 5-point scales coded so that higher scores mean better health, more improved health, and greater overall life satisfaction, respectively. We performed separate linear regression models for the patients with and without asthma and examined the contribution of continuity to each model. Linear regression models with all respondents combined were also performed, and interaction terms were entered for asthma status interacting with the other independent variables. Only respondents who had complete data on all items could be included in the regression analyses. We conducted all analyses with SAS statistical programming software release 6.09 (SAS Institute, Inc; Cary, NC), using complete data for each item.
Results
The characteristics of the respondents appear in Table 1. Their demographic characteristics were typical for the Medicaid population in Kentucky. Although most of the respondents were white, more of the patients with asthma were white than were those without the condition. In addition, the asthma patients reported higher numbers of health care visits and poorer health than those without asthma. Reported continuity of care and respondents’ perceptions of provider communication and patient influence are shown in Table 2. The respondents with and without asthma did not differ on these variables of interest. More than half of the respondents (58.8%) reported always seeing the same health care provider in the past 12 months (scale mean ± standard deviation=3.5 ± 0.7).
Bivariate Analyses
In bivariate analyses, ratings of the physician-patient relationship were compared across continuity of care categories. Individuals who “always” saw the same doctor or provider were compared with a category of “less than always,” which had been collapsed across “most of the time,” “sometimes,” and “rarely or never.” On average, respondents rated provider communication and patient influence between “good” and “very good.” Both persons who did and did not have asthma who saw the same doctor or provider for all their health care visits rated provider communication and patient influence significantly higher than did individuals who had less continuity (P <.01). This is shown in Table 3.
Regression Analyses
We computed separate linear regression models for individuals who did and did not have asthma to assess the contribution of continuity of care in the presence of control variables in predicting ratings of provider communication and patient influence for these groups. All 4 response levels were included in the continuity of care variable. The correlation matrix for the independent variables produced no correlations between independent variables that exceeded 0.5, suggesting that these variables could be included in the same analysis. The P values and standardized regression coefficients for the independent variables in the asthmatic and nonasthmatic models are presented for the provider communication models in Table 4 and for the patient influence models in Table 5. All models were significant at P <.05.
For persons with asthma, continuity of care was the only variable (P=.01) that significantly contributed to the provider communication model (Table 4, Model 1) and the only variable (P=.02) other than life satisfaction (P=.04) that contributed to the patient influence model (Table 5, Model 1). In the provider communication and patient influence models, the standardized estimates for the continuity parameter were 0.15 and 0.14, respectively, higher than any other estimates in the models. The nonstandardized parameter estimates for continuity were 0.26 and 0.25, respectively.
For persons who did not have asthma, continuity of care significantly contributed (P=.001) to both the provider communication (Table 4, Model 2) and patient influence models (Table 5, Model 2). Unlike the models for persons with asthma, 5 additional variables significantly contributed to these models (P≤.01): age, number of visits, general health, health improvement, and life satisfaction. The standardized parameter estimates for continuity were similar to those in the asthmatic models (0.14 for each). Continuity ranked only third among the estimates in the provider communication model and second among the estimates in the patient influence model. The nonstandardized parameter estimates for continuity were 0.24 and 0.23, respectively.
The linear regression models combining all respondents were significant in predicting provider communication (P=.001) and patient influence (P=.001). Continuity of care, age, number of visits, general health, health improvement, and life satisfaction significantly contributed to the models (P≤.01 for each). Asthma status and the interaction terms between that status and the other independent variables were not significant, with the exception of the interaction term between that status and number of visits, which predicted provider communication (P=.03). With the asthma interaction terms largely nonsignificant, subsequent discussion will address only the separate asthmatic and nonasthmatic models.
Discussion
Our results confirm earlier findings that continuity of care is important in health care delivery. For both respondents with and without asthma, continuity of care with an individual provider significantly predicted their ratings of provider communication and patient influence alone and in the presence of control variables. Also, the results suggest that continuity of care may be particularly important in certain populations. Differences in the regression models for the respondents with and without asthma suggest a particularly important role of continuity of care in the physician-patient relationship for patients with this disease. Among those persons, continuity of care was the only variable predicting patient perceptions of physician-patient communication after controlling for many other relevant variables; it was 1 of only 2 variables predicting perceptions of patient influence. Among persons who did not have asthma, continuity shared its importance with several other variables.
Our results do not suggest that continuity is important only to patients with asthma. For both patients with and without asthma, continuity of care was an important predictor of provider communication and patient influence. However, it is the unique prominence of continuity of care in the asthma models that is interesting, in the context of several likely predictive variables that were nonsignificant.
If a sample did not have sufficient size and power to detect significant effects, such differences could have been an artifact of differences in sample size. However, the results of a power analysis show that in the group of patients with asthma (the smaller sample) there was 80% power to detect with 95% confidence a correlation as small as 0.06, which is a miniscule effect. Thus the sample with asthma offered sufficient power to detect the effects of all the independent variables, but only the effect of continuity of care emerged as significant for that group.
What is special about the physician-patient relationship over time for patients with asthma? Our findings suggest that for these patients, understanding of their disease and treatment and a feeling of comanagement with the physician are crucial and seem to be directly related to continuity of care. The patterns we saw in the patients with asthma are consistent with previous work that suggests the importance of continuity of care to patients with chronic illnesses. These patients have reported valuing continuity more than do patients with acute problems,22 and persons with asthma have reported willingness to wait more days for care from their regular physician for moderately serious acute illnesses.14 Studies from the 1980s found that patients with chronic illnesses maintained greater continuity with individual physicians.23,24 The respondents with asthma in this 1997 survey did not report greater continuity than those who did not have it. This makes the prominent role of continuity in their evaluations of the physician-patient relationship more interesting, because differences in the level of continuity do not explain the importance of continuity. The respondents with asthma did report significantly more health care visits than those without asthma. Thus, they maintained high levels of continuity across a more challenging number of visits.
When patients concentrate their care with a single physician, those physicians are more likely to develop an accumulated knowledge about their patients’ medical conditions. This knowledge goes beyond simply knowing the patient’s diagnoses and medications. It includes a finer understanding of the severity of each medical problem and how multiple problems interact. More important, it includes the development of a relationship between the patient and the physician and awareness of the patient’s knowledge of the disease and personal preferences for medical treatment.
It has been argued that the importance of continuity of care cannot be conceptualized simply as the frequency of seeing one physician versus another.25 However, personal continuity suggests an ongoing therapeutic relationship between the patient and the physician. In this case, the nature and quality of the contacts are more important than the number. The current data suggest that perhaps the importance of continuity to the ongoing therapeutic relationship is heightened for patients with asthma. It may be that the immediately perceptible morbidity of an asthma exacerbation and the relief provided by the physician contribute to the patient’s evaluation of the relationship. Positive qualities of physician-patient interaction have been linked to satisfaction for patients with ongoing medical problems26 and to “better health” in chronically ill patients.15 Policies and practices that encourage continuity and an effective therapeutic relationship between the patient and the physician should be investigated and implemented. In the current environment of proposals for disease management treatment teams for diseases such as asthma, it is important that continuity of care between the patient and the physician is not completely eliminated through the use of multiple providers.
Limitations
Our study has several limitations. First, the data were based on self-reports. We did not independently validate either the diagnosis of asthma or reported utilization of care. However, chronic diseases have been successfully assessed through self-reports in a variety of large-scale surveys, such as the National Health Interview Survey. Moreover, the utilization questions are based on reliable and valid items from the CAHPS. Continuity of care was also assessed using a single item asking respondents about the level of continuity they experienced with an individual physician in the past year. The merits of this item as an assessment of perceived continuity include its distinct reference to continuity rather than asking whether the respondent has a regular or usual physician. Single-item reports of having a regular or usual physician have been interpreted as continuity of care.21,27,28 However, having a regular or usual physician is not the same as maintaining continuity of care with an individual provider over time. For example, a patient who reports having a regular physician may see other physicians in that practice for a majority of visits because that regular provider is frequently unavailable when the patient needs acute care. A second limitation of our study is that the data came from a survey of participants in a Medicaid program, thereby potentially affecting the generalizability of the results to a more affluent population. In the Kentucky Medicaid fee-for-service program, recipients may have greater choice of physicians than participants in more restrictive health care plans.
Conclusions
The results of our study of an existing data set suggest several directions for future research. One direction would be to look more specifically at the patient-physician relationship and its impact on outcomes. Patients’ trust in their physicians may be particularly important in understanding continuity of care for chronically ill patients.29 Further research into the mechanisms linking continuity of care and characteristics of the physician-patient relationship could begin to discern the direction of influence between them and their combined impact on health outcomes.
Continuity of care matters. Particularly for patients with asthma, continuity of care with an individual provider is linked to important aspects of health care delivery, specifically physician-patient interaction. Changes in health care systems that increasingly promote discontinuity with individual physicians may be especially disruptive for patients with chronic conditions.
Acknowledgments
Our study was funded in part by the Kentucky Department of Medicaid Services.
1. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304:1287-90.
2. Becker MH, Drachman RH, Kirscht JP. Continuity of pediatrician: new support for an old shibboleth. J Pediatr 1974;84:599-605.
3. Raddish M, Horn SD, Sharkey PD. Continuity of care: is it cost effective? Am J Managed Care 1999;5:727-34.
4. Gill JM, Mainous AG, III. The role of provider continuity in preventing hospitalizations. Arch Fam Med 1998;7:352-57.
5. Mainous AG, III, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health 1998;88:1539-41.
6. Starfield B. Primary care: concept, evaluation, and policy. New York, NY: Oxford University Press; 1992.
7. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greater continuity of care associated with less emergency department utilization? Pediatrics 1999;103:738-42.
8. Cornelius LJ. The degree of usual provider continuity for African and Latino Americans. J Health Care Poor Underserved 1997;8:170-85.
9. Hurley RE, Gage BJ, Freund DA. Rollover effects in gatekeeper programs: cushioning the impact of restricted choice. Inquiry 1991;28:375-84.
10. Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 1995;10:94.-
11. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults—United States, 1990-1993. MMWR 1996;45:350-53.
12. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA 1990;264:1688-92.
13. Simons FE. A comparison of beclomethasone, salmeterol, and placebo in children with asthma: Canadian Beclomethasone Dipropionate-Salmeterol Xinafoate Study Group. N Engl J Med 1997;337:1659-65.
14. Love MM, Mainous AG, III. Commitment to a regular physician: how long will patients wait to see their own physician for acute illness? J Fam Pract 1999;48:202-07.
15. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
16. Lagerlov P, Leseth A, Matheson I. The doctor-patient relationship and the management of asthma. Soc Sci Med 1998;47:85-91.
17. Dillman D. Mail and telephone surveys: the Total Design Method. New York, NY: John Wiley; 1978.
18. National Committee for Quality Assurance. Health Employer Data and Information Set (HEDIS 3.0). Washington, DC: NCQA Press; 1998.
19. US Department of Health and Human Services. Consumer Assessments of Health Plans Study (CAHPS); 1997.
20. Mainous AG, III. Analysis of Medicaid claims data for use in development of clinical practice guidelines: report to the Kentucky Medicaid Program; 1995.
21. O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med 1997;157:1462-70.
22. Fletcher RH, O’Malley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
23. Fleming MF, Bentz EJ, Shahady EJ, Abrantes A, Bolick C. Effect of case mix on provider continuity. J Fam Pract 1986;23:137-40.
24. Godkin MA, Rice CA. Relationship of physician continuity to type of health problems in primary care. J Fam Pract 1981;12:99-102.
25. Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997;314:1870-73.
26. Roter DL, Stewart M, Putnam SM, Lipkin M, Jr, Stiles W, Inui TS. The patient-physician relationship: communication patterns of primary care physicians. JAMA 1997;277:350-56.
27. Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health 1996;86:1748-54.
28. Ettner SL. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-55.
29. Thom DH, Ribisl KM, Stewart AL, Luke DA. Further validation and reliability testing of the Trust in Physician Scale: the Stanford Trust Study Physicians. Med Care 1999;37:510-17.
BACKGROUND: We assessed the role and importance of continuity of care in predicting the perceptions of the physician-patient relationship held by patients with asthma.
METHODS: We analyzed the 1997 statewide probability survey of adult Kentucky Medicaid recipients. The participants included 1726 respondents with 2 or more visits to a physician’s office, clinic, or emergency department in the previous 12 months. Of these, 404 reported having asthma. The respondents used 5-point single-item scales to rate continuity of care, provider communication, and patient influence over treatment.
RESULTS: Multivariate linear regression analyses were used to assess the contribution of continuity of care to provider communication and patient influence in the presence of control variables. Those variables included age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. For persons with asthma, continuity of care was the only variable that significantly contributed to the provider communication model (P=.01) and the only variable other than life satisfaction that contributed to the patient influence model (P <.05 for each). For patients who did not have asthma, continuity of care was one of several variables contributing significantly (P <.05) to the provider communication and patient influence models.
CONCLUSIONS: Particularly for patients with asthma, continuity of care was linked to patient evaluations of their interaction with the physician. Because of this, changes in health care systems that promote discontinuity with individual physicians may be particularly disruptive for patients with chronic diseases.
Continuity of care has been shown to be associated with a variety of positive outcomes including patient satisfaction,1 compliance with medication regimens,2 and health services utilization.3 High continuity of physician care is also associated with a decreased likelihood of future hospitalization.4,5 One explanation for this finding is that continuity leads to increased knowledge and trust between the patient and the physician.6 This increased knowledge and trust may make it easier for the physician to manage medical problems in the office or over the phone and thereby avoid hospitalizing the patient. Similarly, having care continuity with a specific physician is significantly associated with a decreased likelihood of emergency department (ED) use.7
Although data are continually accumulating indicating that continuity between a patient and a clinician has positive benefits, it is clear that it is not always easy to achieve high continuity in practice.8 This is increasingly the case as physicians work in larger groups where there is likely to be less continuity with an individual provider.9 According to data from the 1987 National Medical Expenditure Survey, only half of all patients have high continuity with a physician.8 This situation may be worsening as more Americans are enrolled in managed health care plans that frequently change their panel of approved physicians.10 As a result, patients may be forced to change their physician on multiple occasions, which could have negative consequences on the management of their medical problems.
Since continuity between a patient and a physician has positive health benefits in the general population, it makes intuitive sense that these benefits would be greatest for persons with chronic conditions. Asthma is a common chronic disease affecting 14 to 15 million people in the United States and is the most common chronic disease of childhood, affecting nearly 5 million children in the United States.11 Asthma accounts for more than 470,000 hospitalizations and more than 5000 deaths annually.12 Rates of hospitalization for asthma have been increasing and reflect that it is the most common discharge diagnosis among children.13 In addition to the morbidity and mortality associated with this disease, some treatments have possible adverse effects.14 Thus, the benefits that could accrue from improved health care delivery are considerable.
Patients with asthma have a greater desire than the general population to maintain continuity with a physician, even when the visit is not for asthma.15 A possible reason continuity of care may be important is that the management of chronic conditions requires ongoing monitoring and decisions about when changes in therapy are appropriate. When a patient is seen by the same physician, that provider is more likely to know when tests and treatment changes are indicated. Effective physician-patient interaction is an important component of health care delivery. For patients with chronic illnesses, interaction processes that include the physician giving more information and the patient having greater control during the visit are associated with better health.15 Physician and patient roles in managing asthma differ across physician-patient relationships,16 but the relation between continuity of care and the physician-patient relationship has not been specified for patients with asthma.
It is important to determine the role and importance of continuity in the delivery of health care to patients with asthma. The purpose of our study was to examine the relationship between continuity of care and physician-patient interaction among patients with and without asthma.
Methods
The data for our study came from an omnibus survey of the patient satisfaction of recipients of the Kentucky Medicaid program. Our study is a secondary analysis of that large data set. In 1997 a survey was mailed to a stratified random sample of adult participants (aged Ž18 years) in the Kentucky Medicaid fee-for-service program. The design followed the Dillman method, using an initial wave of surveys with reminder postcards and 2 additional waves of surveys to nonresponders.17 The response rate to the survey was 60%, with a total sample of 2308.
The survey items were based on the Health Employer Data and Information Set (HEDIS 3.0) customer satisfaction survey,18 the Consumer Assessments of Health Plans Study (CAHPS)19 completed by the Agency for Health Care Policy and Research (AHCPR), and satisfaction surveys used in Kentucky during previous assessments in 1987, 1989, and 1991 (KENPAC program). The internal review board of the University of Kentucky approved the survey.
Our sample was limited to individuals who visited primary care physicians often enough to assess continuity. They reported utilization on a single survey item assessing outpatient visits. A total of 1726 respondents reported making 2 or more visits to a physician’s office, clinic, or ED during the previous 12 months. In this group 404 reported having asthma. The prevalence of asthma in this population is higher than in the general population but not exceptionally higher than that found in Medicaid programs.20 Continuity was measured by the question “Over the past 12 months, when you went for medical care, how often did you see the same doctor or provider?” The 4 response categories were “always,” “most of the time,” “sometimes,” and “rarely or never” (reverse scored from 1=”rarely or never” to 4=”always”). Although continuity can be measured in a variety of ways, patient self-reports have commonly been used.1,21 In the present context, perceptions of continuity may be no less important than actual continuity in predicting patients’ evaluative ratings of physician-patient interaction.
The outcome measures were patient assessments of the health care they had received in Medicaid programs during the past 12 months. They are consistent with other self-report measures and were created for the CAHPS by the AHCPR (now the Agency for Healthcare Research and Quality). The present survey reference to 12 months differed from the original CAHPS survey reference to 6 months. The measures included an item about provider communication (“Doctor or provider listened to you and talked with you about your care”) and an item about patient influence (“Your ability to influence the treatment you received from a doctor or provider for your health problems”). These were measured on 5-point scales (reverse scored from 1=poor to 5=excellent).
Analysis
We computed bivariate analyses comparing characteristics of the groups of patients with and without asthma and assessing the relation between continuity of care and physician-patient interaction for each group (chi-square, Student t test). Then the relation between continuity of care and physician-patient interaction was evaluated in multivariate linear regression analyses in the presence of the following control variables: age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. Among the variables available for analysis, these were identified as most likely to confound the relation between continuity of care and patient perceptions of the physician-patient relationship. General health (“In general, would you say your health is:”), health improvement (“Compared to one year ago, how would you rate your health in general now?”), and life satisfaction (“Overall, how satisfied or dissatisfied are you with how your life is going?”) were rated using 5-point scales coded so that higher scores mean better health, more improved health, and greater overall life satisfaction, respectively. We performed separate linear regression models for the patients with and without asthma and examined the contribution of continuity to each model. Linear regression models with all respondents combined were also performed, and interaction terms were entered for asthma status interacting with the other independent variables. Only respondents who had complete data on all items could be included in the regression analyses. We conducted all analyses with SAS statistical programming software release 6.09 (SAS Institute, Inc; Cary, NC), using complete data for each item.
Results
The characteristics of the respondents appear in Table 1. Their demographic characteristics were typical for the Medicaid population in Kentucky. Although most of the respondents were white, more of the patients with asthma were white than were those without the condition. In addition, the asthma patients reported higher numbers of health care visits and poorer health than those without asthma. Reported continuity of care and respondents’ perceptions of provider communication and patient influence are shown in Table 2. The respondents with and without asthma did not differ on these variables of interest. More than half of the respondents (58.8%) reported always seeing the same health care provider in the past 12 months (scale mean ± standard deviation=3.5 ± 0.7).
Bivariate Analyses
In bivariate analyses, ratings of the physician-patient relationship were compared across continuity of care categories. Individuals who “always” saw the same doctor or provider were compared with a category of “less than always,” which had been collapsed across “most of the time,” “sometimes,” and “rarely or never.” On average, respondents rated provider communication and patient influence between “good” and “very good.” Both persons who did and did not have asthma who saw the same doctor or provider for all their health care visits rated provider communication and patient influence significantly higher than did individuals who had less continuity (P <.01). This is shown in Table 3.
Regression Analyses
We computed separate linear regression models for individuals who did and did not have asthma to assess the contribution of continuity of care in the presence of control variables in predicting ratings of provider communication and patient influence for these groups. All 4 response levels were included in the continuity of care variable. The correlation matrix for the independent variables produced no correlations between independent variables that exceeded 0.5, suggesting that these variables could be included in the same analysis. The P values and standardized regression coefficients for the independent variables in the asthmatic and nonasthmatic models are presented for the provider communication models in Table 4 and for the patient influence models in Table 5. All models were significant at P <.05.
For persons with asthma, continuity of care was the only variable (P=.01) that significantly contributed to the provider communication model (Table 4, Model 1) and the only variable (P=.02) other than life satisfaction (P=.04) that contributed to the patient influence model (Table 5, Model 1). In the provider communication and patient influence models, the standardized estimates for the continuity parameter were 0.15 and 0.14, respectively, higher than any other estimates in the models. The nonstandardized parameter estimates for continuity were 0.26 and 0.25, respectively.
For persons who did not have asthma, continuity of care significantly contributed (P=.001) to both the provider communication (Table 4, Model 2) and patient influence models (Table 5, Model 2). Unlike the models for persons with asthma, 5 additional variables significantly contributed to these models (P≤.01): age, number of visits, general health, health improvement, and life satisfaction. The standardized parameter estimates for continuity were similar to those in the asthmatic models (0.14 for each). Continuity ranked only third among the estimates in the provider communication model and second among the estimates in the patient influence model. The nonstandardized parameter estimates for continuity were 0.24 and 0.23, respectively.
The linear regression models combining all respondents were significant in predicting provider communication (P=.001) and patient influence (P=.001). Continuity of care, age, number of visits, general health, health improvement, and life satisfaction significantly contributed to the models (P≤.01 for each). Asthma status and the interaction terms between that status and the other independent variables were not significant, with the exception of the interaction term between that status and number of visits, which predicted provider communication (P=.03). With the asthma interaction terms largely nonsignificant, subsequent discussion will address only the separate asthmatic and nonasthmatic models.
Discussion
Our results confirm earlier findings that continuity of care is important in health care delivery. For both respondents with and without asthma, continuity of care with an individual provider significantly predicted their ratings of provider communication and patient influence alone and in the presence of control variables. Also, the results suggest that continuity of care may be particularly important in certain populations. Differences in the regression models for the respondents with and without asthma suggest a particularly important role of continuity of care in the physician-patient relationship for patients with this disease. Among those persons, continuity of care was the only variable predicting patient perceptions of physician-patient communication after controlling for many other relevant variables; it was 1 of only 2 variables predicting perceptions of patient influence. Among persons who did not have asthma, continuity shared its importance with several other variables.
Our results do not suggest that continuity is important only to patients with asthma. For both patients with and without asthma, continuity of care was an important predictor of provider communication and patient influence. However, it is the unique prominence of continuity of care in the asthma models that is interesting, in the context of several likely predictive variables that were nonsignificant.
If a sample did not have sufficient size and power to detect significant effects, such differences could have been an artifact of differences in sample size. However, the results of a power analysis show that in the group of patients with asthma (the smaller sample) there was 80% power to detect with 95% confidence a correlation as small as 0.06, which is a miniscule effect. Thus the sample with asthma offered sufficient power to detect the effects of all the independent variables, but only the effect of continuity of care emerged as significant for that group.
What is special about the physician-patient relationship over time for patients with asthma? Our findings suggest that for these patients, understanding of their disease and treatment and a feeling of comanagement with the physician are crucial and seem to be directly related to continuity of care. The patterns we saw in the patients with asthma are consistent with previous work that suggests the importance of continuity of care to patients with chronic illnesses. These patients have reported valuing continuity more than do patients with acute problems,22 and persons with asthma have reported willingness to wait more days for care from their regular physician for moderately serious acute illnesses.14 Studies from the 1980s found that patients with chronic illnesses maintained greater continuity with individual physicians.23,24 The respondents with asthma in this 1997 survey did not report greater continuity than those who did not have it. This makes the prominent role of continuity in their evaluations of the physician-patient relationship more interesting, because differences in the level of continuity do not explain the importance of continuity. The respondents with asthma did report significantly more health care visits than those without asthma. Thus, they maintained high levels of continuity across a more challenging number of visits.
When patients concentrate their care with a single physician, those physicians are more likely to develop an accumulated knowledge about their patients’ medical conditions. This knowledge goes beyond simply knowing the patient’s diagnoses and medications. It includes a finer understanding of the severity of each medical problem and how multiple problems interact. More important, it includes the development of a relationship between the patient and the physician and awareness of the patient’s knowledge of the disease and personal preferences for medical treatment.
It has been argued that the importance of continuity of care cannot be conceptualized simply as the frequency of seeing one physician versus another.25 However, personal continuity suggests an ongoing therapeutic relationship between the patient and the physician. In this case, the nature and quality of the contacts are more important than the number. The current data suggest that perhaps the importance of continuity to the ongoing therapeutic relationship is heightened for patients with asthma. It may be that the immediately perceptible morbidity of an asthma exacerbation and the relief provided by the physician contribute to the patient’s evaluation of the relationship. Positive qualities of physician-patient interaction have been linked to satisfaction for patients with ongoing medical problems26 and to “better health” in chronically ill patients.15 Policies and practices that encourage continuity and an effective therapeutic relationship between the patient and the physician should be investigated and implemented. In the current environment of proposals for disease management treatment teams for diseases such as asthma, it is important that continuity of care between the patient and the physician is not completely eliminated through the use of multiple providers.
Limitations
Our study has several limitations. First, the data were based on self-reports. We did not independently validate either the diagnosis of asthma or reported utilization of care. However, chronic diseases have been successfully assessed through self-reports in a variety of large-scale surveys, such as the National Health Interview Survey. Moreover, the utilization questions are based on reliable and valid items from the CAHPS. Continuity of care was also assessed using a single item asking respondents about the level of continuity they experienced with an individual physician in the past year. The merits of this item as an assessment of perceived continuity include its distinct reference to continuity rather than asking whether the respondent has a regular or usual physician. Single-item reports of having a regular or usual physician have been interpreted as continuity of care.21,27,28 However, having a regular or usual physician is not the same as maintaining continuity of care with an individual provider over time. For example, a patient who reports having a regular physician may see other physicians in that practice for a majority of visits because that regular provider is frequently unavailable when the patient needs acute care. A second limitation of our study is that the data came from a survey of participants in a Medicaid program, thereby potentially affecting the generalizability of the results to a more affluent population. In the Kentucky Medicaid fee-for-service program, recipients may have greater choice of physicians than participants in more restrictive health care plans.
Conclusions
The results of our study of an existing data set suggest several directions for future research. One direction would be to look more specifically at the patient-physician relationship and its impact on outcomes. Patients’ trust in their physicians may be particularly important in understanding continuity of care for chronically ill patients.29 Further research into the mechanisms linking continuity of care and characteristics of the physician-patient relationship could begin to discern the direction of influence between them and their combined impact on health outcomes.
Continuity of care matters. Particularly for patients with asthma, continuity of care with an individual provider is linked to important aspects of health care delivery, specifically physician-patient interaction. Changes in health care systems that increasingly promote discontinuity with individual physicians may be especially disruptive for patients with chronic conditions.
Acknowledgments
Our study was funded in part by the Kentucky Department of Medicaid Services.
BACKGROUND: We assessed the role and importance of continuity of care in predicting the perceptions of the physician-patient relationship held by patients with asthma.
METHODS: We analyzed the 1997 statewide probability survey of adult Kentucky Medicaid recipients. The participants included 1726 respondents with 2 or more visits to a physician’s office, clinic, or emergency department in the previous 12 months. Of these, 404 reported having asthma. The respondents used 5-point single-item scales to rate continuity of care, provider communication, and patient influence over treatment.
RESULTS: Multivariate linear regression analyses were used to assess the contribution of continuity of care to provider communication and patient influence in the presence of control variables. Those variables included age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. For persons with asthma, continuity of care was the only variable that significantly contributed to the provider communication model (P=.01) and the only variable other than life satisfaction that contributed to the patient influence model (P <.05 for each). For patients who did not have asthma, continuity of care was one of several variables contributing significantly (P <.05) to the provider communication and patient influence models.
CONCLUSIONS: Particularly for patients with asthma, continuity of care was linked to patient evaluations of their interaction with the physician. Because of this, changes in health care systems that promote discontinuity with individual physicians may be particularly disruptive for patients with chronic diseases.
Continuity of care has been shown to be associated with a variety of positive outcomes including patient satisfaction,1 compliance with medication regimens,2 and health services utilization.3 High continuity of physician care is also associated with a decreased likelihood of future hospitalization.4,5 One explanation for this finding is that continuity leads to increased knowledge and trust between the patient and the physician.6 This increased knowledge and trust may make it easier for the physician to manage medical problems in the office or over the phone and thereby avoid hospitalizing the patient. Similarly, having care continuity with a specific physician is significantly associated with a decreased likelihood of emergency department (ED) use.7
Although data are continually accumulating indicating that continuity between a patient and a clinician has positive benefits, it is clear that it is not always easy to achieve high continuity in practice.8 This is increasingly the case as physicians work in larger groups where there is likely to be less continuity with an individual provider.9 According to data from the 1987 National Medical Expenditure Survey, only half of all patients have high continuity with a physician.8 This situation may be worsening as more Americans are enrolled in managed health care plans that frequently change their panel of approved physicians.10 As a result, patients may be forced to change their physician on multiple occasions, which could have negative consequences on the management of their medical problems.
Since continuity between a patient and a physician has positive health benefits in the general population, it makes intuitive sense that these benefits would be greatest for persons with chronic conditions. Asthma is a common chronic disease affecting 14 to 15 million people in the United States and is the most common chronic disease of childhood, affecting nearly 5 million children in the United States.11 Asthma accounts for more than 470,000 hospitalizations and more than 5000 deaths annually.12 Rates of hospitalization for asthma have been increasing and reflect that it is the most common discharge diagnosis among children.13 In addition to the morbidity and mortality associated with this disease, some treatments have possible adverse effects.14 Thus, the benefits that could accrue from improved health care delivery are considerable.
Patients with asthma have a greater desire than the general population to maintain continuity with a physician, even when the visit is not for asthma.15 A possible reason continuity of care may be important is that the management of chronic conditions requires ongoing monitoring and decisions about when changes in therapy are appropriate. When a patient is seen by the same physician, that provider is more likely to know when tests and treatment changes are indicated. Effective physician-patient interaction is an important component of health care delivery. For patients with chronic illnesses, interaction processes that include the physician giving more information and the patient having greater control during the visit are associated with better health.15 Physician and patient roles in managing asthma differ across physician-patient relationships,16 but the relation between continuity of care and the physician-patient relationship has not been specified for patients with asthma.
It is important to determine the role and importance of continuity in the delivery of health care to patients with asthma. The purpose of our study was to examine the relationship between continuity of care and physician-patient interaction among patients with and without asthma.
Methods
The data for our study came from an omnibus survey of the patient satisfaction of recipients of the Kentucky Medicaid program. Our study is a secondary analysis of that large data set. In 1997 a survey was mailed to a stratified random sample of adult participants (aged Ž18 years) in the Kentucky Medicaid fee-for-service program. The design followed the Dillman method, using an initial wave of surveys with reminder postcards and 2 additional waves of surveys to nonresponders.17 The response rate to the survey was 60%, with a total sample of 2308.
The survey items were based on the Health Employer Data and Information Set (HEDIS 3.0) customer satisfaction survey,18 the Consumer Assessments of Health Plans Study (CAHPS)19 completed by the Agency for Health Care Policy and Research (AHCPR), and satisfaction surveys used in Kentucky during previous assessments in 1987, 1989, and 1991 (KENPAC program). The internal review board of the University of Kentucky approved the survey.
Our sample was limited to individuals who visited primary care physicians often enough to assess continuity. They reported utilization on a single survey item assessing outpatient visits. A total of 1726 respondents reported making 2 or more visits to a physician’s office, clinic, or ED during the previous 12 months. In this group 404 reported having asthma. The prevalence of asthma in this population is higher than in the general population but not exceptionally higher than that found in Medicaid programs.20 Continuity was measured by the question “Over the past 12 months, when you went for medical care, how often did you see the same doctor or provider?” The 4 response categories were “always,” “most of the time,” “sometimes,” and “rarely or never” (reverse scored from 1=”rarely or never” to 4=”always”). Although continuity can be measured in a variety of ways, patient self-reports have commonly been used.1,21 In the present context, perceptions of continuity may be no less important than actual continuity in predicting patients’ evaluative ratings of physician-patient interaction.
The outcome measures were patient assessments of the health care they had received in Medicaid programs during the past 12 months. They are consistent with other self-report measures and were created for the CAHPS by the AHCPR (now the Agency for Healthcare Research and Quality). The present survey reference to 12 months differed from the original CAHPS survey reference to 6 months. The measures included an item about provider communication (“Doctor or provider listened to you and talked with you about your care”) and an item about patient influence (“Your ability to influence the treatment you received from a doctor or provider for your health problems”). These were measured on 5-point scales (reverse scored from 1=poor to 5=excellent).
Analysis
We computed bivariate analyses comparing characteristics of the groups of patients with and without asthma and assessing the relation between continuity of care and physician-patient interaction for each group (chi-square, Student t test). Then the relation between continuity of care and physician-patient interaction was evaluated in multivariate linear regression analyses in the presence of the following control variables: age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. Among the variables available for analysis, these were identified as most likely to confound the relation between continuity of care and patient perceptions of the physician-patient relationship. General health (“In general, would you say your health is:”), health improvement (“Compared to one year ago, how would you rate your health in general now?”), and life satisfaction (“Overall, how satisfied or dissatisfied are you with how your life is going?”) were rated using 5-point scales coded so that higher scores mean better health, more improved health, and greater overall life satisfaction, respectively. We performed separate linear regression models for the patients with and without asthma and examined the contribution of continuity to each model. Linear regression models with all respondents combined were also performed, and interaction terms were entered for asthma status interacting with the other independent variables. Only respondents who had complete data on all items could be included in the regression analyses. We conducted all analyses with SAS statistical programming software release 6.09 (SAS Institute, Inc; Cary, NC), using complete data for each item.
Results
The characteristics of the respondents appear in Table 1. Their demographic characteristics were typical for the Medicaid population in Kentucky. Although most of the respondents were white, more of the patients with asthma were white than were those without the condition. In addition, the asthma patients reported higher numbers of health care visits and poorer health than those without asthma. Reported continuity of care and respondents’ perceptions of provider communication and patient influence are shown in Table 2. The respondents with and without asthma did not differ on these variables of interest. More than half of the respondents (58.8%) reported always seeing the same health care provider in the past 12 months (scale mean ± standard deviation=3.5 ± 0.7).
Bivariate Analyses
In bivariate analyses, ratings of the physician-patient relationship were compared across continuity of care categories. Individuals who “always” saw the same doctor or provider were compared with a category of “less than always,” which had been collapsed across “most of the time,” “sometimes,” and “rarely or never.” On average, respondents rated provider communication and patient influence between “good” and “very good.” Both persons who did and did not have asthma who saw the same doctor or provider for all their health care visits rated provider communication and patient influence significantly higher than did individuals who had less continuity (P <.01). This is shown in Table 3.
Regression Analyses
We computed separate linear regression models for individuals who did and did not have asthma to assess the contribution of continuity of care in the presence of control variables in predicting ratings of provider communication and patient influence for these groups. All 4 response levels were included in the continuity of care variable. The correlation matrix for the independent variables produced no correlations between independent variables that exceeded 0.5, suggesting that these variables could be included in the same analysis. The P values and standardized regression coefficients for the independent variables in the asthmatic and nonasthmatic models are presented for the provider communication models in Table 4 and for the patient influence models in Table 5. All models were significant at P <.05.
For persons with asthma, continuity of care was the only variable (P=.01) that significantly contributed to the provider communication model (Table 4, Model 1) and the only variable (P=.02) other than life satisfaction (P=.04) that contributed to the patient influence model (Table 5, Model 1). In the provider communication and patient influence models, the standardized estimates for the continuity parameter were 0.15 and 0.14, respectively, higher than any other estimates in the models. The nonstandardized parameter estimates for continuity were 0.26 and 0.25, respectively.
For persons who did not have asthma, continuity of care significantly contributed (P=.001) to both the provider communication (Table 4, Model 2) and patient influence models (Table 5, Model 2). Unlike the models for persons with asthma, 5 additional variables significantly contributed to these models (P≤.01): age, number of visits, general health, health improvement, and life satisfaction. The standardized parameter estimates for continuity were similar to those in the asthmatic models (0.14 for each). Continuity ranked only third among the estimates in the provider communication model and second among the estimates in the patient influence model. The nonstandardized parameter estimates for continuity were 0.24 and 0.23, respectively.
The linear regression models combining all respondents were significant in predicting provider communication (P=.001) and patient influence (P=.001). Continuity of care, age, number of visits, general health, health improvement, and life satisfaction significantly contributed to the models (P≤.01 for each). Asthma status and the interaction terms between that status and the other independent variables were not significant, with the exception of the interaction term between that status and number of visits, which predicted provider communication (P=.03). With the asthma interaction terms largely nonsignificant, subsequent discussion will address only the separate asthmatic and nonasthmatic models.
Discussion
Our results confirm earlier findings that continuity of care is important in health care delivery. For both respondents with and without asthma, continuity of care with an individual provider significantly predicted their ratings of provider communication and patient influence alone and in the presence of control variables. Also, the results suggest that continuity of care may be particularly important in certain populations. Differences in the regression models for the respondents with and without asthma suggest a particularly important role of continuity of care in the physician-patient relationship for patients with this disease. Among those persons, continuity of care was the only variable predicting patient perceptions of physician-patient communication after controlling for many other relevant variables; it was 1 of only 2 variables predicting perceptions of patient influence. Among persons who did not have asthma, continuity shared its importance with several other variables.
Our results do not suggest that continuity is important only to patients with asthma. For both patients with and without asthma, continuity of care was an important predictor of provider communication and patient influence. However, it is the unique prominence of continuity of care in the asthma models that is interesting, in the context of several likely predictive variables that were nonsignificant.
If a sample did not have sufficient size and power to detect significant effects, such differences could have been an artifact of differences in sample size. However, the results of a power analysis show that in the group of patients with asthma (the smaller sample) there was 80% power to detect with 95% confidence a correlation as small as 0.06, which is a miniscule effect. Thus the sample with asthma offered sufficient power to detect the effects of all the independent variables, but only the effect of continuity of care emerged as significant for that group.
What is special about the physician-patient relationship over time for patients with asthma? Our findings suggest that for these patients, understanding of their disease and treatment and a feeling of comanagement with the physician are crucial and seem to be directly related to continuity of care. The patterns we saw in the patients with asthma are consistent with previous work that suggests the importance of continuity of care to patients with chronic illnesses. These patients have reported valuing continuity more than do patients with acute problems,22 and persons with asthma have reported willingness to wait more days for care from their regular physician for moderately serious acute illnesses.14 Studies from the 1980s found that patients with chronic illnesses maintained greater continuity with individual physicians.23,24 The respondents with asthma in this 1997 survey did not report greater continuity than those who did not have it. This makes the prominent role of continuity in their evaluations of the physician-patient relationship more interesting, because differences in the level of continuity do not explain the importance of continuity. The respondents with asthma did report significantly more health care visits than those without asthma. Thus, they maintained high levels of continuity across a more challenging number of visits.
When patients concentrate their care with a single physician, those physicians are more likely to develop an accumulated knowledge about their patients’ medical conditions. This knowledge goes beyond simply knowing the patient’s diagnoses and medications. It includes a finer understanding of the severity of each medical problem and how multiple problems interact. More important, it includes the development of a relationship between the patient and the physician and awareness of the patient’s knowledge of the disease and personal preferences for medical treatment.
It has been argued that the importance of continuity of care cannot be conceptualized simply as the frequency of seeing one physician versus another.25 However, personal continuity suggests an ongoing therapeutic relationship between the patient and the physician. In this case, the nature and quality of the contacts are more important than the number. The current data suggest that perhaps the importance of continuity to the ongoing therapeutic relationship is heightened for patients with asthma. It may be that the immediately perceptible morbidity of an asthma exacerbation and the relief provided by the physician contribute to the patient’s evaluation of the relationship. Positive qualities of physician-patient interaction have been linked to satisfaction for patients with ongoing medical problems26 and to “better health” in chronically ill patients.15 Policies and practices that encourage continuity and an effective therapeutic relationship between the patient and the physician should be investigated and implemented. In the current environment of proposals for disease management treatment teams for diseases such as asthma, it is important that continuity of care between the patient and the physician is not completely eliminated through the use of multiple providers.
Limitations
Our study has several limitations. First, the data were based on self-reports. We did not independently validate either the diagnosis of asthma or reported utilization of care. However, chronic diseases have been successfully assessed through self-reports in a variety of large-scale surveys, such as the National Health Interview Survey. Moreover, the utilization questions are based on reliable and valid items from the CAHPS. Continuity of care was also assessed using a single item asking respondents about the level of continuity they experienced with an individual physician in the past year. The merits of this item as an assessment of perceived continuity include its distinct reference to continuity rather than asking whether the respondent has a regular or usual physician. Single-item reports of having a regular or usual physician have been interpreted as continuity of care.21,27,28 However, having a regular or usual physician is not the same as maintaining continuity of care with an individual provider over time. For example, a patient who reports having a regular physician may see other physicians in that practice for a majority of visits because that regular provider is frequently unavailable when the patient needs acute care. A second limitation of our study is that the data came from a survey of participants in a Medicaid program, thereby potentially affecting the generalizability of the results to a more affluent population. In the Kentucky Medicaid fee-for-service program, recipients may have greater choice of physicians than participants in more restrictive health care plans.
Conclusions
The results of our study of an existing data set suggest several directions for future research. One direction would be to look more specifically at the patient-physician relationship and its impact on outcomes. Patients’ trust in their physicians may be particularly important in understanding continuity of care for chronically ill patients.29 Further research into the mechanisms linking continuity of care and characteristics of the physician-patient relationship could begin to discern the direction of influence between them and their combined impact on health outcomes.
Continuity of care matters. Particularly for patients with asthma, continuity of care with an individual provider is linked to important aspects of health care delivery, specifically physician-patient interaction. Changes in health care systems that increasingly promote discontinuity with individual physicians may be especially disruptive for patients with chronic conditions.
Acknowledgments
Our study was funded in part by the Kentucky Department of Medicaid Services.
1. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304:1287-90.
2. Becker MH, Drachman RH, Kirscht JP. Continuity of pediatrician: new support for an old shibboleth. J Pediatr 1974;84:599-605.
3. Raddish M, Horn SD, Sharkey PD. Continuity of care: is it cost effective? Am J Managed Care 1999;5:727-34.
4. Gill JM, Mainous AG, III. The role of provider continuity in preventing hospitalizations. Arch Fam Med 1998;7:352-57.
5. Mainous AG, III, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health 1998;88:1539-41.
6. Starfield B. Primary care: concept, evaluation, and policy. New York, NY: Oxford University Press; 1992.
7. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greater continuity of care associated with less emergency department utilization? Pediatrics 1999;103:738-42.
8. Cornelius LJ. The degree of usual provider continuity for African and Latino Americans. J Health Care Poor Underserved 1997;8:170-85.
9. Hurley RE, Gage BJ, Freund DA. Rollover effects in gatekeeper programs: cushioning the impact of restricted choice. Inquiry 1991;28:375-84.
10. Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 1995;10:94.-
11. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults—United States, 1990-1993. MMWR 1996;45:350-53.
12. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA 1990;264:1688-92.
13. Simons FE. A comparison of beclomethasone, salmeterol, and placebo in children with asthma: Canadian Beclomethasone Dipropionate-Salmeterol Xinafoate Study Group. N Engl J Med 1997;337:1659-65.
14. Love MM, Mainous AG, III. Commitment to a regular physician: how long will patients wait to see their own physician for acute illness? J Fam Pract 1999;48:202-07.
15. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
16. Lagerlov P, Leseth A, Matheson I. The doctor-patient relationship and the management of asthma. Soc Sci Med 1998;47:85-91.
17. Dillman D. Mail and telephone surveys: the Total Design Method. New York, NY: John Wiley; 1978.
18. National Committee for Quality Assurance. Health Employer Data and Information Set (HEDIS 3.0). Washington, DC: NCQA Press; 1998.
19. US Department of Health and Human Services. Consumer Assessments of Health Plans Study (CAHPS); 1997.
20. Mainous AG, III. Analysis of Medicaid claims data for use in development of clinical practice guidelines: report to the Kentucky Medicaid Program; 1995.
21. O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med 1997;157:1462-70.
22. Fletcher RH, O’Malley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
23. Fleming MF, Bentz EJ, Shahady EJ, Abrantes A, Bolick C. Effect of case mix on provider continuity. J Fam Pract 1986;23:137-40.
24. Godkin MA, Rice CA. Relationship of physician continuity to type of health problems in primary care. J Fam Pract 1981;12:99-102.
25. Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997;314:1870-73.
26. Roter DL, Stewart M, Putnam SM, Lipkin M, Jr, Stiles W, Inui TS. The patient-physician relationship: communication patterns of primary care physicians. JAMA 1997;277:350-56.
27. Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health 1996;86:1748-54.
28. Ettner SL. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-55.
29. Thom DH, Ribisl KM, Stewart AL, Luke DA. Further validation and reliability testing of the Trust in Physician Scale: the Stanford Trust Study Physicians. Med Care 1999;37:510-17.
1. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304:1287-90.
2. Becker MH, Drachman RH, Kirscht JP. Continuity of pediatrician: new support for an old shibboleth. J Pediatr 1974;84:599-605.
3. Raddish M, Horn SD, Sharkey PD. Continuity of care: is it cost effective? Am J Managed Care 1999;5:727-34.
4. Gill JM, Mainous AG, III. The role of provider continuity in preventing hospitalizations. Arch Fam Med 1998;7:352-57.
5. Mainous AG, III, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health 1998;88:1539-41.
6. Starfield B. Primary care: concept, evaluation, and policy. New York, NY: Oxford University Press; 1992.
7. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greater continuity of care associated with less emergency department utilization? Pediatrics 1999;103:738-42.
8. Cornelius LJ. The degree of usual provider continuity for African and Latino Americans. J Health Care Poor Underserved 1997;8:170-85.
9. Hurley RE, Gage BJ, Freund DA. Rollover effects in gatekeeper programs: cushioning the impact of restricted choice. Inquiry 1991;28:375-84.
10. Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 1995;10:94.-
11. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults—United States, 1990-1993. MMWR 1996;45:350-53.
12. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA 1990;264:1688-92.
13. Simons FE. A comparison of beclomethasone, salmeterol, and placebo in children with asthma: Canadian Beclomethasone Dipropionate-Salmeterol Xinafoate Study Group. N Engl J Med 1997;337:1659-65.
14. Love MM, Mainous AG, III. Commitment to a regular physician: how long will patients wait to see their own physician for acute illness? J Fam Pract 1999;48:202-07.
15. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-27.
16. Lagerlov P, Leseth A, Matheson I. The doctor-patient relationship and the management of asthma. Soc Sci Med 1998;47:85-91.
17. Dillman D. Mail and telephone surveys: the Total Design Method. New York, NY: John Wiley; 1978.
18. National Committee for Quality Assurance. Health Employer Data and Information Set (HEDIS 3.0). Washington, DC: NCQA Press; 1998.
19. US Department of Health and Human Services. Consumer Assessments of Health Plans Study (CAHPS); 1997.
20. Mainous AG, III. Analysis of Medicaid claims data for use in development of clinical practice guidelines: report to the Kentucky Medicaid Program; 1995.
21. O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med 1997;157:1462-70.
22. Fletcher RH, O’Malley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care 1983;21:234-42.
23. Fleming MF, Bentz EJ, Shahady EJ, Abrantes A, Bolick C. Effect of case mix on provider continuity. J Fam Pract 1986;23:137-40.
24. Godkin MA, Rice CA. Relationship of physician continuity to type of health problems in primary care. J Fam Pract 1981;12:99-102.
25. Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997;314:1870-73.
26. Roter DL, Stewart M, Putnam SM, Lipkin M, Jr, Stiles W, Inui TS. The patient-physician relationship: communication patterns of primary care physicians. JAMA 1997;277:350-56.
27. Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health 1996;86:1748-54.
28. Ettner SL. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-55.
29. Thom DH, Ribisl KM, Stewart AL, Luke DA. Further validation and reliability testing of the Trust in Physician Scale: the Stanford Trust Study Physicians. Med Care 1999;37:510-17.