Clinicians, policy makers, and the literature agree that continuity of care is ideal for a healthy America. How well do teaching hospital clinics, which often have a revolving door of resident physicians, perform on this and quality?
Teaching hospitals are a vital part of the United States health care delivery system. These institutions are responsible for the development and education of the nations future physicians and associated health care providers. Most teaching hospitals are typically located in lower socioeconomic communities; people in these communities usually are dependent on receiving their health care from the staff physicians and their trainees at these teaching hospitals. Likewise, teaching hospitals depend on these communities to provide patients willing to be learned from by trainees. In the primary care clinics of teaching hospitals, continuity is a longstanding problem; most resident physicians are only in their clinics for three years. Patients will potentially only have the same provider for a maximum of three years before being switched over to a different provider who will ultimately provide care for chronic conditions such as diabetes, high blood pressure, or high cholesterol. Several research articles have aimed at identifying the relationship between continuity of care for a patient with a specific primary care provider and the successful management of the patients chronic conditions. This study examines if continuity of care affects the diabetes quality measures for patients at an urban teaching hospital primary care clinic.
The study used existing clinical data from a community-based health center operated by an academic health science center diabetes registry and practice encounter data between January 1, 2008 and December 31, 2009. These data included patients with a primary or secondary diagnosis of diabetes, their demographic information, and clinical information (most recent dates and values for HbA1c, microalbumin, LDL, and blood pressure). Four hundred eighty-four adults were selected from a total of 648 adults in the registry. The sample group had three or more visits to the clinic during the study period. Seventy-seven percent of patients were between 41 and 70 years old, and sixty-three percent were female. Seventy-eight percent of the patients were identified as Hispanic (majority were Dominican background). The mean number of visits per patient during the two years was 11 (range: 334). Patients saw on average approximately three different providers.
The researchers used the Modified Modified Continuity of Care Index (MMCI) to measure the continuity of each patient with a specific provider. Patients who had all their visits with the same provider would have a MMCI equal to 1 and patients who did not see the same provider for any visits would have a MMCI of zero. The participants were then placed in three groups: low, medium, or high quartile MMCI. The diabetes care quality measures were based on the NCQA HEDIS and Diabetes Recognition Program. Chi-squared tests of trends were used to examine the relationship between the MMCI and the diabetes quality measures. The MMCI was 0.71 (p<0.05) for patients between 18-40 years of age, 0.75 (p<0.05) among patients between 41-60 years of age, 0.78 (p<0.05) for patients between 61-70 years of age and 0.80 (p<0.05) for patients equal to or older than 71 years of age. The MMCI did not differ by gender or ethnicity.
There were significant relationships with proportions of patients with poor HbA1c control (i.e. HbA1C >9 percent) and MMCI (31 percent for low MMCI quartile, 26 percent for medium MMCI, 19 percent for top MMCI; p<0.05) and with good LDL-C control (i.e. LDL <100 mg/dL) and MMCI (43 percent for low MMCI, 52 percent for medium MMCI, and 56 percent for top MMCI; p<0.05).
Blood pressure control outcomes and testing rates for HbA1C, LDL, and milcroalbumin were not significantly affected by resident physician continuity of care.
Although the article supports a potential relationship in the level of continuity of care with medical outcomes, the researchers did not consider how the supervising attending physician could also play a part in patients continuity of care. Since each resident physician must discuss their patients cases with their attending physician, the treatment decisions for each patient in the trial may have been similar regardless of the specific resident physician seen during the visit if the same attending was supervising care. Understanding the impact of this variable might alter the level of continuity of care considerably.
As an academic pediatrician, I have worked in these clinics as both a resident and also a supervising attending physician. I have observed how residents treatment plans are heavily influenced by their attending physicians. Residents often follow their supervisors recommendations even when given autonomy to create independent treatment plans. Although patients may only see the resident, teaching hospital primary care clinics must try to ensure patients continuity of care with dedicated supervising physicians and support staff.
Tyree Winters, DO