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      Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality


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          Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.


          Systematic review without meta-analysis.

          Data sources

          MEDLINE, Embase and the Web of Science, from 1996 to 2017.

          Eligibility criteria for selecting studies

          Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients.


          Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors.


          This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important.

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          Most cited references51

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          The association between continuity of care and outcomes: a systematic and critical review.

          Numerous studies have tried to determine the association between continuity and outcomes. Studies doing so must actually measure continuity. If continuity and outcomes are measured concurrently, their association can only be determined with time-dependent methods. To identify and summarize all methodologically studies that measure the association between continuity of care and patient outcomes. We searched MEDLINE database (1950-2008) and hand-searched to identify studies that tried to associate continuity and outcomes. English studies were included if they: actually measured continuity; determined the association of continuity with patient outcomes; and properly accounted for the relative timing of continuity and outcome measures. A total of 139 English language studies tried to measure the association between continuity and outcomes but only 18 studies (12.9%) met methodological criteria. All but two studies measured provider continuity and used health utilization or patient satisfaction as the outcome. Eight of nine high-quality studies found a significant association between increased continuity and decreased health utilization including hospitalization and emergency visits. Five of seven studies found improved patient satisfaction with increased continuity. These studies validate the belief that increased provider continuity is associated with improved patient outcomes and satisfaction. Further research is required to determine whether information or management continuity improves outcomes. © 2010 Blackwell Publishing Ltd.
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            Does continuity of care improve patient outcomes?

            Continuity of care is a cornerstone of primary care that has been promoted by recent trends in medical education and in the way health care delivery is organized. We sought to determine the effect of sustained continuity of care (SCOC) on the quality of patient care. We conducted a systematic review of all articles in Medline (January 1966 to January 2002), Educational Resources Information Center (ERIC), and PSYCH INFO using the terms "continuity of care" or "continuity of patient care." We identified additional titles of candidate articles by reviewing the bibliographies of articles from our original MEDLINE search, contacting experts in primary care, health care management, and health services research, and by reviewing bibliographies of textbooks of primary care and public health. Two investigators (MDC, SHJ) independently reviewed the full text to exclude articles that did not fulfill search criteria. Articles excluded were those that focused on physicians-in-training, on SCOC in a non-primary care setting, such as an inpatient ward, or on transitions from inpatient to the outpatient setting. We also excluded articles that did not correlate SCOC to a quality of care measure. From 5070 candidate titles, we examined the full text of 260 articles and found 18 (12 cross-sectional studies, 5 cohort studies and 1 randomized controlled trial) that fulfilled our criteria. Five studies focused on patients with chronic illness (eg, asthma, diabetes). No studies documented negative effects of increased SCOC on quality of care. SCOC is associated with patient satisfaction (4 studies), decreased hospitalizations and emergency department visits (7 studies), and improved receipt of preventive services (5 studies). SCOC improves quality of care, and this association is consistently documented for patients with chronic conditions. Programs to promote SCOC may best maximize impact by focusing on populations with chronic conditions.
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              Continuity of care and the risk of preventable hospitalization in older adults.

              Preventable hospitalizations are common among older adults for reasons that are not well understood. To determine whether Medicare patients with ambulatory visit patterns indicating higher continuity of care have a lower risk of preventable hospitalization. Retrospective cohort study. Ambulatory visits and hospital admissions. Continuously enrolled fee-for-service Medicare beneficiaries older than 65 years with at least 4 ambulatory visits in 2008. The concentration of patient visits with physicians measured for up to 24 months using the continuity of care score and usual provider continuity score on a scale from 0 to 1. Index occurrence of any 1 of 13 preventable hospital admissions, censoring patients at the end of their 24-month follow-up period if no preventable hospital admissions occurred, or if they died. Of the 3,276,635 eligible patients, 12.6% had a preventable hospitalization during their 2-year observation period, most commonly for congestive heart failure (25%), bacterial pneumonia (22.7%), urinary infection (14.9%), or chronic obstructive pulmonary disease (12.5%). After adjustment for patient baseline characteristics and market-level factors, a 0.1 increase in continuity of care according to either continuity metric was associated with about a 2% lower rate of preventable hospitalization (continuity of care score hazard ratio [HR], 0.98 [95% CI, 0.98-0.99; usual provider continuity score HR, 0.98 [95% CI, 0.98-0.98). Continuity of care was not related to mortality rates. Among fee-for-service Medicare beneficiaries older than 65 years, higher continuity of ambulatory care is associated with a lower rate of preventable hospitalization.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                28 June 2018
                : 8
                : 6
                : e021161
                [1 ] St Leonard’s Practice , Exeter, UK
                [2 ] departmentMedical School , University of Exeter , Exeter, UK
                [3 ] departmentMedical School , University of Manchester , Manchester, UK
                Author notes
                [Correspondence to ] Sir Denis J Pereira Gray; denis.pereiragray@ 123456btinternet.com
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                : 19 December 2017
                : 15 March 2018
                : 20 April 2018
                Patient-Centred Medicine
                Custom metadata

                continuity of care,mortality,systematic review,doctors,doctor patient relationship
                continuity of care, mortality, systematic review, doctors, doctor patient relationship


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