Continuity of care and referral rate: challenges for the future of health care

Continuity of care and referral rate: challenges for the future of health care Abstract Background Continuity of care could reduce health care consumption by patients and reduce the number of referrals to specialist care, but it is unknown if there is a difference in referral rates to specific medical specialties. Aim We aimed to determine the relationship between continuity of care and both the referral rate (referrals per patient per year) and the medical specialties for which this relationship was strongest. Design and setting A retrospective cohort study of 19333 patients in primary care in the north of the Netherlands. Method Patients with at least two contacts with a general practitioner (GP) over a 2-year period (2013–2014) were included. The number of contacts with their own or other GPs were calculated, and referral rates were determined. Continuity of care was included as a dichotomous variable (absent or present). Results The odds of being referred were higher for older patients, females and patients with more practitioner contacts. However, the presence of continuity of care was associated with the highest odds of referral. The referral rate was significantly highest for patients with continuity of care when referred to paediatrics, as well as for patients without continuity of care who were referred to gastroenterology, ophthalmology and psychiatry. Conclusion Increased continuity of care decreases referral to specialist care, most notably for referrals to paediatrics. Despite continued pressures on continuity of care, policy makers should invest in this cornerstone of primary care to temper health care expenditures. Continuity of care, consultation, doctor–patient relationship, primary care, practice management Introduction As health care costs rise, an increasingly greater proportion of the gross domestic product is spent on health care (1). In this context, policy makers must try to restrain budgets, and this can be achieved by ensuring a strong primary care system (2,3) in which the general practitioner (GP) is a gatekeeper for referral to specialist care in hospital on either an outpatient or acute basis (4). The Netherlands adopted this model for primary care some time ago, with patients managed by a single GP who is considered their ‘own’ GP. It is acknowledged that health care costs can be reduced if GPs can prevent unnecessary referrals to specialist care. Continuity of care, which is regarded a cornerstone of primary health care (4), can achieve this goal (5) by developing a strong relationship between GP and patient beyond a single illness episode (6). There are also several dimensions to continuity of care: informational (availability of patients’ records), longitudinal (long-term relationship) and interpersonal (relation with the same GP) continuity (6). In previous literature, it has been hypothesized that familiarity between patient and GP, achieved through interpersonal and longitudinal continuity, means that reassurance and treatment by the GP will be more effective (7). This is because the GP is better able to interpret the patients’ symptoms with the benefit of knowing the premorbid status. When present, continuity of care can moderate the numbers of unnecessary hospitalizations (7–11), and improve confidence and satisfaction with GP care (7,12–15). In addition, continuity of care may reduce health care costs (16,17). For example, continuity of care was shown to reduce the number of hospital referrals in Norway (18), while the absence of continuity of care was associated with more specialist care per patient and higher health care costs in the USA (19,20). However, it is unknown if these effects are present in the Dutch primary health care system. It is also unknown whether continuity of care has more of an impact on referral to certain specialties over others. For example, an illness and the need for referral can be better defined in surgical specialties and referral might be less dependent of the GP, whereas illness and the need for specialist referral could be less clear for other symptoms, such as medically unexplained physical symptoms (MUPS), and these might be affected by continuity of care. This study was performed to analyze two research questions. First, we aimed to determine the relationship between continuity of care and the referral rate (number of referrals per patient per year); second, we wanted to know the medical specialties for which this relationship was strongest. These research questions were analyzed in the Dutch primary care setting, where research on this topic is lacking. Methods Design We conducted a retrospective cohort study using data from the Registration Network Groningen (RNG) for patient contacts from three large primary care centres in the north of the Netherlands. All patient contacts are coded based on International Classification of Primary Care codes for ~30000 patients treated by an average of 17 GPs. The register has been shown to be representative of the national population (21). Patients Patients were included in the cohort when they had two or more face-to-face contacts with a GP from their practice during a 2-year period (2013–2014). Patients with one or no contact were excluded on the assumption that they would not have established a good relationship with their GP. We included both consultations at the practice and home visits, but excluded telephone calls and e-mail consultations because they could not be reliably traced to a specific GP. For every patient, we collected data about their demographics (age and sex) and the number of contacts with a GP. We determined the number of contacts that patients had with both the GP they were registered to (i.e. their ‘own’ GP) and with other GPs. Finally, we determined the number of referrals per patient during the study period, as well as the medical specialty to which they were referred. When there were fewer than 50 referrals to a medical specialty during the 2-year study period, that specialty was not analyzed in the second part of the analysis (the relation between continuity of care and medical specialty). Continuity of care was included as a dichotomous variable: it was defined as present when the patient only had face-to-face contacts with their own GP during the 2-year period, and absent when the patient had one or more contacts with another GP. This definition was consisted with that used in previous research (11,18). We also calculated a continuity of care percentage to measure the difference in continuity of care for patients referred, or not, to each specialty. This continuity of care percentage was calculated as the proportion of contacts with the patients’ own GP from the total number of contacts. Main and secondary outcome measures The main outcome measure was the referral rate, defined as the number of referrals per patient per year. These referrals comprised those to specialist care for outpatient consultations or treatment, as well as those for hospitalization in cases of acute illnesses. The secondary outcome was the medical specialty to which patients were referred. Statistical analysis We used descriptive statistics to report the patients’ age, sex and number and type of referrals. The main outcome measure (number of referrals) was not normally distributed, so we used a Poisson regression analysis to determine the relation with continuity of care (dichotomous variable: 1 = continuity of care; 0 = no continuity of care). The relation between the number of referrals and continuity of care was adjusted for age, sex and the number of contacts with GPs. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. In this analysis, the significance level was set at P < 0.05. Next, we tested whether the continuity of care percentage of referred patients was different to that of non-referred patients. Because this outcome was normally distributed, a student t-test could be used to assess significance, though we used Bonferroni correction for multiple testing. There were 21 medical specialties, so a significance level of P < 0.002381 (0.05/21) was applied. All statistical analyses were performed using IBM SPSS, Version 20.0 (IBM Corp., Armonk, NY). Results Demographic patient data are presented in Table 1. After excluding patients with fewer than two GP contacts during the study period, 19333 patients remained in the dataset. These patients visited their GPs an average of 5.67 times (range, 2–84 times) in 2 years. For every 100 patients per year, there was an average of 41.5 referrals to specialist care (i.e. [0.83/2]*100). Approximately one-quarter of patients only had contact with their own GP, indicating that continuity of care was present. Table 1. Demographic patient data of 19333 patients with two or more contacts, 2013–2014 Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Data are presented as mean (SD) or number (%). aPatients with <2 contacts during a 2-year period were excluded. View Large Table 1. Demographic patient data of 19333 patients with two or more contacts, 2013–2014 Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Data are presented as mean (SD) or number (%). aPatients with <2 contacts during a 2-year period were excluded. View Large The relationships between continuity of care, patient characteristics and all referrals are presented in Table 2. The odds for being referred were higher for older patients, females and patients with a higher number of contacts with the GP. Continuity of care was the strongest predictor of number of referrals (OR: 0.817), when corrected for relevant characteristics. When continuity of care was present, the odds to be referred were lower than when continuity of care was absent. Table 2. Relation between continuity of care, demographic factors and number of referrals of 19333 patients with two or more contacts, 2013–2014 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 CI, confidence interval; OR, odds ratio. View Large Table 2. Relation between continuity of care, demographic factors and number of referrals of 19333 patients with two or more contacts, 2013–2014 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 CI, confidence interval; OR, odds ratio. View Large Table 3 presents the difference in continuity of care by referral to different medical specialties. As shown, the number of referrals increased for gastroenterology, ophthalmology and psychiatry when continuity of care was high. However, the number of referrals increased for paediatrics when continuity of care was low. Table 3. Mean number of referrals to medical specialties of 19333 patients with two or more contacts, 2013–2014 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Mean percentage continuity of care when patients were either referred or not referred to specialist care. *P < 0.002381; continuity of care when referred higher than continuity of care when not referred. **P < 0.002381; continuity of care when referred lower than continuity of care when not referred. View Large Table 3. Mean number of referrals to medical specialties of 19333 patients with two or more contacts, 2013–2014 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Mean percentage continuity of care when patients were either referred or not referred to specialist care. *P < 0.002381; continuity of care when referred higher than continuity of care when not referred. **P < 0.002381; continuity of care when referred lower than continuity of care when not referred. View Large Discussion Summary We found that there was a statistically significant relationship between the referral rate and continuity of care. Patients that were only seen by their own GP during the 2-year study period were almost 20% less likely to be referred to specialist care than patients who were also seen by other GPs (OR: 0.817). Specifically, the referral rate was higher for paediatrics when continuity of care was not present, while patients were more likely to be referred to gastroenterology, ophthalmology and psychiatry when continuity of care was present. Strengths and limitations This study included almost 20000 patients from a representative sample of the Dutch population (21). We included all patients and only used the electronic patient file as the source of data, in contrast to a previous study that only included patients older than 30 years and relied on patient recollection (18). We think that this resulted in data that are more comprehensive, representative and reliable. Indeed, the RNG is itself known to be a reliable and accurate data source, as proven over many years. These factors will have improved the reliability and generalizability of our study. Despite the strengths, there were several limitations. We could not correct for some patient factors that influence the referral rate, such as income, education, comorbidity and self-rated health. Organizational factors may also affect the referral rate, including the characteristics of the GPs office, the age and the experience of the GP and the availability of a specialist outpatient service or hospital. In addition, we did not examine the effects of partial continuity of care; i.e. continuity of care provided consistently by two GPs who share responsibility, which might also temper the referral rate. Finally, we did not include the various patient contacts with other personnel in the general practice, which is important because contact with a medical assistant or primary care nurse can affect continuity of care. Comparisons with existing literature The results of this study are supported by the existing literature, which have shown statistically significant lower referral rates in patients when continuity of care (18–20). But, in these studies, continuity of care was defined by its longitudinal dimension (long-term relationship) or its interpersonal dimension (always the same GP). This study is the first to have combined both the longitudinal (2 years) and interpersonal (only 1 GP) dimensions to explain the effect of continuity of care on the referral rate. Our outcomes support the hypothesis that providing continuity of care can reduce the number of referrals to specialist care, which ultimately could lead to more appropriate care and reduced health care costs, as previously hypothesized by O’Donnell (5). This is relevant to the Dutch primary care system which promotes a longitudinal and interpersonal relationship between patient and GP. However, the results of this study can potentially be generalized to other countries with a similar primary care system. Despite the evidence that continuity of care can decrease referral rates, there are several threats that must be considered. Over the last decade, e.g. increasing number of medical students and primary care practitioners have been female (22,23). Unfortunately, while it is true that female GPs bring many benefits to primary care, they are less likely to work full time and are also less willing to be self-employed (24). Another threat is the growth in demand for a 24/7 economy, which increasingly places pressure on GPs to offer out-of-hours services (25). These developments threaten continuity of care because patients are less likely to be able to visit their own GP only. In this study, we also analyzed the relationship between continuity of care and medical specialty. An interesting finding was that patients were more often referred to paediatrics when continuity of care was absent, possibly because children’s parents had a lack of trust and confidence in an unfamiliar GP. Equally, this could be because of the inability of that GP to reassure the patient or interpret the symptoms when the patient and his or her parents were not known to them through continuity of care. By contrast, we found that patients were more often referred to gastroenterology, ophthalmology and psychiatry when continuity of care was present. This could be because many referrals for these specialties were not urgent and patients were willing to wait for their own GP to be consulted before referral. For example, this might have applied to chronic abdominal pain and rectal bleeding for gastroenterology, cataracts for ophthalmology and depressive or anxiety disorders for psychiatry. The lack of a qualitative aspect to this study means that we may have missed other plausible explanations. Implications for practice Continuity of care is associated with fewer referrals for hospital care, and this effect is largest for referrals to paediatrics. Overall, the results of this study support the importance of continuity of care. Despite organizational changes in primary care—such as the increase in the number of part-time GPs and the greater expectations for longer opening hours—placing increased pressure on continuity of care, policy makers should invest in this cornerstone of primary care to moderate avoidable health care costs. Our findings should also be used to educate trainees and experienced clinicians alike that maintaining continuity of care and building long-term relationships with a patient can reduce unnecessary referrals. Declaration Ethical approval: The study was conducted in accordance with the regulations of the Medical Ethical Board of University Medical Center Groningen, the Netherlands. Conflict of interest: All authors have declared that they have no competing interests. Acknowledgements We thank Dr Robert Sykes (www.doctored.org.uk) for providing editorial services in the final draft of the manuscript. References 1. Lorenzoni L , Belloni A , Sassi F . Health-care expenditure and health policy in the USA versus other high-spending OECD countries . Lancet 2014 ; 384 : 83 – 92 . Google Scholar CrossRef Search ADS PubMed 2. Kocher R , Chigurupati A . The coming battle over shared savings–primary care physicians versus specialists . N Engl J Med 2016 ; 375 : 104 – 6 . Google Scholar CrossRef Search ADS PubMed 3. Kringos D , Boerma W , Bourgueil Y , et al. The strength of primary care in Europe: an international comparative study . Br J Gen Pract 2013 ; 63 : e742 – 50 . Google Scholar CrossRef Search ADS PubMed 4. Allen J , Gay B , Crebolder H ,, et al. The European Definition of General Practice/Family Medicine. WONCA Europe, 2002 . 5. O’Donnell CA . Variation in GP referral rates: what can we learn from the literature ? Fam Pract 2000 ; 17 : 462 – 71 . Google Scholar CrossRef Search ADS PubMed 6. Saultz JW . Defining and measuring interpersonal continuity of care . Ann Fam Med 2003 ; 1 : 134 – 43 . Google Scholar CrossRef Search ADS PubMed 7. Saultz JW , Lochner J . Interpersonal continuity of care and care outcomes: a critical review . Ann Fam Med 2005 ; 3 : 159 – 66 . Google Scholar CrossRef Search ADS PubMed 8. Bayliss EA , Ellis JL , Shoup JA , et al. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system . Ann Fam Med 2015 ; 13 : 123 – 9 . Google Scholar CrossRef Search ADS PubMed 9. Cheng SH , Chen CC , Hou YF . A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system . Arch Intern Med 2010 ; 170 : 1671 – 7 . Google Scholar PubMed 10. Chauhan M , Bankart MJ , Labeit A , Baker R . Characteristics of general practices associated with numbers of elective admissions . J Public Health (Oxf) 2012 ; 34 : 584 – 90 . Google Scholar CrossRef Search ADS PubMed 11. Barker I , Steventon A , Deeny SR . Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data . BMJ 2017 ; 356 : j84 . Google Scholar CrossRef Search ADS PubMed 12. Adler R , Vasiliadis A , Bickell N . The relationship between continuity and patient satisfaction: a systematic review . Fam Pract 2010 ; 27 : 171 – 8 . Google Scholar CrossRef Search ADS PubMed 13. Mainous AG 3rd , Baker R , Love MM , Gray DP , Gill JM . Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom . Fam Med 2001 ; 33 : 22 – 7 . Google Scholar PubMed 14. Nutting PA , Goodwin MA , Flocke SA , Zyzanski SJ , Stange KC . Continuity of primary care: to whom does it matter and when ? Ann Fam Med 2003 ; 1 : 149 – 55 . Google Scholar CrossRef Search ADS PubMed 15. Saultz JW , Albedaiwi W . Interpersonal continuity of care and patient satisfaction: a critical review . Ann Fam Med 2004 ; 2 : 445 – 51 . Google Scholar CrossRef Search ADS PubMed 16. De Maeseneer JM , De Prins L , Gosset C , Heyerick J . Provider continuity in family medicine: does it make a difference for total health care costs ? Ann Fam Med 2003 ; 1 : 144 – 8 . Google Scholar CrossRef Search ADS PubMed 17. Hollander MJ , Kadlec H . Financial implications of the continuity of primary care . Perm J 2015 ; 19 : 4 – 10 . Google Scholar CrossRef Search ADS PubMed 18. Hansen AH , Halvorsen PA , Aaraas IJ , Førde OH . Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey . Br J Gen Pract 2013 ; 63 : 482 – 9 . Google Scholar CrossRef Search ADS PubMed 19. Starfield B , Chang HY , Lemke KW , Weiner JP . Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences . J Ambul Care Manage 2009 ; 32 : 216 – 25 . Google Scholar CrossRef Search ADS PubMed 20. Raddish M , Horn SD , Sharkey PD . Continuity of care: is it cost effective ? Am J Manag Care 1999 ; 5 : 727 – 34 . Google Scholar PubMed 21. Biermans MC , Elbers GH , Verheij RA , et al. External validation of EPICON: a grouping system for estimating morbidity rates using electronic medical records . J Am Med Inform Assoc 2008 ; 15 : 770 – 5 . Google Scholar CrossRef Search ADS PubMed 22. House J . Women in medicine--a future assured . Lancet 2009 ; 373 : 1997 . Google Scholar CrossRef Search ADS PubMed 23. Jefferson L , Bloor K , Maynard A . Women in medicine: historical perspectives and recent trends . Br Med Bull 2015 ; 114 : 5 – 15 . Google Scholar CrossRef Search ADS PubMed 24. Peckham C. Medscape Physician Compensation Report 2015 . New York : Medscape , 2015 . 25. Smits M , Keizer E , Huibers L , Giesen P . GPs’ experiences with out-of-hours GP cooperatives: a survey study from the Netherlands . Eur J Gen Pract 2014 ; 20 : 196 – 201 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Continuity of care and referral rate: challenges for the future of health care

Loading next page...
 
/lp/ou_press/continuity-of-care-and-referral-rate-challenges-for-the-future-of-Bc8qrZM0SW
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0263-2136
eISSN
1460-2229
D.O.I.
10.1093/fampra/cmy048
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Continuity of care could reduce health care consumption by patients and reduce the number of referrals to specialist care, but it is unknown if there is a difference in referral rates to specific medical specialties. Aim We aimed to determine the relationship between continuity of care and both the referral rate (referrals per patient per year) and the medical specialties for which this relationship was strongest. Design and setting A retrospective cohort study of 19333 patients in primary care in the north of the Netherlands. Method Patients with at least two contacts with a general practitioner (GP) over a 2-year period (2013–2014) were included. The number of contacts with their own or other GPs were calculated, and referral rates were determined. Continuity of care was included as a dichotomous variable (absent or present). Results The odds of being referred were higher for older patients, females and patients with more practitioner contacts. However, the presence of continuity of care was associated with the highest odds of referral. The referral rate was significantly highest for patients with continuity of care when referred to paediatrics, as well as for patients without continuity of care who were referred to gastroenterology, ophthalmology and psychiatry. Conclusion Increased continuity of care decreases referral to specialist care, most notably for referrals to paediatrics. Despite continued pressures on continuity of care, policy makers should invest in this cornerstone of primary care to temper health care expenditures. Continuity of care, consultation, doctor–patient relationship, primary care, practice management Introduction As health care costs rise, an increasingly greater proportion of the gross domestic product is spent on health care (1). In this context, policy makers must try to restrain budgets, and this can be achieved by ensuring a strong primary care system (2,3) in which the general practitioner (GP) is a gatekeeper for referral to specialist care in hospital on either an outpatient or acute basis (4). The Netherlands adopted this model for primary care some time ago, with patients managed by a single GP who is considered their ‘own’ GP. It is acknowledged that health care costs can be reduced if GPs can prevent unnecessary referrals to specialist care. Continuity of care, which is regarded a cornerstone of primary health care (4), can achieve this goal (5) by developing a strong relationship between GP and patient beyond a single illness episode (6). There are also several dimensions to continuity of care: informational (availability of patients’ records), longitudinal (long-term relationship) and interpersonal (relation with the same GP) continuity (6). In previous literature, it has been hypothesized that familiarity between patient and GP, achieved through interpersonal and longitudinal continuity, means that reassurance and treatment by the GP will be more effective (7). This is because the GP is better able to interpret the patients’ symptoms with the benefit of knowing the premorbid status. When present, continuity of care can moderate the numbers of unnecessary hospitalizations (7–11), and improve confidence and satisfaction with GP care (7,12–15). In addition, continuity of care may reduce health care costs (16,17). For example, continuity of care was shown to reduce the number of hospital referrals in Norway (18), while the absence of continuity of care was associated with more specialist care per patient and higher health care costs in the USA (19,20). However, it is unknown if these effects are present in the Dutch primary health care system. It is also unknown whether continuity of care has more of an impact on referral to certain specialties over others. For example, an illness and the need for referral can be better defined in surgical specialties and referral might be less dependent of the GP, whereas illness and the need for specialist referral could be less clear for other symptoms, such as medically unexplained physical symptoms (MUPS), and these might be affected by continuity of care. This study was performed to analyze two research questions. First, we aimed to determine the relationship between continuity of care and the referral rate (number of referrals per patient per year); second, we wanted to know the medical specialties for which this relationship was strongest. These research questions were analyzed in the Dutch primary care setting, where research on this topic is lacking. Methods Design We conducted a retrospective cohort study using data from the Registration Network Groningen (RNG) for patient contacts from three large primary care centres in the north of the Netherlands. All patient contacts are coded based on International Classification of Primary Care codes for ~30000 patients treated by an average of 17 GPs. The register has been shown to be representative of the national population (21). Patients Patients were included in the cohort when they had two or more face-to-face contacts with a GP from their practice during a 2-year period (2013–2014). Patients with one or no contact were excluded on the assumption that they would not have established a good relationship with their GP. We included both consultations at the practice and home visits, but excluded telephone calls and e-mail consultations because they could not be reliably traced to a specific GP. For every patient, we collected data about their demographics (age and sex) and the number of contacts with a GP. We determined the number of contacts that patients had with both the GP they were registered to (i.e. their ‘own’ GP) and with other GPs. Finally, we determined the number of referrals per patient during the study period, as well as the medical specialty to which they were referred. When there were fewer than 50 referrals to a medical specialty during the 2-year study period, that specialty was not analyzed in the second part of the analysis (the relation between continuity of care and medical specialty). Continuity of care was included as a dichotomous variable: it was defined as present when the patient only had face-to-face contacts with their own GP during the 2-year period, and absent when the patient had one or more contacts with another GP. This definition was consisted with that used in previous research (11,18). We also calculated a continuity of care percentage to measure the difference in continuity of care for patients referred, or not, to each specialty. This continuity of care percentage was calculated as the proportion of contacts with the patients’ own GP from the total number of contacts. Main and secondary outcome measures The main outcome measure was the referral rate, defined as the number of referrals per patient per year. These referrals comprised those to specialist care for outpatient consultations or treatment, as well as those for hospitalization in cases of acute illnesses. The secondary outcome was the medical specialty to which patients were referred. Statistical analysis We used descriptive statistics to report the patients’ age, sex and number and type of referrals. The main outcome measure (number of referrals) was not normally distributed, so we used a Poisson regression analysis to determine the relation with continuity of care (dichotomous variable: 1 = continuity of care; 0 = no continuity of care). The relation between the number of referrals and continuity of care was adjusted for age, sex and the number of contacts with GPs. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. In this analysis, the significance level was set at P < 0.05. Next, we tested whether the continuity of care percentage of referred patients was different to that of non-referred patients. Because this outcome was normally distributed, a student t-test could be used to assess significance, though we used Bonferroni correction for multiple testing. There were 21 medical specialties, so a significance level of P < 0.002381 (0.05/21) was applied. All statistical analyses were performed using IBM SPSS, Version 20.0 (IBM Corp., Armonk, NY). Results Demographic patient data are presented in Table 1. After excluding patients with fewer than two GP contacts during the study period, 19333 patients remained in the dataset. These patients visited their GPs an average of 5.67 times (range, 2–84 times) in 2 years. For every 100 patients per year, there was an average of 41.5 referrals to specialist care (i.e. [0.83/2]*100). Approximately one-quarter of patients only had contact with their own GP, indicating that continuity of care was present. Table 1. Demographic patient data of 19333 patients with two or more contacts, 2013–2014 Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Data are presented as mean (SD) or number (%). aPatients with <2 contacts during a 2-year period were excluded. View Large Table 1. Demographic patient data of 19333 patients with two or more contacts, 2013–2014 Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Factor N (%) Age 42.0 (±22.9) Sex (female) 10836 (56.0%) Contactsa (2-year period) 5.67 (4.8) Number of referrals (2-year period) per patient 0.83 (1.1) Continuity of care  Present 4910 (25.4%)  Absent 14423 (74.6%) Data are presented as mean (SD) or number (%). aPatients with <2 contacts during a 2-year period were excluded. View Large The relationships between continuity of care, patient characteristics and all referrals are presented in Table 2. The odds for being referred were higher for older patients, females and patients with a higher number of contacts with the GP. Continuity of care was the strongest predictor of number of referrals (OR: 0.817), when corrected for relevant characteristics. When continuity of care was present, the odds to be referred were lower than when continuity of care was absent. Table 2. Relation between continuity of care, demographic factors and number of referrals of 19333 patients with two or more contacts, 2013–2014 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 CI, confidence interval; OR, odds ratio. View Large Table 2. Relation between continuity of care, demographic factors and number of referrals of 19333 patients with two or more contacts, 2013–2014 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 OR 95% CI P value Sex (male) 0.960 0.930–0.991 0.011 Age 1.006 1.005–1.007 <0.001 Number of contacts 1.050 1.048–1.052 <0.001 Continuity of care (present) 0.817 0.785–0.851 <0.001 CI, confidence interval; OR, odds ratio. View Large Table 3 presents the difference in continuity of care by referral to different medical specialties. As shown, the number of referrals increased for gastroenterology, ophthalmology and psychiatry when continuity of care was high. However, the number of referrals increased for paediatrics when continuity of care was low. Table 3. Mean number of referrals to medical specialties of 19333 patients with two or more contacts, 2013–2014 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Mean percentage continuity of care when patients were either referred or not referred to specialist care. *P < 0.002381; continuity of care when referred higher than continuity of care when not referred. **P < 0.002381; continuity of care when referred lower than continuity of care when not referred. View Large Table 3. Mean number of referrals to medical specialties of 19333 patients with two or more contacts, 2013–2014 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Continuity of care when referred Continuity of care when not referred Mean difference 95% confidence interval P value Lower Upper Anaesthesiology 0.68 0.60 0.076 −0.016 0.169 0.107 Cardiology 0.62 0.60 0.016 −0.013 0.046 0.269 Surgery 0.60 0.61 −0.006 −0.030 0.019 0.642 Dermatology 0.64 0.60 0.035 0.151 0.056 0.002 Gynaecology 0.63 0.61 −0.233 −0.002 0.049 0.076 Internal medicine 0.62 0.61 0.007 −0.022 0.037 0.636 Dental surgery 0.58 0.61 −0.026 −0.104 0.052 0.511 ENT medicine 0.60 0.61 −0.007 −0.028 0.015 0.538 Neurology 0.65 0.61 0.040 0.014 0.066 0.003 Pulmonology 0.61 0.61 0.002 −0.041 0.045 0.922 Gastroenterology 0.66 0.61 0.053 0.021 0.086 0.001* Ophthalmology 0.66 0.61 0.054 0.034 0.074 <0.001* Orthopaedics 0.62 0.61 0.012 −0.011 0.035 0.296 Plastic surgery 0.62 0.61 0.009 −0.029 0.047 0.641 Paediatrics 0.54 0.61 −0.073 −0.113 −0.034 <0.001** Psychiatry 0.65 0.61 0.043 0.018 0.069 0.001* Rheumatology 0.62 0.61 0.015 −0.040 0.070 0.599 Rehabilitation medicine 0.63 0.61 0.020 −0.023 0.062 0.372 Sports medicine 0.52 0.61 −0.086 −0.167 −0.005 0.036 Urology 0.63 0.61 0.025 −0.007 0.056 0.122 Vascular surgery 0.64 0.61 0.030 −0.042 0.102 0.412 Mean percentage continuity of care when patients were either referred or not referred to specialist care. *P < 0.002381; continuity of care when referred higher than continuity of care when not referred. **P < 0.002381; continuity of care when referred lower than continuity of care when not referred. View Large Discussion Summary We found that there was a statistically significant relationship between the referral rate and continuity of care. Patients that were only seen by their own GP during the 2-year study period were almost 20% less likely to be referred to specialist care than patients who were also seen by other GPs (OR: 0.817). Specifically, the referral rate was higher for paediatrics when continuity of care was not present, while patients were more likely to be referred to gastroenterology, ophthalmology and psychiatry when continuity of care was present. Strengths and limitations This study included almost 20000 patients from a representative sample of the Dutch population (21). We included all patients and only used the electronic patient file as the source of data, in contrast to a previous study that only included patients older than 30 years and relied on patient recollection (18). We think that this resulted in data that are more comprehensive, representative and reliable. Indeed, the RNG is itself known to be a reliable and accurate data source, as proven over many years. These factors will have improved the reliability and generalizability of our study. Despite the strengths, there were several limitations. We could not correct for some patient factors that influence the referral rate, such as income, education, comorbidity and self-rated health. Organizational factors may also affect the referral rate, including the characteristics of the GPs office, the age and the experience of the GP and the availability of a specialist outpatient service or hospital. In addition, we did not examine the effects of partial continuity of care; i.e. continuity of care provided consistently by two GPs who share responsibility, which might also temper the referral rate. Finally, we did not include the various patient contacts with other personnel in the general practice, which is important because contact with a medical assistant or primary care nurse can affect continuity of care. Comparisons with existing literature The results of this study are supported by the existing literature, which have shown statistically significant lower referral rates in patients when continuity of care (18–20). But, in these studies, continuity of care was defined by its longitudinal dimension (long-term relationship) or its interpersonal dimension (always the same GP). This study is the first to have combined both the longitudinal (2 years) and interpersonal (only 1 GP) dimensions to explain the effect of continuity of care on the referral rate. Our outcomes support the hypothesis that providing continuity of care can reduce the number of referrals to specialist care, which ultimately could lead to more appropriate care and reduced health care costs, as previously hypothesized by O’Donnell (5). This is relevant to the Dutch primary care system which promotes a longitudinal and interpersonal relationship between patient and GP. However, the results of this study can potentially be generalized to other countries with a similar primary care system. Despite the evidence that continuity of care can decrease referral rates, there are several threats that must be considered. Over the last decade, e.g. increasing number of medical students and primary care practitioners have been female (22,23). Unfortunately, while it is true that female GPs bring many benefits to primary care, they are less likely to work full time and are also less willing to be self-employed (24). Another threat is the growth in demand for a 24/7 economy, which increasingly places pressure on GPs to offer out-of-hours services (25). These developments threaten continuity of care because patients are less likely to be able to visit their own GP only. In this study, we also analyzed the relationship between continuity of care and medical specialty. An interesting finding was that patients were more often referred to paediatrics when continuity of care was absent, possibly because children’s parents had a lack of trust and confidence in an unfamiliar GP. Equally, this could be because of the inability of that GP to reassure the patient or interpret the symptoms when the patient and his or her parents were not known to them through continuity of care. By contrast, we found that patients were more often referred to gastroenterology, ophthalmology and psychiatry when continuity of care was present. This could be because many referrals for these specialties were not urgent and patients were willing to wait for their own GP to be consulted before referral. For example, this might have applied to chronic abdominal pain and rectal bleeding for gastroenterology, cataracts for ophthalmology and depressive or anxiety disorders for psychiatry. The lack of a qualitative aspect to this study means that we may have missed other plausible explanations. Implications for practice Continuity of care is associated with fewer referrals for hospital care, and this effect is largest for referrals to paediatrics. Overall, the results of this study support the importance of continuity of care. Despite organizational changes in primary care—such as the increase in the number of part-time GPs and the greater expectations for longer opening hours—placing increased pressure on continuity of care, policy makers should invest in this cornerstone of primary care to moderate avoidable health care costs. Our findings should also be used to educate trainees and experienced clinicians alike that maintaining continuity of care and building long-term relationships with a patient can reduce unnecessary referrals. Declaration Ethical approval: The study was conducted in accordance with the regulations of the Medical Ethical Board of University Medical Center Groningen, the Netherlands. Conflict of interest: All authors have declared that they have no competing interests. Acknowledgements We thank Dr Robert Sykes (www.doctored.org.uk) for providing editorial services in the final draft of the manuscript. References 1. Lorenzoni L , Belloni A , Sassi F . Health-care expenditure and health policy in the USA versus other high-spending OECD countries . Lancet 2014 ; 384 : 83 – 92 . Google Scholar CrossRef Search ADS PubMed 2. Kocher R , Chigurupati A . The coming battle over shared savings–primary care physicians versus specialists . N Engl J Med 2016 ; 375 : 104 – 6 . Google Scholar CrossRef Search ADS PubMed 3. Kringos D , Boerma W , Bourgueil Y , et al. The strength of primary care in Europe: an international comparative study . Br J Gen Pract 2013 ; 63 : e742 – 50 . Google Scholar CrossRef Search ADS PubMed 4. Allen J , Gay B , Crebolder H ,, et al. The European Definition of General Practice/Family Medicine. WONCA Europe, 2002 . 5. O’Donnell CA . Variation in GP referral rates: what can we learn from the literature ? Fam Pract 2000 ; 17 : 462 – 71 . Google Scholar CrossRef Search ADS PubMed 6. Saultz JW . Defining and measuring interpersonal continuity of care . Ann Fam Med 2003 ; 1 : 134 – 43 . Google Scholar CrossRef Search ADS PubMed 7. Saultz JW , Lochner J . Interpersonal continuity of care and care outcomes: a critical review . Ann Fam Med 2005 ; 3 : 159 – 66 . Google Scholar CrossRef Search ADS PubMed 8. Bayliss EA , Ellis JL , Shoup JA , et al. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system . Ann Fam Med 2015 ; 13 : 123 – 9 . Google Scholar CrossRef Search ADS PubMed 9. Cheng SH , Chen CC , Hou YF . A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system . Arch Intern Med 2010 ; 170 : 1671 – 7 . Google Scholar PubMed 10. Chauhan M , Bankart MJ , Labeit A , Baker R . Characteristics of general practices associated with numbers of elective admissions . J Public Health (Oxf) 2012 ; 34 : 584 – 90 . Google Scholar CrossRef Search ADS PubMed 11. Barker I , Steventon A , Deeny SR . Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data . BMJ 2017 ; 356 : j84 . Google Scholar CrossRef Search ADS PubMed 12. Adler R , Vasiliadis A , Bickell N . The relationship between continuity and patient satisfaction: a systematic review . Fam Pract 2010 ; 27 : 171 – 8 . Google Scholar CrossRef Search ADS PubMed 13. Mainous AG 3rd , Baker R , Love MM , Gray DP , Gill JM . Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom . Fam Med 2001 ; 33 : 22 – 7 . Google Scholar PubMed 14. Nutting PA , Goodwin MA , Flocke SA , Zyzanski SJ , Stange KC . Continuity of primary care: to whom does it matter and when ? Ann Fam Med 2003 ; 1 : 149 – 55 . Google Scholar CrossRef Search ADS PubMed 15. Saultz JW , Albedaiwi W . Interpersonal continuity of care and patient satisfaction: a critical review . Ann Fam Med 2004 ; 2 : 445 – 51 . Google Scholar CrossRef Search ADS PubMed 16. De Maeseneer JM , De Prins L , Gosset C , Heyerick J . Provider continuity in family medicine: does it make a difference for total health care costs ? Ann Fam Med 2003 ; 1 : 144 – 8 . Google Scholar CrossRef Search ADS PubMed 17. Hollander MJ , Kadlec H . Financial implications of the continuity of primary care . Perm J 2015 ; 19 : 4 – 10 . Google Scholar CrossRef Search ADS PubMed 18. Hansen AH , Halvorsen PA , Aaraas IJ , Førde OH . Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey . Br J Gen Pract 2013 ; 63 : 482 – 9 . Google Scholar CrossRef Search ADS PubMed 19. Starfield B , Chang HY , Lemke KW , Weiner JP . Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences . J Ambul Care Manage 2009 ; 32 : 216 – 25 . Google Scholar CrossRef Search ADS PubMed 20. Raddish M , Horn SD , Sharkey PD . Continuity of care: is it cost effective ? Am J Manag Care 1999 ; 5 : 727 – 34 . Google Scholar PubMed 21. Biermans MC , Elbers GH , Verheij RA , et al. External validation of EPICON: a grouping system for estimating morbidity rates using electronic medical records . J Am Med Inform Assoc 2008 ; 15 : 770 – 5 . Google Scholar CrossRef Search ADS PubMed 22. House J . Women in medicine--a future assured . Lancet 2009 ; 373 : 1997 . Google Scholar CrossRef Search ADS PubMed 23. Jefferson L , Bloor K , Maynard A . Women in medicine: historical perspectives and recent trends . Br Med Bull 2015 ; 114 : 5 – 15 . Google Scholar CrossRef Search ADS PubMed 24. Peckham C. Medscape Physician Compensation Report 2015 . New York : Medscape , 2015 . 25. Smits M , Keizer E , Huibers L , Giesen P . GPs’ experiences with out-of-hours GP cooperatives: a survey study from the Netherlands . Eur J Gen Pract 2014 ; 20 : 196 – 201 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Family PracticeOxford University Press

Published: May 30, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off