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Continuity of Care Matters in All Health Care Settings.

Concern regarding declining continuity of medical care has been growing during the past 3 decades. Continuity of care has been threatened by an array of forces, including the decrease in primary care physicians, changes in health insurance, the growth of specialization, and the need to ensure easy and timely access to care.1 Most of the initial focus on continuity of care was in outpatient settings. Outpatient continuity with a primary care physician has been linked to decreased emergency department use and hospitalizations, lower costs, and higher patient and physician satisfaction.1 These findings contributed to a greater emphasis on team-based care and other chronic care management models. Another setting that has experienced declines in continuity is the transition from the community to the hospital and back to the community.2 By 2006, most hospitalized Medicare patients received no care from a physician who had previously provided care for them.2 Several studies have found that such discontinuity is associated with higher postdischarge costs and readmission rates.3 Continuity of care received in the hospital has declined as well. Recent studies have suggested that patients admitted for medical illness are likely to be cared for by more than 1 general internist during their stay.4,5 Such discontinuity seems driven by the growth in care by hospitalists and the fact that many hospitalists have work schedules that do not allow for continuity of care. Just as with outpatient medicine, we might expect that hospitalized patients who experience discontinuities in their care also have worse outcomes. That is the question posed in the study by Farid et al.6 The major challenge in asking whether continuity of care in the hospital affects outcomes is the potential for strong confounding. Patients with more severe illness are more likely to see multiple physicians and also more likely to have poor outcomes. A bias this strong is almost never eliminated by traditional approaches to controlling for severity of illness and other factors.7 Farid et al6 avoided this bias in a clever way. Using Medicare charge data, they identified hospitalists working at least 7 days in a row. They then identified patients who had a greater likelihood of poor continuity of care because they were admitted toward the end of a hospitalist’s 7-day shift. They compared these patients with those admitted during the initial few days in a 7-day shift who were therefore less likely to experience discontinuity. Farid et al6 found no difference in mortality in the 30 days after discharge among patients admitted early in the shift vs those admitted close to the end of the shift. However, among patients in the top quartile for risk of death, there was a 1.0% adjusted lower rate of mortality (27.8% vs 26.8%) among those admitted early in the shift. We used an approach similar to that of Farid et al6 to indirectly identify patients at risk of discontinuity.5 We compared patients cared for by hospitalists who usually worked 5 or 7 days in a row with those cared for by hospitalists whose schedules were more intermittent, such as working every third day.4 Patients cared for by hospitalists with intermittent schedules were much more likely to see multiple hospitalists during their stay.4 Both the approach by Farid et al6 and our approach focused on the schedules of the treating hospitalists in determining risk of discontinuity, avoiding the strong selection biases that would occur if the patients were classified by how many different physicians actually provided care during their stay. In our study, patients cared for by hospitalists in the top quartile of continuous schedules had significantly lower postdischarge mortality, readmission rates, and costs and higher rates of discharge home compared with patients cared for by hospitalists with discontinuous schedules.5 + Related article