The proportion of Medicare patients experiencing continuity of care between outpatient and inpatient settings decreased substantially between 1996 and 2006, with decreases occurring in all areas of the country and in all types of hospitals, according to a study in the April 22/29 issue of JAMA.

Continuity of care is generally recognized to have 3 dimensions-continuity in information, continuity in management, and continuity in the patient-physician relationship. "Relationship continuity is the ongoing interaction of a patient with one physician, which results in increased knowledge of patient preferences, better communication, and improved trust," the authors write. "Such outpatient continuity has shown to be associated with improved patient satisfaction, increased use of appropriate preventive health services, greater medication adherence, lower hospitalization rates, more appropriate end of life care, and lower cost." Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization.

Gulshan Sharma, M.D., M.P.H., of the University of Texas Medical Branch, Galveston, Texas, and colleagues examined outpatient to inpatient continuity of care of older adults between 1996 and 2006, with the study including 3,020,770 hospital admissions during this time period. The researchers used enrollment and claims data for a 5 percent national sample of Medicare beneficiaries older than 66 years of age, with the data including patients' demographic and enrollment information, claims for hospital stays and information on physician services.

The researchers found that outpatient to inpatient continuity with any outpatient physician decreased from 50.5 percent in 1996 to 39.8 percent in 2006. Similarly, outpatient to inpatient continuity with a primary care physician (PCP) decreased from 44.3 percent in 1996 to 31.9 percent in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9 percent) and those living in large metropolitan areas (11.7 percent) and in New England (16.2 percent). Approximately one-third of the decrease in continuity between 1996 and 2006 was associated with growth in hospitalist activity.

Patients with co-existing illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCP during hospitalization.

"Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities in care," the authors conclude.

JAMA. 2009;301[16]:1671-1680.


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