Eleanor White

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

Objective 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. Design 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. Results 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. Conclusions 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. PROSPERO registration number CRD42016042091.

Improving continuity: THE clinical challenge

Continuity of care is a core feature of general practice; it creates multiple benefits for patients, doctors and society. Continuity increases trust, patient satisfaction, disclosure of information, take-up of preventive care, adherence to advice, reduction in socio-economic disadvantage, and reduces deaths. However, the level of continuity is reducing in general practice. About 15 consultations are needed with a patient for a GP to acquire enough ‘accumulated knowledge’ to develop a sense of continuing responsibility. This fosters GP sensitivity and mutual understanding, which enable GPs to provide ‘higher-level’ quality of care. The RCGP curriculum states two high-level aims: that GPs need to ‘enhance continuity of care’ and ‘build long-term relationships with patients’. This article analyses these aims by setting them in the context of international research on continuity of care.

Fifty years of longitudinal continuity in general practice: a retrospective observational study

BACKGROUND Continuity of care has been defined as relational continuity between patient and doctor and longitudinal continuity describing the duration of the relationship. Measurement of longitudinal continuity alone is associated with outcomes including patient satisfaction, medical costs, hospital admissions and mortality. METHODS In one UK general practice, records were searched for patients with continuous registration for 50 or more years. Characteristics of these patients were analysed for age, gender, social deprivation, partner registration and length of registration. Trends in numbers and proportions of this group over the previous 14 years were determined. A comparison group of patients, aged 50 or more, and registered in the same practice within the last 2-4 years, was identified. RESULTS Patients registered for 50 years or more with a median registration of 56.2 years numbered 190 out of a population of 8420 (2.3%). These patients increased in number by 35.3% (1.7-2.3%) over 14 consecutive years. There were no differences between groups for GP consultation rate, number of repeat medications and hospital use, despite the significantly higher prevalence of multi-morbidity, depression and diabetes in patients with high continuity. CONCLUSIONS This is the first report of 50-year continuity in general practice. Numbers of such patients and proportions are increasing. Longitudinal continuity is easily measured in general practice and associated with important clinical outcomes.

Medicalisation in the UK: changing dynamics, but still ongoing.

The UK is becoming a thoroughly medicalised nation, with various players: patients, doctors, other professionals, government and public health, acting in some cases to increase or in others to decrease medicalisation. Over a single professional lifetime, general medical practice has reversed from being mainly reactive work with doctors responding to patients’ symptoms, to a pro-active mass assessment of risk with extensive issuing of treatments, increasingly for people without symptoms at all. Statins are the model, already prescribed for about seven million people, with current proposals from the National Institute for Health and Care Excellence that would more than double the number of people receiving them. There are also calls for mass medication to reduce cardiovascular deaths through a ‘polypill’, containing several drugs. The medical literature, mainly written by doctors, described numerous advantages of medical treatments, whereas historically, the social science literature, mainly written by social scientists, often described adverse effects and critiqued medicalisation. The previous gap between the literature of the medical and social sciences has closed and instead there are changing dynamics in medicalisation which create conflicts between different players.

Is the 'scandal' of diabetes care in general practice fact or fiction?

At a national conference in 2013 (the Nuffield Trust Summit), I was challenged about the alleged unacceptable standard of diabetes care in general practice. Similarly Diabetes UK1 refers to the ‘scandal’ of inadequate standards of care. If standards are to be of value to patients and professionals they need to be based on good research and be achievable in usual clinical practice. They must also meet the requirements for ethical and compassionate care. We are satisfied that the current criteria are based on good research and agree with the nine clinical targets promoted by the Department of Health and Diabetes UK following NICE guidance in 2012.2 However, we have serious reservations. Are these standards sensible and ethical and are the national figures accurate? The current Health and Social Care Information Centre3 (HSCIC) asks the audit question: ‘What percentage of people registered with diabetes received the nine NICE key processes of diabetes care?’ and Diabetes UK1 aims to ensure that: ‘ …

Continuity of care is very important

We congratulate Ridd et al on an interesting approach to cancer diagnosis in general practice, but were disappointed that in 2015 they could write: ‘Seeing the same doctor is associated with higher patient satisfaction but evidence that it makes a difference …

Guidelines, ‘scandals’, and supporting clinicians in providing care for patients with diabetes

What’s in a name? Various terms are used to describe guidance for clinicians and ‘guidelines’ is not the only term. Other words used are ‘protocols’ and ‘checklists’, which often deal with non-clinical aspects of teamwork. Connotations can differ. NICE guidelines are ‘guidelines not tram lines’ (Haslam, NICE Chairman, personal communication, 2014), whereas compulsion may occur with surgical checklists. Some consultant surgeons ‘were not enthusiastic’ about using the WHO surgical checklists.1 However, irrespective of clinicians’ attitudes, it is the outcomes for patients which matter. Haynes et al.2 showed that the surgical death rates fell from 1.5% before using checklists to 0.8% after use and the complication rate fell from 11% (before use) to 7% (afterwards).

Response to Vincenti

Gray, White and Russell draw attention to the rise in antidepressant prescriptions in the past decade, when discussing medicalisation in the UK. However, in that time, there has been an explosion in the use of antidepressants for pain relief (especially amitriptyline), so the assumption that this increase reflects a wish by clinicians to avoid psychological therapies for depression may be unfounded. It would be interesting to see what the figures show if the use of antidepressants outside of mental health were first subtracted.

The importance of continuity of care

Dr Benett is right that access and continuity are interlinked and we agree that general practice needs investment in capacity.1 However, it is disappointing to see a clinical director of a CCG writing that there is only ‘equivocal evidence on the relationship between continuity and patient outcomes’. It …

Delayed diagnosis: longer and improved GP training and more GPs are the answer

Hawkes describes how NHS gatekeeping delays diagnosis.1 A serious problem exists in all health systems in quickly diagnosing serious rare diseases. UK NHS cancer outcomes are worse than in some continental countries. GP delay in diagnosis is a serious problem, but so is post-referral delay, relatively fewer x ray machines, and fewer specialist treatments available—both drugs and radiotherapy. England has 28% fewer …