Quantifying, Understanding and Enhancing Relational Continuity
of Care

Here you will find research papers related to continuity of care in primary care. Click on a title to open a full paper in a new window.

Background: Following government calls for General Practices in England to work at scale, some practices have
grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises.
We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes
and patient experience.

Methods: We linked five practice-level datasets in England to obtain a single dataset of practice workforce, list
size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract
type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and
outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size
and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the
research team were used to determine the most informative number of groups. One-way ANOVA was used to assess
how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the
association between practice group and practice performance.

Results: A total of 6024 practices were available for class assignment. We determined that a 3-class grouping
provided the most meaningful interpretation; 4494 (74.6%) were classified as ‘Small GP-reliant practices’, 1400 (23.2%)
were labelled ‘Medium-size GP-led practices with a multidisciplinary team (MDT) input’ and 131 (2.2%) practices
were named ‘Large multidisciplinary practices’. Small GP-reliant practices outperformed larger multidisciplinary
practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices
with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices
and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size
GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage
where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger
multidisciplinary practices had higher cancer detection rates than small GP-reliant practices.

Conclusion: Small GP-reliant practices were found to provide better patient reported access, continuity of care,
experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection

Aim: To evaluate the effectiveness, feasibility and acceptability of a multicomponent intervention for improving personal continuity for older patients in general practice.

Design: A cluster randomised three-wedged, pragmatic trial during 18 months.

Setting: 32 general practices in the Netherlands. 


Participants: 221 general practitioners (GPs), practice assistants and other practice staff were included. Practices were instructed to include a random sample of 1050 patients aged 65 or older at baseline and 12-month follow-up.

Intervention: The intervention took place at practice level and included opTimise persOnal cOntinuity for oLder (TOOL)-kit: a toolbox containing 34 strategies to improve personal continuity.

Outcomes: Data were collected at baseline and at six 3-monthly follow-up measurements. Primary outcome measure was experienced continuity of care at the patient level measured by the Nijmegen Continuity Questionnaire (NCQ) with subscales for personal continuity (GP knows me and GP shows commitment) and team/cross-boundary continuity at 12-month follow-up. Secondary outcomes were measured in GPs, practice assistants and other practice staff and included work stress and satisfaction and perceived level of personal continuity. In addition, a process evaluation was undertaken among GPs, practice assistants and other practice staff to assess the acceptability and feasibility of the intervention.

Results: No significant effect of the intervention was observed on NCQ subscales GP knows me (adjusted
mean difference: 0.05 (95% CI −0.05 to 0.15), p=0.383), GP shows commitment (0.03 (95% CI −0.08 to 0.14), p=0.668) and team/cross-boundary (0.01 (95% CI −0.06 to 0.08), p=0.911). All secondary outcomes did not change significantly during follow-up. Process evaluation among GPs, practice assistants and other practice staff showed adequate acceptability of the intervention and partial implementation due to the COVID-19 pandemic and a high perceived workload.

Conclusion: Although participants viewed TOOL-kit as a practical and accessible toolbox, it did not improve personal continuity as measured with the NCQ. The absence of an effect may be explained by the incomplete implementation of TOOL-kit into practice and the choice of general outcome measures instead of outcomes more specific for the intervention.

Abstract: Continuity of care has long been recognised as a core feature of general practice. Relational continuity is associated with multiple, overlapping benefits for patients, doctors and society. Continuity increases trust, patient satisfaction and adherence to advice, while reducing hospital use and deaths. Repeated 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. However, the level of continuity is reducing in UK general practice. This article provides the context of international research on continuity of care and describes ways to improve continuity.

Objectives: To determine whether general practitioner (GP) workforce contributes to the link between practice funding and patient experience. Specifically, to determine whether increased practice funding is associated with better patient experience, and to what degree an increase in workforce accounts for this relationship. Setting Primary care practice level analysis of workforce, funding and patient experience of all NHS practices in England.


Primary and secondary outcome measures: The link between NHS-provided funding to general practice (payments per patient) and patient experience, as per the General Practice Patient Survey, was evaluated. Subsequently, mediation analysis, adjusted for covariates, was used to scrutinise the extent to which GP workforce accounts for this relationship (measured as the number of GPs per 10,000 patients).


Participants: We included all general practices in England for which there was relevant data for each primary variable. Atypical practices were excluded, such as those with a patient list size of 0 or where the workforce variable was recorded as being more than 3 SD from the mean. After exclusion, 6139 practices were included in the final analysis.


Results: We found that workforce (GPs per 10,000 population) significantly (p<0.001) acts as a mediator in the effect of practice funding on overall patient experience even after adjusting for rurality, sex and age, and deprivation. On average, the mediated effect constitutes 30% of the total effect of practice funding on patient experience.


Conclusions: The increase in the number of doctors in primary care in England appears to be a mechanism through which augmented practice funding could positively impact patient ex

Purpose: Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients.

Methods: We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel

negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex.

Results: The patients’ mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions.

Conclusions: A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Background: The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care.


Objective(s): This review aimed to synthesize the extant research on applications of the PD approach in primary care.


Methods: Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioural Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS).


Results: In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels.


Conclusions: Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation. 

Background: Personal continuity of care is a core value of general practice. It is increasingly threatened by societal and healthcare changes.


Aim: To investigate the association between personal continuity and both practice and patient characteristics; and to incorporate GPs’ views to enrich and validate the quantitative findings.


Design and Setting: A mixed-methods study based on observational, routinely collected healthcare data from 269 478 patients from 48 Dutch general practices (2013–2018) and interviews with selected GPs.


Methods: First, four different personal continuity outcome measures were calculated relating to eight practice and 12 patient characteristics using multilevel linear regression analyses. Second, a thematic analysis was performed of semi-structured interviews with 10 GPs to include their views on factors contributing to personal (dis) continuity. These GPs worked at the 10 practices with the largest difference between calculated and model-estimated personal continuity.


Results: Both a larger number of usual GPs working in a practice and a larger percentage of patient contacts with locum GPs were dose-dependently associated with lower personal continuity (highest versus lowest quartile –0.094 and –0.092, respectively, P<0.001), whereas days since registration with the general practice was dose-dependently associated with higher personal continuity (highest versus lowest quartile +0.017, P<0.001). Older age, number of chronic conditions, and contacts were also associated with higher personal continuity. The in-depth interviews identified three key themes affecting personal continuity: team composition, practice organisation, and the personal views of the GPs


Conclusions: Personal continuity is associated with practice and patient characteristics. The dose-dependent associations suggest a causal relationship and, complemented by GPs’ views, may provide practical targets to improve personal continuity directly. z

Background: Despite well-documented clinical benefits of longitudinal doctor–patient continuity in primary care, continuity rates have declined. Assessment by practices or health commissioners is rarely undertaken.


Aim: Using the Usual Provider of Care (UPC) score this study set out to measure continuity across 126 practices in the mobile, multi-ethnic population of East London, comparing these scores with the General Practice Patient Survey (GPPS) responses to questions on GP continuity. Design and setting A retrospective, cross-sectional study in all 126 practices in three East London boroughs.


Methods: The study population included patients who consulted three or more times between January 2017 and December 2018. Anonymised demographic and consultation data from the electronic health record were linked to results from Question 10 (‘seeing the doctor you prefer’) of the 2019 GPPS.


Results: The mean UPC score for all 126 practices was 0.52 (range 0.32 to 0.93). There was a strong correlation between practice UPC scores measured in the 2 years to December 2018 and responses to the 2019 GPPS Question 10, Pearson’s r correlation coefficient, 0.62. Smaller practices had higher scores. Multilevel analysis showed higher continuity for patients ≥65 years compared with children and younger adults (β coefficient 0.082, 95% confidence interval = 0.080 to 0.084) and for females compared with males.


Conclusions: It is possible to measure continuity across all practices in a local health economy. Regular review of practice continuity rates can be used to support efforts to increase continuity within practice teams. In turn this is likely to have a positive effect on clinical outcomes and on satisfaction for both patients and doctors.

Background: International trends have shifted to creating large general practices. There is an assumption that interdisciplinary teams will increase patient accessibility and provide more cost-effective, efficient services. Micro-teams have been proposed to mitigate for some potential challenges of practice expansion, including continuity of care.


Aim: To review available literature and examine how micro-teams are described, and identify opportunities and limitations for patients and practice staff.


Design and setting: This was an international systematic review of studies published in English.


Method: Databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus) and grey literature were searched. Studies were included if they provided evidence about implementation of primary care micro-teams. Framework analysis was used to synthesise identified literature. The research team included a public contributor co-applicant. The authors conducted stakeholder discussions with those with and without experience of micro-team implementation.


Results: Of the 462 studies identified, 24 documents met the inclusion criteria. Most included empirical data from healthcare professionals, describing micro-team implementation. Results included characteristics of the literature; micro-team description; range of ways micro-teams have been implemented; reported outcomes; and experiences of patients and staff.


Conclusions: The organisation of primary care has potential impact on the nature and quality of patient care, safety, and outcomes. This review contributes to current debate about care delivery and how this can impact on the experiences and outcomes of patients and staff. This analysis identifies several key opportunities and challenges for future research, policy, and practice.


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