Continuity of care is potentially a matter of life and death

Continuity of care between physicians and patients may be significantly associated with lower mortality, according to an international systematic review recently published in BMJ Open. This finding applies to both specialist and primary care physicians.

Previous research has indicated that continuity of care—continual contact between a patient and the same physician—is a hallmark of practice and tied to higher patient satisfaction, increased health promotion, better patient adherence, and lower utilization of hospital services.

“There is a clear rationale for the effectiveness of continuity of care as doctors collect ‘accumulated knowledge’ about an individual patient which they then use in subsequent consultations to tailor advice,” the investigators wrote.

Since 2010, researchers have looked at whether continuity of care can reduce patient death, which is one of the ultimate goals in patient care. Lead author Sir Denis J. Pereira Gray, OBE, HonDSc, FRCP, FRCGP, FMedSci, Emeritus Professor, St. Leonard's Research General Practice, University of Exeter, Exeter, UK, and colleagues mined databases to systematically derive 22 high-quality studies to discover whether continuity of care decreased patient mortality rates.

All the studies chosen for review were either cohort or cross-sectional, and the majority controlled for covariates. Importantly, the team adopted a global purview when reviewing research, with studies representing different cultures and health-care systems.

“We had nine different countries on four different continents in all sorts of different health systems, so we don’t think it’s a local or cultural effect, we think it’s a human effect,” said Dr. Gray.

Most studies were from North America (n=11), but 7 were done in Europe, 2 in Taiwan, and 1 each in Israel and South Korea. In this systematic review, Dr. Gray and fellow researchers included all studies examining any patient group or attending physician type, as long as they examined the relationship between levels of continuity of care and death rates, as measured by primary outcomes including all-cause, time/age-limited or cause-specific mortality. Moreover, they assessed bias and confounding factors (eg, age, sex, race, and social status). Notably, a meta-analysis of results was impossible based on study heterogeneity.

In 18 of 22 studies (81.8%), the researchers found that greater continuity of care correlated with decreased mortality rates. In two studies, no significant associations were observed, which was probably due to the short timescales of these studies that limited the physician-patient relationship. Furthermore, one other study showed no correlation likely because the physician-patient relationship assessed was weak.

In one study, continuity of care based on claims-based data was associated with higher mortality rates. But these claims-based data reflected only quantity—not quality—of physician-patient visits. Moreover, in this same study, increased levels of continuity of care as reported by patients themselves were associated with lower all-cause mortality.

“The effect sizes were generally small but these were in the same range as some treatment effects, as very large, repeatable effects on mortality are rare,” the team wrote. “In addition, for some studies included in this review, effect sizes were calculated using very small increments in the continuity measure.”

One obvious limitation of the current study was its observational nature. Furthermore, the reviewers conceded that reverse causality could be afoot. For instance, when a patient’s health deteriorates close to death, this patient could engage in increased continuity of care with the same physician. Conversely, a patient who is very sick could miss appointments.

Dr. Gray and co-authors suggested that one mechanism underlying the association between continuity of care and decreased death rates is that when patients continually see the same physicians, adherence improves and treatment regimens become more personalized. Furthermore, patient outlook improves and the physician is seen as more compassionate and responsive.

Nevertheless, according to the authors, continuity of care has more recently been de-emphasized throughout the world. “For 200 years,” the authors concluded, “medical advances have been mainly technical and impersonal which has reduced attention to the human side of medicine. This systematic review reveals that despite numerous technical advances, continuity of care is an important feature of medical practice, and potentially a matter of life and death.”